a research paper on family planning

Family planning science and practice lessons from the 2018 International Conference on Family Planning

Jean Christophe Rusatira Roles: Conceptualization, Data Curation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Claire Silberg Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Alexandria Mickler Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Carolina Salmeron Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Jean Olivier Twahirwa Rwema Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Maia Johnstone Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Michelle Martinez Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Jose G. Rimon Roles: Conceptualization, Funding Acquisition, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Linnea Zimmerman Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

This article is included in the International Conference on Family Planning gateway.

Family planning, return on investment, women empowerment, reproductive rights, reproductive health, gender empowerment, contraceptive technology

Revised Amendments from Version 1

We have amended the paper to address the comments from the reviewers. Abstract section: We have re-written the abstract to improve readability and clarify the thematic grouping process of the 15 tracks into 6 themes and to address other comments made by the reviewers. Introduction section: We have included more context on the theme. Lessons from ICFP 2018 section: We have made edits to address various comments to expand on the demographic dividend framing and human rights-oriented framing.  We have also incorporated more information on the investments and political environment necessary to harness the DD. We have revised the Male Involvement in FP Programming section and provided copyediting to make the section more succinct. We have also made editorial copy editing to remove grammatical errors and improve the flow of the paper. References section: We have updated the reference list.

See the authors' detailed response to the review by Nguyen Toan Tran See the authors' detailed response to the review by Ann Biddlecom See the authors' detailed response to the review by Gillian Mckay

The views expressed in this article are those of the author(s). Publication in Gates Open Research does not imply endorsement by the Gates Foundation.

Introduction

The family planning (FP) community acknowledges that access to safe, high quality, voluntary family planning is a human right. However, the majority of girls and women, particularly in developing countries, continue to have limited and inequitable access to sexual and reproductive health rights, information, and services, including FP 1 . Although more than 500 million couples in developing countries use FP, the United Nations estimates that by 2030, nearly 200 million women seeking to delay or avoid having a birth will have an unmet need for modern contraception 2 . This demand will likely continue to grow as record numbers of young people enter the prime reproductive ages in the decades to come. It is thus essential that the family planning community identifies high impact approaches to address the major barriers and gaps affecting equitable access to quality family planning.

Since its inception in 2009, the International Conference on Family Planning (ICFP) has served as a strategic inflection point for the FP and reproductive health community worldwide. ICFP serves as an international forum for scientific and programmatic exchange that enables the sharing of available findings and the identification of knowledge gaps, in addition to facilitating the use of new knowledge to transform policy. At the London Summit in 2012, the global FP community set an aspirational goal to enable 120 million more women and girls to access voluntary quality FP by 2020, and the FP community broadened that goal to include universal access to reproductive health care and services by 2030 3 , 4 . The ICFP has been an important, collaborative effort in the buildup to establishing that goal, raising visibility, creating momentum around FP, and leading to concrete changes in policy and programs.

The 2018 ICFP, held in Kigali, Rwanda, was centered on the overarching theme, “Investing for a Lifetime of Returns”. This theme was chosen because of the essential role of FP for the realization of all 17 Sustainable Development Goals (SDGs) and spoke to the various returns that investments in FP provides — from better sexual and reproductive health outcomes and improvements in maternal and child health, to education and women’s empowerment, to long-term environmental benefits and socio-economic growth 5 . Over 700 oral presentations were featured at the conference and covered FP advocacy wins, services developments, and research. Oral presentations were grouped into the following conference tracks: 1) Returns on investment in family planning and the demographic dividend; 2) Policy, financing, and accountability; 3) Demand generation and social and behavior change; 4) Fertility intention and family planning; 5) Reproductive rights and gender empowerment; 6) Improving quality of care, 7) Expanding access to family planning; 8) Advances in contraceptive technology and contraceptive commodity security; 9) Integration of family planning into health and development programs; 10) Sexual and reproductive health and rights among youth and adolescents; 11) Men and family planning; 12) Family planning and reproductive health in humanitarian settings; 13) Faith and family planning; 14) Urbanization and reproductive health; 15) Advances in monitoring and evaluation methods. This paper summarizes the highlights of the scientific program and identifies key findings presented during the oral sessions in the fields of research, programming, and advocacy in order to inform future work in these fields.

The findings summarized in this paper are from 64 abstracts from individual and preformed panel submissions accepted for oral presentations at ICFP 2018. Each co-author of this paper reviewed abstracts from up to three conference tracks based on their expertise and provided summaries from these tracks, organized by emerging key themes. The final abstracts were selected for inclusion in this paper based on the novelty of the findings and contribution to the FP field. These summaries were incorporated to develop the final draft of the paper.

Lessons from ICFP 2018

Investing in family planning for a lifetime of returns.

Measuring the returns on investments in FP is crucial for continued funding and support for FP programs. The business cases for FP presented at ICFP demonstrated the ways in which cost-effective FP programming may save money in the short-term and long-term at the individual, community, donor, and national levels. Willcox and colleagues developed a model based on 47 county referral hospitals in Kenya, which demonstrated that for every dollar invested in training and equipment for implant removal services, a future return of USD $1.62 would be accrued from the economic benefits of continued implants uptake 6 . Costing data presented by Tumusiime and colleagues found that in Senegal and Uganda, the total costs—including direct medical costs (i.e. provider time, supplies, drugs), costs of self-injection training (based on a one-page instruction sheet scenario), and direct non-medical costs (i.e. client travel and time costs)—are significantly lower for the self-injection of depot medroxyprogesterone acetate administered subcutaneously (DMPA-SC) as opposed to provider-administered injectables 7 . In Nigeria, Adedeji and colleagues found that for every $1 invested in high-impact intervention-focused FP programs, an estimated $1.40 may be saved on maternal and newborn care, and another $4 could be saved on treating complications from unplanned pregnancies 8 . While self-administered DMPA-SC may provide a cost-effective approach to improving access to long-acting reversible contraceptive (LARC) methods, a study conducted in Rwanda identified LARCs to be more cost-effective than non-LARC methods post-partum, with a savings of $31.42 per pregnancy averted for two years following birth, and additional cost savings expected over longer time frames 9 .

FP may also be a catalyst for the demographic transition and an opportunity to realize the benefits of the demographic dividend. The demographic dividend describes the changes in the population age structure caused by reductions in population-level fertility and mortality rates. These structural population changes result in a large working-age population and a smaller number of youth dependents 10 . With the correct set of political, economic, educational, and employment policies and opportunities, countries characterized by this population age structure have the potential to take advantage of the large working age population to bolster socio-economic development and create generational wealth 11 . Furthermore, this demographic transition may help countries achieve SDG targets. Modeling has shown that FP investments can positively affect SDGs across several sectors including health, governance, economic growth, agriculture, and education 12 , 13 . Despite improvements in FP funding and financing, expanded financial investments in FP are still needed throughout much of sub-Saharan Africa in order to successfully reach the FP targets necessary for countries to reap their demographic dividend potential 14 , 15 .

Strategies to sustain FP advances include long-term financing for FP, particularly the transition from donor-dependent financing to locally owned initiatives. Donor funding to support FP continues to fall short of the amount needed to address the unmet need of family planning globally and the extent of this gap varies significantly across countries and regions 16 . To mitigate the impact of this shortage in donor funding, it is critical for countries to plan for shifts in financing options, including the procurement of finances for subsidized commodities. Locally owned community-based health insurance (CBHI) schemes, characterized by voluntarily pooled funds, may be a promising option in order to sustain FP financing 17 . Research on CBHI schemes from sub-Saharan Africa showed positive effects on healthcare utilization and FP uptake. In Ethiopia, Pathfinder International found that women who were enrolled in a CBHI scheme were 1.3 times more likely to practice modern FP than those who were not enrolled 18 . Since 2014, the Ethiopian government has slowly shifted away from donor-dependence and has launched and expanded the number of CBHI and social health insurance (SHI) programs in more than one-third of districts. Based on current projections, by 2025, the number of modern contraceptive users in Ethiopia will have doubled from 6 million to 12 million, and the private sector will account for 40% of them 19 .

Data gleaned from nationally representative datasets showed a similar global pattern in factors associated with FP utilization. Findings from the Ethiopia (2016), Kenya (2014), Nigeria (2013), and Philippines (2013) Demographic Health Surveys (DHS), as well as Indonesia’s 2015 Susenas survey, revealed trends in the number of insured women and the modern contraceptive prevalence rate (mCPR); specifically, the ratio of mCPR between insured versus uninsured individuals was greatest among women of the lowest socioeconomic status (SES) in the Philippines, Kenya, Indonesia, and Ethiopia 20 – 23 . Insurance coverage was shown to be directly associated with FP utilization. These findings signify the importance of comprehensive health insurance for FP access, particularly amongst marginalized groups 24 . Another important finding related to FP access and insurance showed how national health priorities supersede FP access. While FP is often included under universal health coverage (UHC) schemes, the inclusion of FP is often not operationalized or realized 25 . Data from 22 priority FP2020 countries showed that the challenges to comprehensive UHC include government prioritization of less cost-effective yet urgent curative services, instead of preventive care or primary services 26 .

Additionally, research on health financing highlighted opportunities for new financing models and insurance schemes. In Tanzania, the United Nations Fund for Population Activities (UNFPA) and DKT International implemented an innovative micro-insurance scheme for urban youth and adolescents, which demonstrated high uptake in just one year of initiation. This program, “iPlan”, required a nominal annual fee of $10, after which an individual received comprehensive sexual and reproductive health (SRH) services including contraceptive counseling and commodities for one year 27 . Similarly, researchers found that the Public-Private Partnership Health Posts model in Rwanda was a cost-effective and viable solution for individuals living more than 60 minutes away from health facilities 28 . The social franchising model created by the Family Health Guidance Association of Ethiopia (FGAE) was also shown to be a cost-effective model as compared to static clinics. When compared to the FGAE-owned static clinics, the cost per Couple Years of Protection (CYP), (an indicator used to estimate protection from pregnancy by family planning/contraceptive methods during a one-year period) 29 was significantly less expensive. CYP provided through the FGAE social franchise model was estimated to be between USD $0.73-$1.77, compared to USD $25.61-37.35 per CYP provided at the FGAE-owned static clinics 30 .

Addressing inequities in family planning for adolescents, youth, and key populations

Inequities in access to FP exist across women from different socio-economic groups, age cohorts, health statuses, and physical abilities. Compared to women of other reproductive ages, adolescent girls and young women (AGYW) have specific FP and sexual and reproductive health needs, including low contraceptive uptake, high risk of unintended pregnancies and unsafe abortions, high risk of sexually transmitted infections, and a greater risk of acquiring HIV 31 , 32 .

Involving youth in advocacy and programming efforts was shown to be critical in order to ensure that their unique FP needs are met. Reproductive Health Uganda developed an innovative program to support young people in realizing their right to hold state-actors accountable for improving access to youth-friendly health services. The initiative led to the successful allocation of county-level funds for youth-friendly services in all sectors and created a network of youth advocates for FP programming 33 . In Kenya, the Network for Adolescents and Youth of Africa developed a holistic advocacy network in Kisii County that led to the allocation of KES 7,000,000 (USD 68,000) to contraceptive procurement and FP services in the financial year 2016/2017, the first time a line item for FP was included in the county budget 34 .

FP programs for youth with hearing and speech impairments included a sexual health education program for adolescents in Vietnam and a social media literacy program integrating SRH and FP information exchange in Burkina Faso 35 , 36 . In Egypt, Love Matters Arabic Project was launched to engage young people on SRH issues, dispel myths and taboos, and improve access to accurate and reliable SRH and FP information 37 . Some researchers maintain that to attract youth and gain their trust, programming must include a pleasure component and tie this information to healthy sexual behaviors and practices 29 , 38 . This hypothesis needs further exploration in future research and programming.

Other key populations highlighted during the conference included youth living in conflict zones, people living with HIV, women with disabilities, female sex workers, people who use drugs, individuals with a low socioeconomic status, and individuals who do not identify as heterosexual 39 , 40 . A nationally-representative survey from Ethiopia found that more than 95% of women living with a mental, physical, or visual disability face obstacles in physically accessing health facilities and are less likely to have access to FP information 38 . Furthermore, this sub-population may be more likely to face discrimination by healthcare providers. These barriers to FP services and knowledge may have direct consequences on health outcomes. For example, among women with disabilities who have ever had a pregnancy, more than 85% reported that the pregnancies were unintended 41 .

Studies from conflict zones in Afghanistan, Cameroon, Liberia, Sierra Leone, and Yemen showed that girls who marry before the age of 18 have lower rates of FP use, less intention to use in the future, and a significantly higher risk of unintended pregnancy, compared to married women 18 years of age and older 42 . Among Somali refugee girls aged 10–19 and living in Ethiopia, nearly 75% of girls were aware of how to become pregnant, but fewer were aware of the risks associated with inadequate birth spacing. Despite nearly one in five girls having already given birth, 40% of participants remained unaware of methods to avoid pregnancy 43 .

People living with HIV may also have trouble accessing comprehensive FP services. A study from Uganda found that unmarried women with an HIV-positive status and women of high parity were significantly less likely to use FP post-partum 44 . Women who take antiretroviral therapy have desires to bear children, learn about contraception, and receive information on methods to prevent mother-to-child transmission of HIV 45 . To this end, it is important that programs recognize this population’s unique desires and needs. A program in London demonstrated the promise of service integration to improve access to FP for women living with HIV; Mabonga and colleagues found a 50% increase in LARC use after the integration of FP and HIV services in a postnatal contraception clinic in London 46 . Integrating HIV and FP services into one convenient location helps promote healthy SRH and child health outcomes, while also easing client burden associated with traveling between different clinics.

Reproductive justice: Abortion care, family planning, and women’s wellbeing

Unsafe abortions have emerged as one of the key neglected public health problems, accounting for more than 1 in 10 maternal-related deaths worldwide 47 . Accordingly, abstracts discussing safe abortion access and FP were cross-cutting through the conference’s tracks. Research on unsafe abortions underscored the determinants of abortion practices as well as inequities in the accessibility of safe abortion services. For example, in both Nigeria and Rwanda, younger, uneducated women in rural areas are more likely to seek out and use abortion services. However, due to restrictive abortion laws, these abortions are often unsafe, which poses not only health challenges but legal challenges as well 48 . In 2012, 24% of all incarcerated women in Rwanda were imprisoned for participating in clandestine, illegal abortions 49 . Access to safe abortion services is a critical component of comprehensive SRH yet continues to be heavily restricted in many parts of the world. Several authors called for targeted advocacy for legal provisions to ensure the availability of safe abortion services 50 , 51 . Amendments to national laws, increased and expanded training of providers, and improved access to medical abortions were highlighted as priorities for policymakers 24 , 52 . Furthermore, emphasis was placed on the recognition of social disparities and inequities in abortion prevalence and access 45 .

Analyses of post-abortion care (PAC) programs for women in humanitarian settings in DRC and Yemen found that providers may effectively shift from unsafe practices of dilation and curettage (D&C) to manual vacuum aspiration and medical treatment with misoprostol. Over a period of 5 years, the percentage of PAC clients requiring evacuation who received D&C as treatment was reduced from of 18.6% to 2.0% in DRC and from 25% to 2.8% in Yemen 53 .

Expanding access to safe abortion services can also directly increase women’s access to FP. Research from Kenya found that, regardless of pregnancy intentions, over 70% of women who attended PAC initiated contraceptives during their PAC visit 54 . Analyses of post-abortion family planning (PAFP) service delivery across two states in India also revealed that 28% of women adopted a contraceptive method within two months after their abortion 55 . Another study from Kenya found that women’s PAFP method varied based on the type of abortion the woman experienced. While women who had undergone surgical abortions were more likely to choose intrauterine devices or other LARC methods, women who had medical abortions were more likely to choose implants. While this may be due to the fact that IUDs can be inserted following a surgical abortion but not following a medical abortion, further research is necessary to ensure women receive the FP method that best suits their needs, preferences, and fertility desires 56 . Insights into context-specific ideals of family size as well as abortion care-seeking behaviors are important in understanding how to improve future PAFP service delivery and increase contraceptive use 51 .

Couple dynamics and family planning decision-making

Research on women’s covert use of FP underscored the ethical tensions between supporting and validating women’s ability to exercise reproductive autonomy without disclosure to a partner while also striving to engage male partners in reproductive health decisions 57 . Research revealed that a woman’s decision to covertly use FP may be linked to discordant partner views on childbearing and fertility desires 58 . One study found that when men expressed beliefs that contraception is “women’s business”, women were more likely to engage in covert use and not disclose their FP decisions to their partners 53 . However, women who use FP covertly often struggle with the cost of contraceptives and worry about concealing FP from their partners 53 . Power dynamics continue to influence FP use, even when women choose to use FP methods covertly.

Couple power dynamics and household decision-making also influences FP utilization. Easterlina and colleagues found that 75% of women in West Pokot, Kenya, identified their husband or partner as the biggest barrier to voluntary FP use 59 . In the Afar region of Ethiopia, 58.8% of women reported not having the freedom to make independent fertility decisions 60 . Conversely, researchers have found that the odds of using modern contraception increases significantly when couples make decisions together 61 . Couples who reported shared decision-making on everyday life choices (e.g. financial decisions) in Ibadan, Nigeria, were more likely to report using FP than couples in which decisions were made solely by the husband 62 . Other factors which have been found to influence FP uptake include the educational status of couple dyads, couple’s knowledge of reproductive health and rights, women’s economic security and involvement in microcredit schemes, and gender equitable household dynamics 63 , 64 .

Male involvement in family planning programming

Considering men’s influence on FP decisions, involving male partners in FP programming is essential to meeting FP goals globally. Males have a desire to learn about FP and contraception but often have limited or inaccurate information which fuels false beliefs and myths. In Uganda, when men were asked why they do not allow their wives to use modern FP methods, participants expressed fears that their wives were likely to become promiscuous if they began using contraception. The researchers also found that male participants’ beliefs about FP were often inaccurate, inconsistent, or grounded in gendered stereotypes, fueling fears about wives’ promiscuity 65 . Similarly, research from Kenya showed that 50% of men in Western Kenya lack accurate knowledge on the possible benefits of healthy timing and spacing of pregnancies 55 . In Nepal, men’s limited understanding of contraceptives were shown also to impact their partner’s uptake of IUDs 66 .

Research revealed the potential of male champions and advocacy networks in changing social norms, educating male peers, and creating a culture receptive and open to family planning discussions. In Uttar Pradesh, India, a community-based information diffusion strategy was used to dispel FP myths and misconceptions and provide comprehensive information on non-scalpel vasectomy. To accommodate the diverse lives of men living in informal settlements, men were engaged by their peers at traditional male gathering points at convenient times, such as evening meetings for rickshaw pullers 67 . In Zamboanga City, Philippines, a packaged community-based learning program, EL HOMBRE, used a peer-to-peer information dissemination technique to share information related to FP, family matters, and family planning 68 . Similarly, a male champions program was rolled out successfully in Western Kenya, where 50 male champions held sensitization forums once a month to encourage discussions on healthy timing and spacing of pregnancies 55 . In Benin, USAID/ANCRE implemented a “men as advocates” intervention that included counseling male spouses on FP when their partners left the maternity ward and creating groups of “committed men” to sensitize male peers. Over the course of a year, post-partum FP counseling for males increased by more than 100% across 47 health facilities 69 .

Couple-based approaches to behavioral change and FP uptake also show promise. Project Concern International implemented a social and behavioral change program that used couples as community change agents to address restrictive social norms and SRH myths, improve couple communication strategies, and aid couples in the development of their FP and fertility goals 70 . The Emanzi program in Uganda also showed a positive changes in equitable gender norms, a rise in shared decision-making in the household, and a significant increase in FP uptake 71 .

Gender-transformative programming is grounded in the notion that changes in gendered norms, beliefs, and behaviors lead to positive health outcomes. Landmark gender-transformative programs included the Bandebereho intervention in Rwanda, which consisted of 15-week group education meetings for more than 4,000 young adult men and women and 1,700 expectant and new fathers and couples. When compared to the control group, findings showed an increase in the proportion of young people who had sought SRH services, as well as changes in positive gender norms and increases in shared decision-making 72 . The GroupUp Smart education curriculum in Rwanda targeted prepubescent male and female adolescents and their parents. The program found that adolescent boys’ awareness of preventing pregnancy increased from 65% to 81% and their knowledge of reproductive health significantly increased. Compared to pre-intervention, adolescent boys experienced significant increases in gender equity scores, pointing to the notion that SRH education which includes a gender component may be more beneficial than SRH education alone, particularly when introduced earlier in life 73 .

Breakthroughs in novel contraceptives and systems improvement in family planning

Research advances in contraceptive technology highlighted the importance of beginning with the end-user in mind. In Nigeria and India, initial acceptability research of a microneedle contraceptive patch (MNP) explored client perceptions of the method and quantified desired MNP attributes. Across both contexts, prospective users liked the potential for self-application and both providers and clients found the method to be easily used. Researchers also wanted to identify user preferences for other attributes, including the method’s effect on menstruation, duration of effectiveness, placement location, pain, and the potential for skin reactions at the application site 74 . These findings underscored high overall acceptability of microneedles as a novel delivery method, yet also emphasized the importance of reducing side effects associated with existing contraceptive methods.

Use of the levonorgestrel intrauterine system (LNG-IUS) has risen rapidly in high-income countries and is one of the most effective forms of contraception available. However, the cost of the method is typically a barrier to clients in low-income countries. Research by Marie Stopes International Nigeria and FHI360 piloted the introduction of an affordable version of the LNG-IUS at multiple service delivery points and found that users, providers, and key opinion leaders were receptive and enthusiastic about the method. Many clients also reported reduced menstrual bleeding as a key non-contraceptive benefit of the method. This research also suggested that a multi-stakeholder approach, including coordinated demand-generation activities, may be important in order to advance the scale-up of LNG-IUS in Nigeria and in other similar contexts 75 .

Improved access to subdermal implants and other long-acting methods like IUDs have raised concerns on whether women can access timely removal services on-demand. Data from pilot studies examining the subdermal implant removal tool, RemovAid, suggested that this novel device is safe to proceed to larger studies, and with it, physicians can safely remove one-rod implants and minimize the removal time to just under seven minutes 76 . Furthermore, initial acceptability research revealed that a novel postpartum IUD inserter would be attractive in India due to high unmet need and a lack of trained providers 77 . These products would not require additional supplies, aside from what it’s packaged with, and demonstrated high client and provider satisfaction.

Novel approaches to service delivery and contraceptive commodity procurement included the development of an “informed push” model, which would change the public health sector’s reporting system to allow for consolidated transport routes and combined supply delivery. Rather than following a typical model where an individual health facility is responsible for FP commodity reporting, product requisition, and pick-up, this model relied on health “zone staff” to optimize transport routes and report on stockouts and product consumption. By consolidating FP commodities alongside other health products and optimizing transit routes, the study demonstrated a substantial reduction in the incidence of stockouts and a decline in transit costs 78 . In India, an application developed by the Ministry of Health and Family Welfare also seeks to collect consumption data, forecast demand, and track commodity distribution. While still in the formative stage, individual states have demonstrated an interest in customization of the app per state to allow the government to improve commodity distribution and transfers by tracking “live” data 79 .

Lastly, algorithm-based fertility apps, such as the Dynamic Optimal Timing application, demonstrated a typical-use failure rate that was comparable to or better than other user-initiated methods, including fertility-awareness based methods. This method delivered consistently correct information to women about their daily fertility status, which suggests that the app could allow women to self-manage fertile days to avoid pregnancy 80 .

The 2018 ICFP scientific program underscored new advances in family planning research, programs, and advocacy work, that have important practical and policy implications. Short- and long-term benefits of FP investments were highlighted, from increased empowerment at both the individual and couple levels to reduced maternal mortality and improved population health. Nevertheless, achieving these dividends as a result of FP investments continues to be thwarted by insufficient funding, limited contraceptive choices, and persistent inequality in accessing FP programs and services.

The growing reproductive-age population, particularly in developing countries, and the increasing demand for FP requires innovative financing initiatives to meet the demand and ensure resilient health systems. Community-based health insurance schemes and public-private partnerships between the Ministries of Health and local businesses are promising solutions to ensure that all girls and women with unmet need can access and utilize FP. Future research should focus on scaling cost-effective, self-administered technologies.

While progress is being made globally on improving access to contraceptive services, urgent actions are required to address the FP needs of specific subpopulations that lag behind. These populations include AGYW, female sex workers, women and girls with disabilities, women living with HIV, and populations living in conflict-afflicted regions as well as other humanitarian settings. Research focusing on such populations is becoming increasingly highlighted at ICFP but remains very limited compared to research and program efforts focused on other populations. Future research should explore the needs of such unique sub-populations and evaluate interventions and programs that may successfully be scaled to address the FP needs of these marginalized groups. Gender and social norms continue to play a key barrier in FP demand generation. Further research is needed to evaluate the effectiveness of gender transformative programs that aim to address gender norms that perpetuate social and health inequalities. Empowerment efforts need to continue to engage men as partners while considering women’s autonomy in FP decisions, and ensure that context-specific couple dynamics and social norms are integrated into programming.

Despite achievements and advances in FP access and utilization, the abortion space still lags behind. Unsafe abortions and abortion-related fatalities remain a neglected and preventable public health problem. Current and future advocacy efforts should focus on the legal provision of abortion care to ensure the availability of safe, decriminalized abortion services. Such efforts should be undertaken in parallel with expanded training for providers, while utilizing the opportunities to integrate FP methods in post-abortion care. To further understand PAC, future research is needed to determine what influences a woman’s decision to use contraceptives post-abortion and the specific method choice selected, and why.

Continued improvements in information systems have allowed for the rapid reporting of inventories, consolidated transport routes, and combined supply delivery. Such systems present an opportunity to address supply chain challenges and prevent stock-outs from the sub-national to the national levels. Artificial intelligence and algorithm-based applications present opportunities for FP information access through mobile user technologies. Allowing such systems to communicate with the supply chain may allow women to better access their contraceptive method of choice and allow couples to achieve their desired family size.

Implementation science research should also focus on understanding the key drivers that affect the uptake of research findings. This research can be used to inform evidence dissemination and utilization by policymakers and other decisionmakers at the local and national levels. FP is not only a social justice issue, but a smart investment for individuals and communities. Ensuring that local leaders and policymakers properly understand these two rationales for FP could be key to success for the global community and may lead to more prosperous and resilient communities. Over the last few years, the concept of the demographic dividend has provided a broader ground for advocates to support FP efforts. The economic theory of the demographic dividend tends to resonate well with policymakers and peoples from various religious backgrounds, including religious leaders. Nevertheless, challenges remain for the human-rights rationale to be as widely accepted as the economic theory.

ICFP 2018 generated rich evidence on successes achieved in recent years and highlighted continued gaps in research, implementation and advocacy. Science and practice lessons demonstrated the need for a multi-sectoral, interdisciplinary approach among FP stakeholders in order to inform new actions to attain the 2030 universal access goal. The universal access goal presents an opportunity for the world to close the gap in FP inequities between individuals of different socioeconomic backgrounds and attain shared prosperity across communities. Investing in FP paves the path for generational wealth and a range of health returns. Addressing FP advocacy, services, and research challenges and continuously sharing lessons learned and best practices through platforms such as ICFP will be essential for countries to accelerate progress towards the universal access goal and ultimately, meet the needs of all women and girls.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

• 1.   Boerma T, Requejo J, Victora CG, et al. : Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Lancet. 2018; 391 (10129): 1538–1548. PubMed Abstract | Publisher Full Text
• 2.   United Nations, Department of Economic and Social Affairs, Population Division: World Family Planning 2017 - Highlights (ST/ESA/SER.A/414). 2017. Reference Source
• 3.   Brown W, Druce N, Bunting J, et al. : Developing the “120 by 20” goal for the Global FP2020 Initiative. Stud Fam Plann. 2014; 45 (1): 73–84. PubMed Abstract | Publisher Full Text
• 4.   UN (United Nations): Transforming our world: The 2030 Agenda for Sustainable Development. Accessed 19 August 2020. 2015. Reference Source
• 5.   Starbird E, Norton M, Marcus R: Investing in family planning: key to achieving the sustainable development goals. Glob Health Sci Pract. 2016; 4 (2): 191–210. PubMed Abstract | Publisher Full Text | Free Full Text
• 6.   Willcox M, Kariuki E, Nyaga FK: System dynamics modeling of quality care for implant removal services: a cost-benefit analysis of investments in health workforce competence and equipment availability. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 7.   Tumusiime J, Ba M, Morozoff C, et al. : What is the price of innovation? Costs and cost-effectiveness of self-administered DMPA-SC (Sayana Press) compared to health worker-administered DMPA-IM in Uganda and Senegal. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 8.   Adedeji O, Keita D, Afolabi K, et al. : Business Case for Investing in FP in Nigeria 2018 to 2020 – Cost benefit analysis. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 9.   Williams P, Tummala A, Morales K, et al. : Is post-partum FP uptake for married women of reproductive age (12-49 years) in Rwanda cost effective for a lifetime horizon from a health system perspective? Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 10.   Bloom D, Canning D, Sevilla J: The demographic dividend: A new perspective on the economic consequences of population change. Rand Corporation. 2003. Publisher Full Text
• 11.   Lee, R, Mason A: Reform and support systems for the elderly in developing countries: capturing the second demographic dividend. Genus. 2006; 62 (2): 11–35. Reference Source
• 12.   Ntibanyurwa A, Habarugira V, Alemu D, et al. : Unlocking Youth Potential to Harness the Demographic Dividend (DD): Evidence from National Demographic Dividend profile in Rwanda. Paper presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 13.   Sacher S, Jurczynska K, Moreland S, et al. : To what extent can FP boost achievement of the Sustainable Development Goals? Introducing the FP-SDGs Model and regional results. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 14.   Ndizeye S, Placid M, Tagoola F, et al. : The Investment Case for FP in Uganda. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 15.   Thompson L: Fertility, Population Growth and the Economic Impacts of Child Marriage. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 16.   Grollman C, Cavallaro FL, Duclos D, et al. : Donor funding for family planning: levels and trends between 2003 and 2013. Health Policy Plan. 2018; 33 (4): 574–582. PubMed Abstract | Publisher Full Text | Free Full Text
• 17.   Ekman B: Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan. 2004; 19 (5): 249–270. PubMed Abstract | Publisher Full Text
• 18.   Kassie G: The effect of community-based health insurance on modern FP utilization in Ethiopia. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 19.   Fagan T, Prabhakaran S, Dutta A: Beyond FP2020 Commitments: How Can Ethiopia Mobilize Domestic Resources to Scale-Up and Sustain Access to FP Services as Part of its Efforts to Achieve Universal Health Coverage? Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 20.   Central Statistical Agency/CSA/Ethiopia and ICF: Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF. 2016. Reference Source
• 21.   Kenya National Bureau of Statistics, Ministry of Health/Kenya, National AIDS Control Council/Kenya, Kenya Medical Research Institute, National Council for Population and Development/Kenya, and ICF International: Kenya Demographic and Health Survey 2014. Rockville, MD, USA: Kenya National Bureau of Statistics, Ministry of Health/Kenya, National AIDS Control Council/Kenya, Kenya Medical Research Institute, National Council for Population and Development/Kenya, and ICF International. 2015. Reference Source
• 22.   National Population Commission - NPC/Nigeria and ICF International: Nigeria Demographic and Health Survey 2013. Abuja, Nigeria: NPC/Nigeria and ICF International. 2014. Reference Source
• 23.   Philippine Statistics Authority - PSA and ICF International: Philippines National Demographic and Health Survey 2013. Manila, Philippines: PSA and ICF International. 2014. Reference Source
• 24.   Ross R, Fagan T, Dutta A: Is Health Insurance Associated with Improved FP Access? A Review of Household Survey Data from Seven FP2020 Countries. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 25.   Coolen A, Boddamn-Whetham L: Financing for equity and choice: finessing FP inclusion in Ghana’s National Health Insurance. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 26.   Holtz J: Family Planning and Universal Health Coverage: Together or Apart? Paper presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 27.   Kabba-Kebbay J, Richard Nkanda E: An Innovative “Health Insurance Plan” to Reach University Students with SRH services through social marketing. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 28.   Eagan A, Gashumba D, Gahungu Z, et al. : Expanding access to FP services in Rwanda through public and public-private partnership health posts. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 29.   Darroch JE, Singh S: Estimating unintended pregnancies averted from couple-years of protection (CYP). New York: Guttmacher Institute, 2011; 1 (10). Reference Source
• 30.   Haile GM, Girma EM, Riro SM: FP Through Franchised Private Clinics: The Case of Family Guidance Association of Ethiopia. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 31.   Na W: Attitude towards LARC among 15-19 year olds adolescents who were seeking induced abortion in China. Abstract presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 32.   Adeniyi F, Francis E, Femi A, et al. : What dictates the timing of first use of modern contraceptives? Survival Analysis of Time to Uptake of Modern Contraceptives among Never-Married Women in Nigeria, Mozambique, and Cote d’Ivoire. Abstract presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 33.   Mugenyi S, Wasswa H, Tayebwa E: Nothing About Us, Without Us: Expanding Access to FP/SRH Services Through Youth-Led Social Accountability. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 34.   Oliech I: Harnessing effective partnership for advocacy: A case of FP Advocacy in Kisii County. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 35.   Bedoui R: Disability inclusive comprehensive sexuality education for Vietnamese adolescents of Quang Tri Province. Abstract presented at: 5th International Conference on Family Planning (ICFP); November 12-15; Kigali, Rwanda. ICFP Program. Reference Source
• 36.   Tao O: Tribune santé ados et jeunes : une plateforme pour renforcer l’accès des jeunes aux informations et services grâce aux réseaux sociaux. Abstract presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 37.   Ramy M: Love Matters Arabic innovative youth-oriented sexual education toolkit. Abstract presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 38.   van Clief L: How Pleasure drives traffic and trust of youth online at Love Matters. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 39.   Petraglia J, Abdoulaye O, Aliou S, et al. : Innovations in behavior change for adolescents and youth in Niger. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 40.   Levy-Braide B, Ijaiya M, Fajola A, et al. : Uptake of FP Methods Amongst Women Living with HIV in Obio Cottage Hospital, in Rivers State, Nigeria. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 41.   Atnafu S: FP services utilization and its associated factors among women with disabilities. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 42.   Singh R: FP and Unintended Births of Child Brides in Conflict Zones. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 43.   Karp C, Schlecht J, Myers A, et al. : Reproductive health and service knowledge of adolescent refugees and internally displaced persons (IDPs) in Ethiopia, Lebanon, and Myanmar. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 44.   Nakalema S, Nabaggala MS, Lamorde M, et al. : Predictors of FP use among HIV positive post-partum women attending an urban HIV clinic. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 45.   Kahabuka C, Mbita G, Winani K, et al. : What are the FP and safer conception needs of HIV-positive female sex workers in Dar es Salaam? Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 46.   Mabonga E, Taylor C, Brum R, et al. : Does the introduction of a dedicated postnatal contraception clinic improve reproductive choices for HIV positive women? Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 47.   Gebremedhin M, Semahegn A, Usmael T, et al. : Unsafe abortion and associated factors among reproductive aged women in Sub-Saharan Africa: a protocol for a systematic review and meta-analysis. Syst Rev. 2018; 7 (1): 130. PubMed Abstract | Publisher Full Text | Free Full Text
• 48.   Bell S, Omoluabi E, OlaOlorun F, et al. : Abortion Incidence and Safety in Nigeria: Findings from a Population-Based Survey. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 49.   Shipow A, Kagaba A, Mugeni N, et al. : Understanding the Causes, Practices, and Consequences of Terminating Pregnancies: Experiences of Women Incarcerated for Illegal Abortion in Rwanda. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 50.   Manning V,Gandhi M: From policy to action: expanding health worker roles for comprehensive abortion care in India. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 51.   Singh S: Incidence of abortion and unintended pregnancy in six Indian states: An overview of findings. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 52.   Tank J: Role of professional bodies in strengthening women’s access to CAC services. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 53.   Casey S,Gallagher M: Increasing use of manual vacuum aspiration and misoprostol in in humanitarian settings. Paper presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 54.   Loi UR, Klingberg-Allvin M, Faxelid E, et al. : Pregnancy intention and post abortion contraceptive uptake: a cohort study in Kisumu, Kenya. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 55.   Fancis Zavier AJ, Santhya KG, Khan N: Post-abortion contraceptive intentions and use among married young women in Rajasthan and Uttar Pradesh, India. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program Reference Source
• 56.   Rank C, Gardezi L, Adalla D, et al. :Using client information systems to examine post-abortion FP uptake: Insights from Marie Stopes centres in Kenya. Paper presented at:5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 57.   Biswabandita C: Concordant and Discordant report of Contraceptive Use by couples and its Association with Marital Relations and Men’s attitude: Evidence from India, NFHS 2015-16. Paper presented at:5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 58.   Wood SN, Moreau C, Karp C, et al. : Covert use of FP among sub-Saharan African women – reasons, challenges and consequences. Paper presented at:5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 59.   Moseti E, Kiprop C: From Barriers to Champions: Men take lead in Advocating for Healthy Timing and Spacing of Pregnancy and FP in West Pokot County Kenya. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 60.   Gudu W, Bekele D, Awcash FS, et al. : The role of partners on fertility decision and utilization of contraceptives among women in four emerging regions of Ethiopia. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 61.   Do M, Hutchinson P: Attitudes, perceived norms and behaviors in FP discussions with partner, and associations with contraceptive use among young people in Nigeria. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 62.   Neetu J: The role of spousal participation in household decision-making on contraceptive use among young couples in Ibadan, Nigeria. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 63.   Otupiri E, Apenkwa J, Ansong JK, et al. : Women empowerment and contraceptive use in peri-urban Kumasi, Ghana. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 64.   Lemma K: Factors influencing married women’s decision-making power on reproductive health and rights in Mettu rural district, South-West Ethiopia. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 65.   Hardee K, Ahaibwe G, Depio S, et al. : Men’s Views of FP and their Access to Services in Uganda. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 66.   Sapkota S, Bhatt D, Lama R, et al. : ‘I don’t decide alone’: Understanding Decision-Making Pathways to IUCD Uptake Among Married Men and Women in Nepal. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 67.   Srivastava S, Behera S, Sharma V: Increasing Male Participation in FP in Uttar Pradesh, India. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 68.   Villano J: Experiential Learning Health Obligation of Men in the Barangay and Role in Women’s Empowerment (EL HOMBRE). Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 69.   Dunia G: Effective male engagement to increase FP uptake in Benin. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 70.   Galvin L, et al. : A Community Couples Approach To FP Programming in Bihar, India: A Case Study of Couple-to-Couple Engagement for Improved FP Practices. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 71.   Wynne L, Mubiru F, Kirunda R, et al. : Emanzi – a proven affective male engagement intervention designed for scale-up. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 72.   Rutayisire F: Bandebereho: A gender-transformative comprehensive intervention to promote sexual and reproductive health, reduce violence, and promote equality among young people and new and expectant parents. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 73.   Mukabatsinda M: Boys need to know this too: Improving puberty awareness and gender equality among very young adolescents in Rwanda. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 74.   Brunie A, Callahan R, OlaOlorun F, et al. : What do women want? A mixed-method study on potential user preferences for a contraceptive microneedle patch in India and Nigeria. Paper presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 75.   Eva G, Nanda G, Rademacher K, et al. : Assessing Provision of the Levonorgestrel Intrauterine System in Nigeria. Paper presented at: 5th International Conference on Family Planning (ICFP); November 12-15; Kigali, Rwanda. ICFP Program. Reference Source
• 76.   Bratlie M, Iwarsson KE, Gemzell-Danielsson K, et al. : Hand-held device for removing a one-rod, subdermal contraceptive implant: results of a pilot study and future work. Paper presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 77.   Singh S: How to take innovation from conceptual idea to practice in the public health field- Emerging learning from India while introducing “Innovation Postpartum IUD ( PPIUD ) Inserter”. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 78.   Roijmans F, Yalaza M, Salumu F, et al. : Informed Push Model: a distribution model of FP commodities and medicines for low resource settings. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 79.   Khan NA, Sikdar SK: FP LMIS: Institutionalizing decision making, ensuring and strengthening commodity security and protecting client’s rights. Paper presented at: 5th International Conference on FP (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source
• 80.   Jennings V, Shattuck D, Haile L: Expanding contraceptive choice with the Dot app: A proven, effective method for pregnancy prevention. Paper presented at: 5th International Conference on Family Planning (ICFP); November 12–15; Kigali, Rwanda. ICFP Program. Reference Source

Comments on this article Comments (0)

Open Peer Review

• It was not clear to me how many panels there were at the conference. Were the 65 individual and preformed abstracts the sum total of the 700+ oral presentations made? If this was a sub-section, how were these abstracts chosen for inclusion?
• How did the process of thematic grouping of the 15 tracks into 6 themes take place?   
• Include a line in the abstract around the methods.
• Quite technical language is used from time to time, which may be inaccessible to those outside of the FP space. e.g. Community Based Health Insurance & Couple Years of Protection: these terms could be better explained in the text or in a footnote.
• There are too many acronyms, many of which are only used once, therefore could likely be removed to make the paper easier to read.
• Some light copy-editing is needed for grammatical errors.

Is the rationale for the Open Letter provided in sufficient detail?

Does the article adequately reference differing views and opinions?

Are all factual statements correct, and are statements and arguments made adequately supported by citations?

Is the Open Letter written in accessible language?

Where applicable, are recommendations and next steps explained clearly for others to follow?

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Reproductive health in humanitarian crises, with a focus on outbreaks of infectious disease.

• At ICFP 2018, there were 700+ oral presentations presented, submitted as both individual and performed abstracts. Each abstract is counted as one oral presentation. All abstracts were reviewed for the novelty of their findings and 64 abstracts were selected for the final paper. We clarified this in the Introduction and Abstract.
• The thematic groupings were based on key findings from the selected abstracts and major thematic areas highlighted in these findings. The 15 tracks were from the abstract submissions and guided the review process, but for the purposes of this paper, new thematic areas were defined based on the main findings from the abstracts.
• The abstract has been revised and this comment has been addressed.
• Thank you for your comment. We have addressed this by explaining CYP and CBHI directly in the text of the paper.
• We agree with this comment and have removed all acronyms that only occur once in the paper. We have kept acronyms that are used more than once.
• We have made editorial copy editing to remove grammatical errors.
• Respond or Comment
• COMMENT ON THIS REPORT
• With regard to the abstract, a line on
• With regard to the abstract, a line on the open letter objective and methods would help transition between the introduction paragraph and the second one.
• It would be helpful to learn more about why the theme of “Investing for a lifetime of returns” was chosen, taking into account the tensions between the macro level (e.g. economic and environmental) and individual level (e.g. empowerment, rights, and justice, which are just touched upon).
• The second para under “Investing in family planning” feels incomplete without acknowledging that access to quality education and employment opportunities is critical to realize the benefits of the demographic dividend.
• Consider stressing how the conference has embraced and contributed to highlighting the development and humanitarian nexus - as well as safe abortion!  
• The frequent use of abbreviations might impede the text flow.  
• Slight text editing required (grammar).  
• Check references: 2 and 4: UN DESA vs "DESA/Desa, UN". 2: more recent source available? Duplicates 44 & 45?

Reviewer Expertise: Global health with a focus on sexual and reproductive health and rights, including contraception and postpartum family planning, in development and humanitarian settings

• The abstract has been revised and multiple section breaks have been added to make reading the abstract easier.
• We have made changes in the paper to address this comment: this theme was chosen because of the essential role of FP to achieving the 17 Sustainable Development Goals and spoke to the various returns that investments in FP provide — from reproductive health outcomes, to maternal and child health improvements, to empowerment, increases in education, and population-level socioeconomic growth.
• This was addressed in the new iteration of the paper.
•  This was addressed in the new iteration of the paper.
• We have removed all acronyms that only occur once in the paper. We have kept acronyms that are used more than one time.  
• Editorial copy editing was provided to remove grammatical errors and improve the flow of the paper.  
• This has been addressed in the new iteration of the paper.
• It would be useful to take a further step back from the analysis of content to raise the larger debates on framing family planning that can often be in conflict among stakeholders with different objectives and agendas for action (government, donor, advocates): e.g., Demographic Dividend framing with fertility reduction a focus and macro-level benefits emphasized versus a human rights-oriented framing, where individual well-being and attention to inequities and reproductive justice are a central focus. On page 8 this situation is raised but not discussed (“FP is not only a social justice issue, but a smart investment for individuals  and communities.”)   
• On a related note, could the authors speak to what motivated the thematic framing of the 2018 conference to be “Investing for a Lifetime of Returns”?   
• At least a nod to job growth and productivity-related policy supports is needed around the demographic dividend explanation (“The demographic transition leads to numerous, subsequent population-level and societal benefits…”). The fertility reductions and age structure shifts are necessary but not sufficient. Education and health investments are required as well as the ability of the economy to productively employ workers.   
• Abstract: State the evidence and method in one sentence on which the theme-based key points are based (i.e., content analysis of conference abstracts). Also, the general phrase “locally owned models provide alternative financing solutions” is not clear for a general reader, perhaps add an example (such as….)   
• The abstract has a heavy focus on research alone (“ICFP 2018 highlighted research advances, implementation science wins, and critical knowledge gaps in global FP access and use.”) and yet a substantial part of the program was devoted to utilization (advocacy, policy and program shifts).   
• (page 6) Clarify if the contrast group is individual decision-making? (“…have been found to be significantly associated with couple’s FP decision-making 60,61 ”)   
• Explicit attention by the authors (and the conference) to safe abortion is merited as it is a topic and essential intervention often ignored or sidelined in the scientific literature. A helpful contribution of the conference. 
• Where possible, minimize the use of acronyms for readability (e.g., AGYW).   
• Reference 2 is not correct. The statement is about the number of couples in 2030 with unmet need for modern methods (and the 2020 revision is available now for all women, not just married women -- https://www.un.org/en/development/desa/population/theme/family-planning/cp_model.asp ), but the reference is a much older publication on population estimates (DESA, UN. United Nations Department of Economic and Social Affairs/Population Division: World Population Prospects: The 2008 Revision. 2009b.)   
• (page 6) Given the restricted space of an open letter and the number of studies covered, suggest not highlighting the same local study twice (Easterlina and colleagues).   
• Reference 4 is an official UN publication - the SDGs - and not from the Dept of Social and Economics Affairs (DESA).   
• References 44 and 45 are duplicates.   
• Light copy-editing needed (e.g., in abstract “Promising evidence show that…”, “couple discordance…directly influence…”; elsewhere “95% of women living with a mental…faces…).

Reviewer Expertise: Demographic research focused on contraceptive use, abortion, reproductive decisionmaking and adolescent sexual and reproductive health.

• This was addressed in the new version of the paper.
• Thank you for this comment. We have made changes in the paper to address this comment: this theme was chosen because of the essential role of FP to achieving the 17 Sustainable Development Goals and spoke to the various returns that investments in FP provide — from reproductive health outcomes to maternal and child health improvements, to empowerment, increases in education, and population-level socioeconomic growth .
• We have revised this section and incorporated information on the investments and political environment necessary to harness the DD.  
• We have provided more details to clarify in the Abstract the process of selecting the final themes for the paper.  
• The abstract has been revised considerably and we have attempted to address this comment.  
•             We checked this abstract and changed the wording to provide clarifications.         
• This has been addressed in the new iteration of the paper. Correct citation: United Nations, Department of Economic and Social Affairs, Population Division (2017). World Family Planning 2017 - Highlights (ST/ESA/SER.A/414).
• The Easterlina et al. paper was used to augment data on male partners’ lack of education and misinformation related to FP. We have kept the citation but revised the Male Involvement in FP Programming section and provided copyediting to make the section more succinct.  
• This has been addressed in the new iteration of the paper. Correct citation 4. UN (United Nations). 2015. Transforming our world: The 2030 Agenda for Sustainable Development. https://sustainabledevelopment.un.org/post2015/transformingourworld. Accessed 19 August 2020.
• This has been addressed in the new iteration of the paper.  
• Editorial copy editing was provided to remove grammatical errors and improve the flow of the paper.

Reviewer Status

Alongside their report, reviewers assign a status to the article:

Reviewer Reports

• Ann Biddlecom , Guttmacher Institute, New York City, USA
• Nguyen Toan Tran , University of Technology Sydney, Sydney, Australia; University of Geneva, Geneva, Switzerland
• Gillian Mckay , London School of Hygiene and Tropical Medicine, London, UK

Comments on this article

All Comments (0)

Competing Interests Policy

Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:

• Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper.
• You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors.
• You are a close professional associate of any of the authors (e.g. scientific mentor, recent student).
• You work at the same institute as any of the authors.
• You hope/expect to benefit (e.g. favour or employment) as a result of your submission.
• You are an Editor for the journal in which the article is published.
• You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements.
• You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors.
• You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on.

Stay Updated

Sign up for content alerts and receive a weekly or monthly email with all newly published articles

Register with Gates Open Research

Already registered? Sign in

Not now, thanks

Are you a Gates-funded researcher?

If you are a previous or current Gates grant holder, sign up for information about developments, publishing and publications from Gates Open Research.

We'll keep you updated on any major new updates to Gates Open Research

The email address should be the one you originally registered with F1000.

You registered with F1000 via Google, so we cannot reset your password.

To sign in, please click here .

If you still need help with your Google account password, please click here .

You registered with F1000 via Facebook, so we cannot reset your password.

If you still need help with your Facebook account password, please click here .

If your email address is registered with us, we will email you instructions to reset your password.

If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance.

• Research article
• Open access
• Published: 09 October 2021

Understanding family planning decision-making: perspectives of providers and community stakeholders from Istanbul, Turkey

• Duygu Karadon   ORCID: orcid.org/0000-0003-1086-8607 1 ,
• Yilmaz Esmer 1 ,
• Bahar Ayca Okcuoglu 1 ,
• Sebahat Kurutas 1 ,
• Simay Sevval Baykal 1 ,
• Sarah Huber-Krum 2 ,
• David Canning 2 &
• Iqbal Shah 2  

BMC Women's Health volume  21 , Article number:  357 ( 2021 ) Cite this article

9250 Accesses

4 Citations

Metrics details

A number of factors may determine family planning decisions; however, some may be dependent on the social and cultural context. To understand these factors, we conducted a qualitative study with family planning providers and community stakeholders in a diverse, low-income neighborhood of Istanbul, Turkey.

We used purposeful sampling to recruit 16 respondents (eight family planning service providers and eight community stakeholders) based on their potential role and influence on matters related to sexual and reproductive health issues. Interviews were audio-recorded with participants' permission and subsequently transcribed in Turkish and translated into English for analysis. We applied a multi-stage analytical strategy, following the principles of the constant comparative method to develop a codebook and identify key themes.

Results indicate that family planning decision-making—that is, decision on whether or not to avoid a pregnancy—is largely considered a women’s issue although men do not actively object to family planning or play a passive role in actual use of methods. Many respondents indicated that women generally prefer to use family planning methods that do not have side-effects and are convenient to use. Although women trust healthcare providers and the information that they receive from them, they prefer to obtain contraceptive advice from friends and family members. Additionally, attitude of men toward childbearing, fertility desires, characteristics of providers, and religious beliefs of the couple exert considerable influence on family planning decisions.

Conclusions

Numerous factors influence family planning decision-making in Turkey. Women have a strong preference for traditional methods compared to modern contraceptives. Additionally, religious factors play a leading role in the choice of the particular method, such as withdrawal. Besides, there is a lack of men’s involvement in family planning decision-making. Public health interventions should focus on incorporating men into their efforts and understanding how providers can better provide information to women about contraception.

Peer Review reports

There is considerable literature on the decision-making process related to fertility, and various factors have been proposed as predictors of family planning decision-making. Women’s characteristics, such as age, parity, level of education, level of income, occupation, and work status are the most frequently cited factors [ 1 , 2 ]. Additionally, previous studies have analyzed diverse factors that influence family planning decision-making within the family, such as power relations [ 3 ] and dominance of male partners [ 2 , 4 ]. Various studies in Turkey have found that many men are motivated to use family planning and would like to share responsibility for family planning decision-making (to use or not use any family planning method) [ 5 , 6 ]. However, there is also a tendency to view family planning as “woman's domain,” which refers to deciding whether to avoid pregnancy or not [ 7 ].

We would like to emphasize that cultural values also play an important role in impacting the use of family planning. Among these cultural factors, perhaps religious values top our list. Previous studies have also included ethnicity, male preference, traditional family values as well as the economic value of children as potential causal factors in determining family planning decisions. The present study aims at identifying significant contextual factors that are likely to influence use of family planning such as socio-cultural and religious norms.

In the 1960s, Turkey adopted a national family planning policy that advocated the use of both traditional and modern contraceptive methods (i.e., sterilization, intrauterine devices (IUDs), implants, injectables, pills, condoms, emergency contraception, lactational amenorrhea (LAM), and standard days method), and expanded access to contraception through health clinics. According to the 2018 Turkey Demographic and Health Survey, women are very knowledgeable about contraception: 97% of all Turkish women know at least one method of contraception [ 8 ]. Further, almost half of married women use a modern contraceptive method [ 8 ]. The most commonly used modern methods are male condoms (19%), IUDs (14%), and female sterilization (10%) [ 8 ]. However, while the use of modern contraceptives increased steadily in the 1980s and 1990s, the prevalence rate has stagnated since the 2000s. Further, a sizable proportion of women continue to rely on traditional methods of family planning, such as withdrawal [ 8 ].

The dominant (almost exclusive) religion in Turkey is Islam. The government, which has been in power since 2002, actively promotes policies that encourage high fertility and discourage contraception and abortion. The Turkish Ministry of Health is responsible for designing and implementing health policies and overseeing all private and public healthcare services in the country. All residents of Turkey who are registered with the Sosyal Güvenlik Kurumu (SGK) Footnote 1 can receive free medical treatment in hospitals contracted by the agency. The services are provided by government hospitals, Aile Sağlığı Merkezi (ASM), Footnote 2 Ana Çocuk Sağlığı ve Aile Planlama Merkezi (AÇSAP), Footnote 3 maternity, and children’s hospitals, training and research hospitals, university hospitals, private hospitals, and private polyclinics. Family planning and abortion services are provided both in public, and private sectors, and modern methods may be accessed for free in government-funded primary health care units and hospitals or from pharmacies and private practitioners for a fee [ 9 ]. In general, most women and couples obtain modern contraception from public sector sources, and pharmacies are the leading source of oral contraceptives and male condoms [ 8 ]. Women and men can also purchase emergency contraception, hormonal and copper IUDs, three-month contraceptive injections (Depo-Provera), and one-month contraceptive injections (Mesigyna) from pharmacies. IUDs cannot be inserted at pharmacies but are taken to health facilities to be inserted. Male condoms can also be purchased from markets and beauty shops.

The Turkish national curriculum does not provide sex education and the subject is rarely discussed in schools [ 10 ]. Since there is no formal education on reproductive health, most people are informed about family planning though friends, relatives as well as printed or social media. Basic information, education, and communication materials about contraception are provided by health facilities.

This study aims to delineate the factors that influence family planning decision-making processes from the perspectives of community stakeholders such as prayer group leaders, parent-teacher association members, and family planning service providers. We attempt to understand and explain these factors within the context of social and political tensions in Turkey most important of which are ethnic and secular-religious cleavages.

Study procedures

We used purposive sampling [ 11 , 12 ] to interview eight family planning service providers and eight community stakeholders in Bagcilar, Istanbul. Our sample includes fifteen females and one male participant. We determined the number of interviews based on the principles of theoretical saturation (i.e., the criterion for judging when to terminate interviewing at the point when no new information was being generated [ 13 ].

Bagcilar is one of the largest districts in Turkey with a population of 745,125 in 2019 [ 14 ]. We sampled key informants from different professional backgrounds, with different social status within their respective communities, and based on their role in influencing reproductive health. This enabled us to understand broader community and provider perspectives about women’s health concerns. In-depth interviews were conducted between April and May 2019.

We partnered with a local research firm that had extensive experience in conducting qualitative studies in the area. The research firm and research team generated a list of potential community stakeholders (such as members of local government, religious leaders, women’s groups, and community groups) and the research team made visits to the study area to organize the interviews. We identified service providers from public and private hospitals that offered family planning services in the study area, from a health facility assessment that we conducted less than six months prior. To map the availability of and access to family planning and abortion services, we conducted a facility survey in public and private facilitates that provided reproductive health services in the study area. The facility survey captured data on service availability and facility readiness (including staffing, hours of operation, and payment of user fees), services provided (including counseling, physical examination and contraceptive, and abortion methods), and commodity supplies. These were supplemented with in-depth interviews with key informants. The research firm used separate standardized scripts to recruit family planning providers and community stakeholders. The recruitment script included details about the study, its aim, and contact information for the principal investigators. The research firm scheduled a time for interview with providers and community stakeholders who were willing to participate in the study.

All respondents spoke Turkish and interviews were conducted by a trained Turkish female interviewer who was employed by the research firm. The interviewer had a university degree and was employed as a fieldwork director by the local research firm at the time of the interview. After a refresher training session about principles and techniques of qualitative research, ethics and confidentiality, and role-playing exercises with a supervisor, the interviewer piloted two different semi-structured interview guides (see selected questions in Table 1 ) (one interview with a family planning service provider and one interview with a community stakeholder). The interview guides were developed for this study in English and translated into Turkish (see Additional files 1 and 2 ). A randomly selected sample (approximately 5%) of the transcripts were back-translated and reviewed by the research team to ensure that translations were consistent and of high quality. The service provider interview guide included several topics related to accessing family planning, factors influencing decision to use contraception, and barriers to and facilitators of family planning use in the community. The community stakeholder interviewer guide captured information on socio-cultural beliefs influencing community preferences and attitudes regarding family planning. Topics were related to the availability and accessibility of contraceptives, the demand for contraception and abortion services, the influence of attitudes and beliefs on contraception and abortion accessibility, decision-making, and behavior of women regarding gender norms and decision-making between couples. The Turkish version of the interview guide was amended based on questions and feedback obtained during training and pilot test.

All participants received written information about the study and provided oral consent to participate. We did not collect any identifying information from participants. Face-to-face interviews were conducted in a private space (i.e., private rooms at the facilities for family planning service providers and community stakeholders’ homes), and audio recorded with permission from the participants. The interviewer took field notes during the interview. On average, interviews lasted approximately one hour. After interviews were completed, the research team transcribed each interview in Turkish and then translated it into English for coding and analysis. Transcripts were double-coded by the research team to ensure accuracy. We did not share transcripts with participants. Before data collection we received ethical approval from the Boards of Harvard School of Public Health and Bahcesehir University.

We used ATLAS.ti (Version 8.0, Scientific Software Development, Berlin) to manage and analyze the data. We further used an inductive, thematic analytical approach, guided by the principles of the constant comparative method to identify key themes arising from the data [ 12 ]. First, four researchers reviewed eight transcripts and developed an initial list of codes and general themes (see Additional file 3 ). Specifically, we used in vivo coding in ATLAS.ti to code participants’ spoken words and used their own words as codes. For example, one participant commented, “ One of my clients said that she would not use birth control pills because it was a sin.” The final title of the code became “sin” and similar statements referring to abortion as a sin were grouped together to create the theme. Next, four members of the study team read two transcripts aloud together and open-coded all text, in line with the principles of open coding and an inductive approach [ 12 ]. We reviewed all codes together (more than 200 codes), merging similar codes and grouping codes into themes and sub-themes. Next, once all major themes and sub-themes were agreed upon, we generated a final codebook, which included 51 sub-codes in six main coding groups, including demographics, family planning, abortion, socially-oriented perspectives, quality of services, and family planning programs. The study team double coded all transcripts. Two members of the study team were assigned to each interview in order to enhance the quality of the analysis.

Several key themes emerged from the data related to family planning decision-making. All themes were identified by two members of the study team. We decided to characterize emerging dominant themes related to most frequently discussed topics across all interviews.

Participants’ profile

Background characteristics of participants are shown in Table 2 . There were six physicians/gynecologists and two midwives in the group of family planning providers. The service providers in our sample had been providing family planning services for between one and 22 years. Regarding community stakeholders, two were associated with Ak Parti—the religiously conservative, ruling political party- as members Footnote 4 and representatives, Footnote 5 two were local parent-teacher association members, one was a neighborhood representative’s assistant and another was a member of a local prayer group. Additionally, there was a pharmacist and a pharmacist’s assistant in the group of community stakeholders. The pharmacist and the pharmacist’s assistant were assigned to the community stakeholder group since they frequently provided informal advice to women about contraceptive use and other reproductive health-related topics.

We wanted to understand family planning decision-making process in relation to decisions about whether to avoid pregnancy or not. Three main themes identified by the study team emerged from the transcripts, including the decision-making process, the role of male partners, and the role of religious beliefs on reproductive health decisions, that provide insight into how women and couples decide to use contraception, how they learn about contraception, and the types of contraceptives women and couples prefer (Table 3 ). In general, we found that there was considerable demand for modern contraceptives among women. The majority of respondents mentioned the increasing awareness about modern contraceptive methods, most notably young women wishing to delay or space childbearing and women who wish to limit births once they achieve their ideal family size. Providers’ narratives implied that they are supportive of these growing modern contraceptive trends and actively encouraged young women to take actions to meet their reproductive needs.

Decision-making process: preferences and access

Respondents differed in what they perceived as the most preferred contraceptive method for women. While they discussed a variety of modern contraceptive methods used by women in their communities, many agreed that traditional methods, such as withdrawal or periodic abstinence, were preferred. They frequently believed these traditional methods to be more effective than other modern methods, and also explained that women prefer these methods to avoid side effects and also for convenience in use. A gynecologist who had been serving in this position for four months said:

If you leave it to the clients, they will still use the withdrawal method. It does not matter if they are educated or not. Nearly 70% of them still use the withdrawal method… They think it is safe. They say they have been using it for five years and nothing happened, so they continue [to use it] . (Interviewee 15, Family planning provider)

Most respondents agreed that the use of contraception is a woman’s decision. A parent-teacher association member noted that “… women have to think about [birth control] as they are the ones who take care of the children. So the women make the decisions.”  (Interviewee 8, Community stakeholder). Moreover, another participant summarized the situation with the following comment: “ Because they [women] don’t want to get pregnant. It is always the women who endure the hardships of pregnancy, so they make the decisions” (Interviewee 11, Community stakeholder). Although most respondents agreed that women are more likely than men to be involved in the choice of a preferred contraceptive method, decision-making within a family is multi-layered. Some respondents reported that mothers-in-law and fathers-in-law are also important actors who exert an influence on family planning matters. A physician who had been providing family planning services for approximately nine years explained:

I had a few clients whose mothers-in-law wanted their daughters-in-law to have more children. And this affects the spouses or the husbands and they think about having another child. As they live together, the mother-in-law or even the father-in-law influences [their decisions to have another child] . (Interviewee 6, Family planning provider)

All participants reported that modern contraceptive methods are widely available and easy to access from health care centers and pharmacies. The majority of respondents (both providers and community stakeholders) reported that women trust and respect family planning service providers. Nevertheless, with regard to obtaining information, women trust the contraceptive experience of other people like their friends and family members and therefore mostly rely on second hand information. A community stakeholder commented:

First, they [women] talk among themselves. For example, she asks me how I manage birth control, how I prevent pregnancy. I say that I use the pill or injections or that my husband uses a method. She says that if it is good, she will do it too. Then she goes to the health center to ask the nurses…It is the culture of the women here, nothing else. It is better for them to hear it instead of searching and learning, I think . (Interviewee 1, Community stakeholder)

A few participants discussed the influence that the characteristics of providers can have on decision-making. The narratives suggested that decision-making is influenced by accessibility and quality of services. One community stakeholder said:

If the doctor is male, women are shy, but just a little…Their husbands don’t let them [go]. They say “If the doctor is male, you can’t go… When we go there again with our husbands, and the doctor will say that I have been here before. Then I will have problems with my husband” they say . (Interviewee 1, Community stakeholder)

Most participants did not report difficulties with accessing contraception for any particular group of women, and they agreed that unmarried women and adolescent girls can access modern contraception. A few reported that modern contraceptive methods are available, but it is difficult for single women to obtain them, which is an indication of barriers to access among this sub-group of women.

As far as I know, single persons wouldn’t get them from somebody they know [meaning a provider, pharmacist, or friend]. It is easily accessible, but the social pressure is serious. So, it is easily accessible, but it is hard to get . (Interviewee 3, Community stakeholder)

Our findings suggest that there is no single explanation for family planning decisions among women in the study setting. Various factors influence family planning decisions, and factors such as the source of information, characteristics of service provider, and marital status play a role.

Role of male partners

Most respondents stated that demand for modern contraceptive services is stronger among women compared to men. The majority of respondents reported that men do not favor modern contraceptive use, but do not actively object to using them. It was evident from participants’ narratives that family planning decisions remain a “woman’s domain”—that is, it is women who typically decide whether to avoid pregnancy or not. Additionally, family planning service providers reported that men have very limited involvement with pregnancy planning and fertility decisions and that women often do not trust men to be involved in such decisions.

Men are not trusted to be involved with family planning by women. Men are fine with [women’s decisions] …I think this responsibility is given to the women in Turkey. Men do not care about it much . (Interviewee 15, Family planning provider)

A gynecologist who has provided family planning services for 14 years said:

…men have birth control methods such as withdrawal and condoms but generally the women come here to consult about the methods. But a lot of men use birth control too. When the women use IUD or the pill and experience side-effects, I think the men understand and they resort to methods such as withdrawal and condoms . (Interviewee 10, Family planning provider)

Participants reported that men are more likely to desire more children compared to women, but the burden of childrearing falls on women. A local midwife who had provided services for ten years in the community explained:

When [women] bear a child, most husbands do not help with childcare. It is as if the child belongs only to the mother; supposedly, he is the father. When the child is sick, the mother takes care of him/her; and when the mother is sick, the father cannot take care of the child… Men generally say that they are unable to take care of children. So, women want birth control methods to avoid consecutive births . (Interviewee 14, Family planning provider)

A local pharmacist who has been in that position for 36 years also indicated that men desire to have more children than their wives. She said:

…especially the husbands want more children, so the women sometimes get these [family planning methods] without telling their husbands . (Interviewee 3, Community stakeholder)

The role of religious beliefs

Participants reported few barriers to contraception, and the narratives suggest relatively few reasons for non-use. However, a frequent theme was the importance of religious beliefs on reproductive health decisions. A few participants reported that women believe that modern contraception, in general, or use of certain methods in particular, are sinful behavior. A gynecologist who had been in that position for 20 years said:

…our religious belief is against it; according to our faith, family planning is forbidden. What can you do with this person? He/she wouldn’t do it even if it were free . (Interviewee 9, Footnote 6 Family planning provider)

Further, a parent-teacher association member and a gynecologist reported that:

Some spouses consider [birth control] to be a sin. We hear it from our friends … Interviewee 8, Community stakeholder) Actually, there is prejudice against most of the birth control methods in our society… Modern contraception is considered a sin. They [referring to the people in the community] do not want birth control. Women do not want IUD. They use the withdrawal method . (Interviewee 13, Family planning provider)

Additionally, beliefs about the moral status of contraception seem to be influenced by women’s social networks. A pharmacist described the effects of shared beliefs around contraceptive decision-making, thus:

One of my clients said that she would not use birth control pills because it was a sin. A couple of months later, she got pregnant and had to have an abortion. I asked her who had recommended it; it turned out to be someone I knew. Then I called that person and said “Why are you misinforming people?” She told me that it was a sin. I told her “Isn’t abortion a sin? She had to have an abortion.” She said that it was not alive until it was three months old. I told her “Look, you don’t have the knowledge about it but you have opinions. You are misinforming people and playing with their lives. A lifeless thing does not grow; it is alive since the first moment that sperm fertilizes the egg. Do not misinform people, please. Send the people to the health centers or doctors but don’t misinform them.” She was offended but I think that the conversation was effective. (Interviewee 3, Community stakeholder)

The narratives suggest that there is contradiction between faith and behavior. In particular, women think that contraception could be against the will of God, but act in accordance with the dictates of modern life.

The findings from this study highlight the major factors that influence family planning decision-making. According to the 2018 Turkey Demographic and Health Survey, 99.5 percent of married women of reproductive age know at least one method of contraception [ 8 ]. Our results are consistent with the existing literature which shows that contraceptive methods (either modern or traditional method) are widely known in the community. Thus, a key finding from the study is that women, and particularly married women, are aware of at least one method of contraception. Therefore, high levels of knowledge of contraceptives provide opportunities for programs to address barriers that could hinder translation of such knowledge into practice.

We found that, according to the perceptions of key informants, traditional methods were preferred over modern methods, and most respondents explained that women prefer traditional methods mostly due to the absence of side effects and ease of use. There is widespread perception that modern methods might have undesired side effects. Additionally, there are religious reasons such as couples’ consideration of natural, easy use the method with more minor side effects for traditional methods being the most preferred methods. According to Cebeci et al., however, even religious beliefs should not be identified as the dominant barrier to contraceptives; they rather affect the choice of particular methods such as withdrawal [ 7 ]. The effect of religious beliefs on contraceptive choice may be the reason why couples continue to rely on traditional methods. There is, however, a need for studies to better understand the motivations for preference for traditional methods in the study setting and how women could be supported to ensure that such methods meet their reproductive needs.

Participants reported that family planning is a “women’s domain” although sometimes other family members, such as mothers-in-law and fathers-in-law, may influence decision-making. A study among married individuals in Umraniye which is another district of Istanbul also found that family planning decision-making was perceived as a “women’s issue” by male partners [ 7 ]. Yet, decision-making is not limited to women and women’s partners; family members are also involved in their contraceptive choices. These patterns underscore a need for a better understanding of intra-family relations and opportunities that such relations provide for supporting women in the study setting to realize their reproductive goals.

Our findings show that although women trust family planning providers on contraceptive issues, they have more confidence in the previous family planning experiences of other people like their friends, neighbors, or relatives. This underscores the significance of women’s social networks as a source of information as well as a determinant of behavior. As Yee and Simon found, women identified their social networks as one of the most influential factors in the family planning decision-making process, especially about side-effects, safety, and effectiveness, and most of them considered that information more reliable than other sources of information [ 15 ]. Husbands, however, do not tend to share information about contraception with one another. Thus, husbands may look to their wives to receive accurate and reliable information about contraception [ 16 ]. Understanding how women’s and men’s social networks influence contraceptive use in this setting may be key to increasing contraceptive use among women who do not want a pregnancy. Intervention studies might also consider leveraging women’s social networks to provide education about contraception (e.g., peer educators or women’s groups).

Related to the accessibility and quality of services that influence decision-making, our findings show that women prefer female to male physicians and consultants in matters related to contraception. In addition, some of the community stakeholders reported prejudice in accessibility to contraceptive methods against unmarried women. Pharmacies provide male condoms, pills, and emergency contraception without a written prescription in Turkey. The pharmacy sector provides more than 45% of the male-condom and pills [ 8 ]. Many unmarried women find it more convenient to obtain contraceptive supplies from pharmacies, despite contraception not being free at pharmacies. This is likely because many single women prefer to avoid social pressure in healthcare facilities and fear being ostracized for engaging in what is regarded as illegitimate sex. The finding that many women in the study setting prefer obtaining contraceptives from pharmacies suggests a need for improving the capacity of pharmacists to provide contraceptive information and counseling to clients.

Various studies in Turkey have found that a variety of perspectives need to be taken into account to fully understand family planning decision-making processes. On the one hand, men report that family planning is a shared responsibility [ 6 ], and that pregnancy planning should be done jointly between partners [ 17 ] which is consistent with existing evidence showing that male involvement and shared decision-making is a key element of reproductive decisions [ 5 , 18 ]. On the other hand, several studies show that men and women are not resistant to contraception, although women are perceived to be the ones making family planning decisions [ 7 , 19 ]. Our findings show that men are not much involved in family planning decision-making and it is often women who decide whether to avoid pregnancy or not. While some respondents suggest that men might be opposed to contraception, the majority reported that men were simply indifferent. Additionally, lack of men’s involvement likely stems from pro-natalist views. The findings suggest a need for a better understanding of couple-level contraceptive decision-making and how best to engage men in supporting women’s reproductive needs.

Studies show that various factors influence fertility decisions, including the number of living children [ 20 , 21 ], level of education of parents and especially of female partners [ 22 ], and socio-cultural norms and religious attitudes [ 17 ]. However, men, in almost every setting, desire more children than women [ 17 , 23 ]. In general, both family planning service providers and community stakeholders in our study reported that men desire more children compared to women. However, the burden of childrearing falls on women, which reflects gender roles in the family. Men’s desire for children could be associated with a need to continue the family line and enhance their social value [ 24 ], making sense in terms of the social value of having a child primarily for men [ 25 ]. This a further indication of the need for understanding the perspectives of men in the study setting and how best to involve them in supporting women’s reproductive needs.

Our findings showed that women placed greater importance on religious beliefs although in practice, such beliefs did not have a direct influence on decisions regarding family planning. Although women believed that contraception could be against the will of God, this did not stop them from using the methods. This is consistent with findings from another qualitative study which showed that religious beliefs were not barriers to contraception, but such beliefs influenced the choice of methods [ 7 ]. Religion does not often dissuade women and men from wanting small families, but instead of using the most effective methods, they instead rely on methods that they perceive to be in alignment with religious beliefs or methods that are not as bad as others. Although most respondents in our study reported that contraception is perceived as a sin, women still used methods. It is possible that religious values may encourage the use of traditional methods, such as withdrawal, that have a long and historical tradition of being used in this setting. Cebeci and colleagues found that, in addition to people’s consideration of withdrawal as a natural, easy to use method with less side effects compared to modern methods, some considered it the method encouraged by Prophet Muhammad, which indicates that modern methods are perceived as harmful [ 7 ]. The findings underscore a need for family programs in the study setting to incorporate empowerment principles in client counseling in order to address misconceptions about modern contraceptives influenced by religious beliefs.

Our findings may be influenced by the manner in which participants were selected. In particular, community stakeholders and service providers were purposively selected based on their familiarity with women’s reproductive health-related topics, including family planning, and the sample included only one male participant. All interviews were conducted in Turkish and translated into English for analysis. Although some meanings could be lost in the process, a small sample of the transcripts were back-translated to determine the extent of such loss. There was no loss in meanings due to translation from one language to another. Additionally, all interviews were conducted in a private space to reduce the risk of social desirability bias. By its very nature, our sample has limited external validity which prevents us from making inferences about patterns in the study setting or the country as a whole. Although our findings, based on a limited purposive sample with key informants, are consistent with the findings of other studies using larger samples with more diverse groups of women, further qualitative research with representative samples of reproductive age women is needed to determine the extent to which our findings are consistent with the prevailing patterns in the country as a whole.

Our study sheds light on the factors that play a role in women’s contraceptive decisions in Turkey, a country with a strong national family planning policy but characterized by political-religious differences in beliefs about use of family planning. Our first take is that women (as well as couples) have a strong preference for traditional methods and particularly withdrawal. Religious factors in particular and socially conservative values in general play an important role in the choice of method. However, it should also be noted that the strong preference for traditional methods is a more general phenomenon that is not limited to the prevalence of religious and conservative values.

Second, in most cases, men play a minimal, if any, in family planning decisions. This is of both practical and academic interest especially in a male-dominant culture. From a policy viewpoint it points out to the need of educating not only women but also men about the availability, advantages, disadvantages and possible risk of available methods.

Third and last, the link between values and family planning decisions at all levels seems to be evident and this relationship deserves further investigation.

Availability of data and materials

Anonymized data can be availed upon reasonable request to the first author.

Social Security Institution.

Family Health Centers.

Maternal and Child Health and Family Planning Centers.

AK Parti member is also member of parent-teacher association.

They are not politicians, but they act as liaisons between community members and the political party.

Male participant.

Abbreviations

intrauterine devices

lactational amenorrhea

Sosyal Güvenlik Kurumu

Aile Sağlığı Merkezi

Ana Çocuk Sağlığı ve Aile Planlama Merkezi

Koc I. Determinants of contraceptive use and method choice in Turkey. J Biosoc Sci. 2000;32(3):329–42.

Article   CAS   Google Scholar  

Tadele A, Tesfay A, Kebede A. Factors influencing decision-making power regarding reproductive health and rights among married women in Mettu rural district, south-west, Ethiopia. Reprod Health. 2019;16(1):155.

Article   Google Scholar  

Darteh EKM, Doku DT, Esia-Donkoh K. Reproductive health decision making among Ghanaian women. Reprod Health. 2014;11(1):23.

Orji EO, Ojofeitimi PEO, Olanrewaju BA. The role of men in family planning decision-making in rural and urban Nigeria. Eur J Contracept Reprod Health Care. 2007;12(1):70–5.

Ozvaris SB, Dogan BG, Akin A. Male involvement in family planning in Turkey. World Health Forum. 1998;19(1):76–8.

CAS   PubMed   Google Scholar  

Sahin NH. Male university students’ views, attitudes and behaviors towards family planning and emergency contraception in Turkey. J Obstet Gynaecol Res. 2008;34(3):392–8.

Cebeci DS, Erbaydar T, Kalaca S, Harmancı H, Calı S, Karavus M. Resistance against contraception or medical contraceptive methods: a qualitative study on women and men in Istanbul. Eur J Contracept Reprod Health Care. 2004;9(2):94–101.

Hacettepe University Institute of Population Studies. Turkey Demographic and Health Survey [Internet]. 2018 [cited 2020 Apr 24]. http://www.hips.hacettepe.edu.tr/tnsa2018/rapor/TDHS2018_mainReport.pdf .

Karavus M, Cali S, Kalaca S, Cebeci D. Attitudes of married individuals towards oral contraceptives: a qualitative study in Istanbul, Turkey. J Fam Plann Reprod Health Care. 2004;30(2):95–8.

Yücesan A, Alkaya SA. Ignored issue at schools: Sexual health education. SDÜ Tıp Fakültesi Dergisi. 2018 Mar 1 [cited 2021 Mar 24]. https://doi.org/10.17343/sdutfd.342828 .

Berg BL. Qualitative research methods for the social sciences. 2nd ed. Boston: Allyn and Bacon; 1995.

Google Scholar  

Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory. London: SAGE Publications; 1998.

Glaser B, Strauss A. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine; 1967.

National Statistics Institute (TURKSTAT) [Internet]. 2019 [cited 2020 Feb 3]. https://biruni.tuik.gov.tr/medas/?kn=95&locale=tr .

Yee LM, Simon M. The role of the social network in contraceptive decision-making among young, African American and Latina women. J Adolesc Health. 2010;47(4):374–80.

Ortayli N, Bulut A, Ozugurlu M, Cokar M. Why withdrawal? Why not withdrawal? Men’s perspectives. Reproduct Health Matters. 2005;13(25):164–73.

Zeyneloğlu S, Kisa S, Delibas L. Determinants of family planning use among Turkish married men who live in South East Turkey. Am J Men’s Health. 2013;7(3):255–64.

Mistik S, Nacar M, Mazicioglu M, Cetinkaya F. Married men’s opinions and involvement regarding family planning in rural areas. Contraception. 2003;67(2):133–7.

Angin Z, Shorter FC. Negotiating reproduction and gender during the fertility decline in Turkey. Soc Sci Med. 1998;47(5):555–64.

Miller WB, Pasta DJ. Behavioral intentions: which ones predict fertility behavior in married couples? J Appl Soc Psychol. 1995;25(6):530–55.

Casterline JB, Han S. Unrealized fertility: fertility desires at the end of the reproductive career. Demogr Res. 2017;36(14):427–54.

Testa MR. On the positive correlation between education and fertility intentions in Europe: individual- and country-level evidence. Adv Life Course Res. 2014;21:28–42.

Tuloro T, Deressa W, Ali A, Davey G. The role of men in contraceptive use and fertility preference in Hossana town, Southern Ethiopia. Ethiop J Health Dev. 2006;20(3):152–9.

Odu O, Jadunola K, Parakoyi D. Reproductive behaviour and determinants of fertility among men in a semi-urban Nigerian community. J Community Med Prim Health Care. 2005;17(1):13–9.

Kagitcibasi C. The changing value of children in Turkey. Honolulu: East-West Population Institute; 1982.

Book   Google Scholar  

Download references

Acknowledgements

The authors thank the family planning service providers and the community stakeholder who participated in the study.

This study was funded by an anonymous donation to Harvard TH Chan School of Public Health. This funding source had no role in the design of this study, data collection, analyses, interpretation of the data, or decision to submit the manuscript for publication.

Author information

Authors and affiliations.

Bahcesehir Universiy, Istanbul, Turkey

Duygu Karadon, Yilmaz Esmer, Bahar Ayca Okcuoglu, Sebahat Kurutas & Simay Sevval Baykal

Harvard T.H. Chan School of Public Health, Boston, MA, USA

Sarah Huber-Krum, David Canning & Iqbal Shah

You can also search for this author in PubMed   Google Scholar

Contributions

DK drafted the first version of the manuscript. DK, BAO, SSB, and SK conducted an open coding of all transcripts and grouped the codes into themes. Data analysis was conducted by DK and BAO. YE, SHK, IS, and DC reviewed the manuscript for substantial intellectual content and contributed to the interpretation of the data. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Duygu Karadon .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Declaration of Helsinki and all procedures involving human participants were approved by the Ethics Board of Bahcesehir University and the Institutional Review Board at Harvard University (Protocol #: IRB17-1806). All participants received written information about the study and provided oral consent to participate in the research. Oral consent procedures were approved by the Ethics Board of Bahcesehir University and the Institutional Review Board at Harvard University. Before each interview, the consent script was read aloud to women. Enumerators asked participants to provide oral consent to take part in the study and recorded the answer on the tablet. Oral consent was obtained, rather than written consent, to protect the privacy of respondents.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1:.

Key Informant Interview Guide-Community Stakeholders.

Additional file 2:

Key Informant Interview Guide-Family Planning Service Providers.

Additional file 3:

Coding tree.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Karadon, D., Esmer, Y., Okcuoglu, B.A. et al. Understanding family planning decision-making: perspectives of providers and community stakeholders from Istanbul, Turkey. BMC Women's Health 21 , 357 (2021). https://doi.org/10.1186/s12905-021-01490-3

Download citation

Received : 23 September 2020

Accepted : 24 September 2021

Published : 09 October 2021

DOI : https://doi.org/10.1186/s12905-021-01490-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Family planning
• Decision-making
• Health decisions
• Qualitative data

BMC Women's Health

ISSN: 1472-6874

• General enquiries: [email protected]

• Research note
• Open access
• Published: 13 August 2018

Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia

• Ayele Semachew Kasa   ORCID: orcid.org/0000-0003-3320-8329 1 ,
• Mulu Tarekegn 1 &
• Nebyat Embiale 2  

BMC Research Notes volume  11 , Article number:  577 ( 2018 ) Cite this article

71k Accesses

35 Citations

Metrics details

To assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia, 2017.

The study showed that the overall proper knowledge, attitude and practice of women towards family planning (FP) was 42.3%, 58.8%, and 50.4% respectively. Factors associated with the practice of FP were: residence, marital status, educational status, age, occupation, and knowledge, and attitude, number of children and monthly average household income of participants. In this study, the level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies. Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced. Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Introduction

Family planning (FP) is defined as a way of thinking and living that is adopted voluntary upon the bases of knowledge, attitude, and responsible decisions by individuals and couples [ 1 ]. Family planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods [ 2 ].

Family planning deals with reproductive health of the mother, having adequate birth spacing, avoiding undesired pregnancies and abortions, preventing sexually transmitted diseases and improving the quality of life of mother, fetus and family as a whole [ 3 , 4 ].

The Federal Ministry of Health (FMOH) has undertaken many initiatives to reduce maternal mortality. Among these initiatives, the most important is the provision of family planning at all levels of the healthcare system [ 5 , 6 ]. Currently, short-term modern family planning methods are available at all levels of governmental and private health facilities, while long-term method is being provided in health centers, hospitals and private clinics [ 6 ].

The study done in Jimma Zone, Ethiopia showed that good knowledge on contraceptives did not match with the high contraceptive practice [ 7 ]. Different researchers showed that the highest awareness but low utilization of contraceptives making the situation a serious challenge [ 8 , 9 ].

Most of reproductive age women know little or incorrect information about family planning methods. Even when they know some names of contraceptives, they don’t know where to get them or how to use it. These women have negative attitude about family planning, while some have heard false and misleading information [ 10 , 11 ] and the current study aimed in assessing the knowledge, attitude and practice (KAP) of FP among women of reproductive age group in South Achefer District, Northwest Ethiopia.

Methods and materials

Study design and setup.

A community-based cross-sectional study was conducted in South Achefer District, Amhara Region, Northwest Ethiopia from March 01–April 01, 2017. Systematic sampling technique was used to recruit the sampled reproductive age women (15–49 years old). Based on the number of households obtained from the Kebele’s (Smallest administrative division) health post, the sample size (389) was distributed to the households. The sampling interval was determined based on the total number of 4431 households in the kebele. The first household was taken by lottery method and if there were more than one eligible individual in the same household one was selected by lottery method.

The data collection questionnaire was developed after reviewing different relevant literatures. The questionnaire, first developed in English language and then translated to Amharic (local language). Pretest was done on 5% of the total sample size at Ashuda kebele. After the pretest, necessary modifications and correction took place to ensure validity.

Those reproductive age women who answered ≥ 77% from knowledge assessing questions were considered as having good knowledge, those women who scored ≥ 90% from attitude assessing questions were considered as having favorable attitude and those women who scored ≥ 64% from practice assessing questions were considered as having good over all practice towards FP [ 7 ].

Data processing and analysis

The collected data was cleaned, entered and analyzed using SPSS version 21 software. Descriptive statistics were employed to describe socio-demographic, knowledge, attitude and practice variables. Chi squared (χ 2 ) test was used to determine association between variables. Associations were considered statistically significant when P-value was, < 0.05.

Socio-demographic characteristics of participants

The response rate in this study was 97.9%. Among 381 participants included, 185 (49%) were from rural villages. About 47% of the participants were illiterate and 52% were completed primary education. The monthly household income of the majority (42.5%) of the participants was between 1000 and 3000 Ethiopian birr. Regarding the family size of the participant’s, majority (48.3%) of them had ≥ 3 children.

The mean age of participants was 29.7 ± 6.4. Two hundred forty six (64.6%) and 133 (34.9%) were house wife’s and farmers respectively by their occupation. Almost two-third (65.4%) of participants were married, 24.9% were divorced by their marital status (Table  1 ).

Knowledge status of participants

All of participants ever heard about family planning methods. The major sources of information were from health workers (57.5%) and radio (41.5%). Regarding perceived side effects of using family planning, 13.1%, 24.9%, 9.7% and 52.2% of participants were responded heavy bleeding, irregular bleeding, an absence of menstrual cycle and abdominal cramp respectively were mentioned as a side effect. Among those who have children; 24.6% gave their last birth at home and 75.5% gave their last birth at the health institution. Regarding the overall knowledge of study participants, 161 (42.3%) had good knowledge towards family planning and the rest 220 (57.7%) had poor knowledge.

Attitude status of participants

The majority (88.5%) of the respondents ever discussed on family planning issues with their partners and wants to use it in the future. About 24.5% of the participants reported that they believe family planning exposes to infertility. Almost 23 (22.8%) of study participants reported that using family planning contradicts with their religion and culture. Regarding the overall attitude, 224 (58.8%) of the participants had favorable attitude and 157 (41.2%) had unfavorable attitude towards family planning.

Practice on family planning

Three fourth (75.3%) of study participants ever used contraceptive methods. The main types were pills (7.4%) and injectable (77.2%). The most common current reasons for not using were a desire to have a child (53.2%) and preferred method not available (46.8%). Almost half (50.4%) of study participants had good practice and the rest 49.6% had poor practice.

Factors associated with family planning practice

Study participants’ religion was not included in the analysis due to lack of variance, since almost all (99.2%) of participants were Orthodox Christians by their religion.

Women who had good knowledge were more likely to practice FP than those who have low knowledge (χ 2  = 117.995, d.f. = 1, P  < 0.001) and women who had favorable attitude towards FP were more likely to practice FP (χ 2  = 106.696, d.f. = 1, P  < 0.001). It was also seen that residence, age, educational status, occupation, marital status, number of children and monthly income of the were significantly associated with the practice of FP [(χ 2  = 69.723, d.f. = 1, P  < 0.001), (χ 2  = 104.252, d.f. = 2, P  < 0.002), (χ 2  = 119.264, d.f. = 1, P  < 0.001), (χ 2  = 41.519, d.f. = 1, P  < 0.001), (χ 2  = 39.050, d.f. = 1, P  < 0.001), (χ 2  = 144,400, d.f = 3, P  < 0.001) and (χ 2  = 179.366, d.f. = 1, P  < 0.002)] respectively (Table  2 ).

Increasing program coverage and access of family planning will not be enough unless all eligible women have adequate awareness for favorable attitude and correctly and consistently practicing as per their need. Increasing awareness/knowledge and favorable attitude for practicing FP activities at all levels of eligible women are strongly recommended [ 6 ].

The results of the present study showed that 42.3% of study participants had good knowledge, 58.8% had favorable attitude, and 50.4% had good practice towards family planning. This finding was lower than a study conducted in Jimma zone, Southwest Ethiopia [ 7 ], Sudan [ 9 ], Tanzania [ 12 ] and another study done in Rohtak district, India [ 13 ]. The difference may be due to; studies done in Jimma zone, Sudan, Tanzania and Rohtak district involve only those coupled/married women. Married women might have good knowledge and attitude for practicing family planning. But in the current study, all women of reproductive age group regardless of their marital status were studied and this may lower their knowledge and attitude.

The current study showed that, 50.4% of reproductive age women were practicing family planning which was almost in line with a study done in Cambodia [ 14 ] and higher than a study done in rural part of Jordan [ 15 ] and India [ 16 ]. But it was lower than studies conducted in Jimma zone, Ethiopia [ 7 ], Rohtak district, India [ 13 ], urban slum community of Mumbai [ 17 ] and in Sikkim [ 18 ] in which 64%, 62%, 65.6% and 62% of participants respectively used family planning. The difference might be due to that study participants in Jimma zone, Rohtak and Mumbi were relatively residing in large city/town and this may help them to have a better access for family planning compared to the study done in South Achefer District.

In the current study, urban residents were more likely to use family planning methods (71.4%) than their rural counterparts (28.1%). This finding was in line with the findings from Ethiopian Demographic Health Survey (EDHS) [ 2 ]. This might be due to the reason that urban residents are more aware of family planning and hence practicing better.

It has also found that women who completed primary & secondary education were practicing family planning than those who were uneducated (77.1% and 20.6%) respectively. This finding was in line with a study done in Jimma, Ethiopia [ 19 ]. This might be due to the fact that women who were able to read and write would think in which FP activities are useful to be economically, self-sufficient and more likely to acquire greater confidence and personal control in marital relationships including the discussion of family size and contraceptive use.

This study showed that, age of the study participants had an association with practicing FP. Those reproductive age women’s whose age > 30 years were practicing family planning better than those whose age < 18 years. This finding was in line with a study done in India [ 20 ]. This might be due to the reason that, when age increases mothers awareness, attitude and practice towards family planning may increase. In addition, as age increases the chance of practicing sexual intercourse increases and as a result they would be interested to utilize family planning in one or another way.

It has also revealed that women’s average monthly household income has an association with their FP practicing habit. Those study participants whose average monthly income < 1000 ETB were using FP better than whose average monthly income > 3000 ETB. This is might be because those relatively who had better income may need more children and those with low income may not want to have more children beyond their income.

The current study also showed that knowledge and attitude of reproductive age women were related to FP utilization. Those reproductive age women who had good knowledge were utilized FP better than from those who were less knowledgeable. Those participants with favorable attitude were practicing better than those who had unfavorable attitude. This is might be due to the fact that knowledge and attitude for specific activities are the key factors to start behaving and maintaining it continuously.

Conclusion and recommendation

The level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies.

Study participant’s residence, marital status, educational level, occupation, age, knowledge, attitude, their family size and their monthly average income were associated with FP utilization habit of reproductive age women.

Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced.

Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Limitation of the study

As the data were collected using interviewer administered questionnaire, mothers might not felt free and the reported KAP might be overestimated or underestimated.

We do not used qualitative method of data collection to gather study participant’s internal feeling about family planning, so that triangulation was possible. In addition, barriers for utilizing contraception not addressed.

Abbreviations

Ethiopian Demographic Health Survey

Ethiopian birr

Federal Ministry of Health

family planning

knowledge, attitude and practice

World Health Organization. Standards for maternal and neonatal care. Geneva: World Health Organization; 2006.

Google Scholar  

Central Statistical Agency. Ethiopian Demographic and Health Survey 2016 key indicators report. Addis Ababa and Maryland, Ethiopia; 2016.

World Health Organization. Fact sheets on family planning, World Health Organization. https://www.cycletechnologies.com/single-post/2017/02/14/World-Health-Organization-Updated-Family-Planning-Contraception-Fact-Sheet . Accessed 8 Feb 2018.

United Nations. World contraceptive use, 2009 wall chart. New York United Nations Population Division: United Nations; 2009. http://www.un.org/esa/population/publications/contraceptive2009/contracept2009_wallchart_front.pdf . Accessed 3 Mar 2018.

Central Statistical Agency. Ethiopia Mini Demographic and Health Survey 2014. Addis Ababa; 2014. http://www.dktethiopia.org/publications/ethiopia-mini-demographic-and-health-survey-2014 . Accessed 12 Feb 2018.

Federal Ministry of Health. National Guideline for Family Planning Services in Ethiopia; 2011. http://www.moh.gov.et/documents/20181/21665/National+Family+Planning+Guideline_Ethiopia_2011.pdf/ . Accessed 17 Feb 2018.

Tilahun T, Coene G, Luchters S, Kassahun W, Leye E. Family planning knowledge, attitude and practice among married couples in Jimma Zone, Ethiopia. PLoS ONE. 2013;8(4):e61335.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Menhaden AL, Khalil AO, Hamdan-Mansour AM, Sato T, Imoto A. Knowledge, attitudes, and practices towards family planning among women in the rural southern region of Jordan. East Mediterr Heal J. 2012;18(6):1–6.

Handady SO, Naseralla K, Sakin HH, Alawad AAM. Knowledge, attitude, and practice of family planning among married women attending primary health centerin Sudan. Int J Public Heal Res. 2015;3(5):243–7.

Gaur DR, Goel MK, Goel M. Contraceptive practices and related factors among female in predominantly rural Muslim area of North India. Internet J World Heal Soc Polit. 2008;5(1):1–5.

Oyedokun AO. Determinants of contraceptive Usage: lessons from Women in Osun State, Nigeria. J Humanit Soc Sci. 2007;1:1–14.

Lwelamira J, Mnyamagola G, Msaki MM. Knowledge, attitude and practice (KAP) towards modern contraceptives among married women of reproductive age in Mpwapwa District, Central Tanzania. Curr Res J Soc Sci. 2012;4(3):235–45. https://www.researchgate.net/publication/299488265 . Accessed 9 Feb 2018.

Gupta V, Mohapatra D, Kumar V. Family planning knowledge, attitude, and practices among the currently married women (aged 15–45 years) in an urban area of Rohtak district, Haryana. Int J Med Sci Public Heal. 2016;5(4):627–32.

Article   Google Scholar  

Sreytouch Vong. Knowledge, attitude and practice (KAP) of Family planningamong married women in BanteayMeanchey. Cambodia: Ritsumeikan Asia Pacifi c University; 2006.

Mahadeen AI, Khalil AO, Sato T, Imoto A. Knowledge, attitudes and practices towards family planning among women in the rural southern region of Jordan. East Mediterr Heal J. 2012;18(6):567–72.

Article   CAS   Google Scholar  

Quereishi MJ, Mathew AK, Sinha A. Knowledge, attitude and practice of family planning methods among the rural females of Bagbahara block Mahasamund district in Chhattishgarh State, India. Glob J Med Public Heal. 2017;6(2):1–7. http://www.gjmedph.com . Accessed 5 Mar 2018.

Khan MM, Shaikh STSA. Study of knowledge and practice of contraception in urban slum community, Mumbai. Int J Curr Med Appl Sci. 2014;3(2):35–41.

Prachi R, Das GS, Ankur B, Shipra J, Binita K. A study of knowledge, attitude and practice of family planning among the women of reproductive age group in Sikkim. J Obs Gynecol India. 2008;58(1):63–7. https://www.researchgate.net/publication/228480182 . Accessed 16 Apr 2018.

Beekle AT. Awareness and determinants of family planning practice in Jima, Ethiopia. Int Nurs Rev. 2006;53:269.

Article   PubMed   CAS   Google Scholar  

Mohanan P, Kamath ASB. Fertility pattern and family planning practices in rural area in dakshina Kannada. Indian J Com Med. 2003;28:15–28.

Download references

Authors’ contributions

AS: approved the proposal with some revisions, participated in data analysis. MT: wrote the proposal, participated in data collection analyzed the data and drafted the paper. NE: approved the proposal with some revisions, participated in data analysis. All authors read and approved the final manuscript.

Acknowledgements

We are very grateful to all study participants for their commitment in responding to our questionnaires.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Not applicable.

Consent to publish

Ethics approval and consent to participate.

Ethical clearance was obtained from the Ethical Review Committee of Bahir Dar University, College of Medicine & Health Sciences, and School of Nursing. The objective and purpose of the study were explained to officials at the Woreda and Kebele (smallest governmental administrative division) and a written permission consent was obtained from the study participants. For those study participants whose age is below 18 years consent to participate in the study was obtained from their parent during the data collection time.

No fund was received.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author information

Authors and affiliations.

Department of Nursing, College of Medicine & Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Ayele Semachew Kasa & Mulu Tarekegn

Department of Surgery, School of Medicine, College of Medicine & Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Nebyat Embiale

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Ayele Semachew Kasa .

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Semachew Kasa, A., Tarekegn, M. & Embiale, N. Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia. BMC Res Notes 11 , 577 (2018). https://doi.org/10.1186/s13104-018-3689-7

Download citation

Received : 28 June 2018

Accepted : 06 August 2018

Published : 13 August 2018

DOI : https://doi.org/10.1186/s13104-018-3689-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Family planning

BMC Research Notes

ISSN: 1756-0500

• General enquiries: [email protected]

• Open access
• Published: 01 April 2021

Awareness and use of family planning methods among women in Northern Saudi Arabia

• Ghzl Ghazi Alenezi 1 &
• Hassan Kasim Haridi   ORCID: orcid.org/0000-0002-8425-0204 2  

Middle East Fertility Society Journal volume  26 , Article number:  8 ( 2021 ) Cite this article

17k Accesses

5 Citations

1 Altmetric

Metrics details

Evaluation of awareness and use of family planning methods is important to improve services and policies. This study aimed to assess awareness and use of family planning methods among women in an urban community in the north of Saudi Arabia.

A cross-sectional study was carried out in a maternity hospital and 12 primary health care (PHC) centers in Hail City between December 1st, 2019, and May 30, 2020.

Four hundred married sexually active women aged 18–49 years were interviewed using a pretested structured questionnaire. The mean age of the participant was 32.0±7.5 years, 73.5% were university educated, and 58% were housewives. More than two-thirds of them (67.6%) had ≥3 living children. Most women (85%) ever used, and 66.5% were currently using any method of contraception; however, only one in five who get counseling for the contraceptive method used, and 40% of the last births were unplanned for. Almost all women reported unavailable family planning clinics in their primary healthcare centers. Most participants (83.0%) desired to have >3 children, which indicates that the main purpose of family planning was child spacing rather than limitation. Relying on natural methods as being safer (36.3%), desire to have more children (19%), being afraid from side effects (15.3%), and possibility of difficulty getting pregnant or might cause infertility (13.0%) were reasons the participants viewed for unsung modern contraceptives.

This study revealed that most women in urban Hail community, northern Saudi Arabia, were aware about and have a positive attitude towards family planning. The majority of the participants ever used, and two-thirds were currently using any contraceptive method/s, which is higher than the national estimate for Saudi Arabia. However, only one in five counseled by healthcare providers for the type of contraceptive method used. Unavailability of family planning services in primary health care centers impedes getting professional counseling. It is imperious to consider family planning clinics to provide quality family planning services.

A woman’s ability to choose whether and when to become pregnant directly affects her health and well-being. Voluntary family planning saves lives and accelerates sustainable human and economic development [ 1 ]. Family planning implies the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births [ 2 ]. Use of contraception prevents pregnancy-related health risks for women and children. When births are separated by less than 2 years, the infant mortality rate is 45% higher than it is when births are 2–3 years and 60% higher than it is when births are four or more years apart [ 3 ]. Family planning offers a range of potential non-health benefits that encompass expanded educational opportunities and empowerment for women and sustainable population growth and economic development for countries [ 4 ]. Family planning is achieved through contraception, defined as any means capable of preventing pregnancy, and through the treatment of involuntary infertility. The contraceptive effect can be obtained through temporary or permanent means. Temporary methods include periodic abstinence during the fertile period, coitus interrupts (withdrawal), using the naturally occurring periods of infertility (e.g., during breastfeeding and postpartum amenorrhea), through the use of reproductive hormones (e.g., oral pills and long-acting injections and implants), placement of a device in the uterus (e.g. ,copper-bearing and hormone-releasing intrauterine devices), and interposing a barrier that prevents the ascension of the sperm into the upper female genital tract (e.g., condoms, diaphragms, and spermicides). Permanent methods of contraception include male and female sterilization [ 2 , 4 ].

Availability of family planning methods and family planning service quality are important dimensions of the global health policies [ 5 ]. Regarding availability, the principles state that health care facilities, providers, and contraceptive methods need to be available “to ensure that individuals can exercise full choice from a full range of methods” and that furthermore, contraceptive methods are to be accessible without informational or other barriers. Regarding service quality issues, the principles state that “client-provider interactions respect informed choice, privacy and confidentiality, client preferences, and needs” [ 5 ].

Even though women in Saudi Arabia have a high total fertility rate compared to developed countries, a major change has occurred in the last decades. The total fertility rate decreased from 7.17 in 1980 to 4.10 in 2000 and to 2.27 in 2020 [ 6 ], a decrease by 45% in the last two decades and by more than two thirds in the last four decades. This substantial change in fertility profile occurred as a consequence of sociodemographic development in the Saudi community, especially in women’s education and work [ 7 , 8 ] as important factors in changing the beliefs of fertility and behaviors towards birth spacing, and the use of the contraceptives.

Monitoring and evaluation of awareness and utilization of family planning methods in communities are important to improve the quality and effectiveness of services, policies, and planning with resulting beneficial impacts on health and quality of life of women, children, families, and communities. An important aspect of research in this respect is to explore views and practices of women in the reproductive age with regard to family planning and fertility preferences, so we aimed in this study to assess awareness, attitude, and use of family planning methods among women in urban community at the north of Saudi Arabia.

Study design and the participants

This cross-sectional study was conducted in Hail City, the main urban area in Hail region, at the north of Saudi Arabia, between December 1st, 2019, and May 30, 2020. A maternity hospital and 12 primary health care (PHC) centers were the setting of this study. PHC centers were selected at random among a total of 24 PHC centers serving all neighborhood of Hail City. The eligible subjects were married women, residing in Hail City for at least 1 year, aged 18–49 years, who were sexually active, not in the menopause with no contraindication from getting pregnant. Participants were selected at random from women in the waiting areas, who visited the selected health care facility for any reason and invited to undergo an interview. Sample size was calculated using Cochran’s Sample Size Formula [ 9 ] to comprise 384 participants, assuming 50% of women are using contraceptive methods (to maximize sample size) and 5% margin error within 95% confidence level. However, a successful 400 eligible participants were interviewed. A prior consent was obtained from the participants before the interview. Efforts were maximally taken during recruiting and interviewing eligible participants in the study to avoid any potential selection or information bias.

Data collection and analysis

A pretested, predesigned questionnaire was used by the investigator to interview the selected study participants. The questionnaire included sociodemographic information regarding age, education, family size, and family income, and questions covered awareness with regard to the concept and methods of family planning and attitude towards and practice of family planning. Data obtained was coded, entered into, and analyzed using Epi Info 7.1.3 program (CDC, Atlanta, GA, USA). Descriptive statistical measures as percentages and proportions were used to express qualitative data. Quantitative data were expressed as mean and standard deviation. Data was presented as tables and graphs as relevant.

A total of 400 women completed the interview among 418 women asked to participate in the study (96.7% response rate). Time factor and wouldn’t like to share personal information were most of the reasons mentioned for non-participation.

The mean age of the participants was 32.0 ± 7.5 years. The age-wise distribution of the participants is shown in Table 1 . Most participants received university education (294, 73.5%). More than half (211, 52.8%) of the participants reported family income <10,000 SR, while those who reported high income ≥15,000 SR were 96 (24.0%). The mean living children per woman was 2.9±2.5 children, with about one-third (130, 32.5%) had more than 3 children (Table 1 ).

Table 2 summarizes awareness about and attitude towards family planning among the study participants. About two-thirds 259 (64.8%) perceived family planning concept as a means for pregnancy spacing, while 88 (22.0%) perceived it as a means of pregnancy limitation, the others 53 (13.3%) were not familiar with the meaning of family planning. Almost all participants (399; 99.8%) were familiar with hormonal contraceptive pills, IUDs (387, 96.8%), and withdrawal (396, 99.0%), and most (364, 91.0%) were familiar with condom and breastfeeding (330, 82.5%) as a means of contraception methods. Still, a good percent was familiar with abstinence (307, 76.8%) and injectable hormonal (252, 63.0%) and hormonal patch (245, 61.3%) contraceptives. Less commonly familiar methods were female sterilization (145, 36.3%), female barrier (92, 23.0%), and male sterilization (68, 17.0%). Figure 1 demonstrates sources of knowledge about family planning among participants. Most sources were non-reliable sources, such as family/friends (67.5%), general internet sites (43.8%), and social media (34/0%); meanwhile, only half (50.3%) of the participants reported consulting healthcare workers.

Sources of knowledge about family planning methods (%)

The vast majority (384, 96.0%) were favoring family planning (agree/strongly agree), with almost the same percent mentioned that family planning have multiple benefits. More than two-thirds (282, 70.5%) of the participating women reported husbands’ support with regard to family planning. A small percent (17.0%) desired a small number (1–3) of children; 55.0% desired more than 3 children, while 28.0% would not like to limit their children number and leave it open. More than two-thirds (67.5%) preferred pregnancy spacing for more than 2 years.

Table 3 summarizes family planning practices as reported by participant women. The majority ( n =341; 85.3%, CI= 81.4–88.6) ever used and 266 (66.5%, CI= 61.6–71.1) were currently using contraceptive method/s. Methods currently mostly used were pills ( n =144, 54.1%), withdrawal ( n =58, 21.8%), IUDs ( n =29, 10.9%), hormonal patches ( n =14, 5.3%), and condom ( n =12, 4.5%) (Fig. 2 ).

Contraceptive method currently used among participants (%)

Less than half ( n =144; 44.0%) of the respondents reported that their husbands practice contraception. The frequently used method was withdrawal ( n =147, 36.8%) and to a lesser extent condom ( n =55, 13.8%) and abstinence during ovulation period ( n =32, 8.0%).

More than 60% (121, 60.5%) bought the contraceptive directly from private pharmacies over the counter as a personal choice, others (52, 26.0%) brought the contraceptive method after medical advice in private dispensary/hospital, and few (27, 13.5%) were prescribed after medical advice in a governmental health care facility.

Table 4 summarizes respondent’s views about the important reasons behind the non-use of modern contraceptive methods among some women. Favoring natural contraceptive methods (36.3%), the desire of more children (19.0%), being afraid of health side effects and complications (15.3%). Other mentioned causes were being afraid of difficulty of getting pregnant (6.5%), the misconception that modern contraceptives may cause infertility (6.5%), and the other miscellaneous causes/non-response (16.4%).

A fundamental change has occurred in Saudi society over the last decades. Socioeconomic development, urbanization, and women’s education and work [ 7 , 8 , 10 ] led to changes in fertility beliefs and behaviors. Results of the present study shed light on an urban community in the north of Saudi Arabia, exploring views, attitudes, and practices of women in the childbearing period regarding family planning, fertility preferences, and health-seeking behavior.

In this study, most of the participating women (85.3%) ever used, and 66.5% were currently using any family planning method/s, which is by far higher than the national estimate for Saudi Arabia (18.6%) stated in the United Nations (UN) “World Fertility and Family Planning 2020” report and also higher than the international prevalence average, where, in 2019, 49% of all women in the reproductive age range 15–49 years were using some form of contraception [ 11 ]. Similarly, the prevalence was also higher than the reported figures in surrounding Gulf Arab countries such as the United Arab Emirates (33.4%), Kuwait (35.5%), Bahrain (32.2%), Oman (19.6%), Qatar (29.1%), and other Arab countries such as Egypt (43.2%), Jordan (31.1%), Iraq (35.1%), Syria (31.6%), Tunisia (34.3%), and Morocco (36.7%) [ 11 ]. However, the estimate is fairly similar to rates in Western countries such as the UK (71.7%), France (63.4%), Italy (55.6%), Spain (56.5%), and the USA (61.4%) [ 11 ].

This reported higher rate of family planning methods used in our study population actually concealing a high proportion of couples using traditional unreliable methods, where one in 4 was using these methods compared to <10% internationally [ 11 ].

Almost all (96.0%) of the participants in our study praised the concept of family planning and agreed about the benefits of family planning for maternal and child health and well-being. Furthermore, the majority of the participants (85.3%) were ever used or currently using (66.5%) family planning methods. This finding indicates the high acceptability of the family planning concept and points to the real desire of families to plan for the timing of pregnancy occurrence and space between children. Translation of this high acceptance and the higher prevalence of using contraceptives was not reflected in lower fertility profile or smaller family size in our sample. About one-third (32.5%) were already having more than 3 living children, and 83.0% reported that they still want more children, and half of them (49.2%) reported that they prefer to have more than 3 children. This indicates that the main purpose of using contraceptive methods among the majority of the participants is birth spacing rather than birth limitation. This finding is consistent with previous study conducted in southwestern Saudi Arabia, where 60.0% of contraceptive users were spacer [ 12 ]. This could be explained on the background of cultural factors, religious traditions and customs of an Islamic society as well as personal views.

An important finding in our study is that, the use of contraceptive methods among participants largely depends upon their personal views (55.0%) or family/friends’ experience (23.2%), while only 21.8% of the participants received medical advice before using their current contraceptive method. This might explain the higher number of couples who relied on unreliable contraceptive methods and the considerable percentage (40%) of the participants who reported that their last pregnancy was unplanned for, which might be attributed to failure of the contraceptive method used. This is not surprising when we find that all participants reported unavailability of a family planning clinic in their PHC centers, with only one in three (33.8%) who reported that their PHC centers may provide family planning counseling and just 2.8% who reported accessibility for prescribing family planning methods. This situation indicates that, in spite of the high social necessity for family planning revealed by the high demand on family planning methods, there is no parallel availability of organized health services coping for this unmet need of women in the region. As a consequence, health-seeking behavior is self-guided based on personal information and beliefs and/or unreliable sources such as experience of relatives and friends. This crucial need for family planning services was also reported in other studies in Saudi Arabia [ 12 ]. The availability of family planning services allows couples to meet their desired birth spacing and family size and contributes to improved health outcomes for children, women, and families [ 13 , 14 , 15 ].

Two important consequences might result from choosing a family planning method without medical advice; first, the likelihood of occurrence of avoidable side effects and complications which might affect the users’ beliefs and behavior; second, due to resorting to traditional methods of family planning, high rates of contraceptive failure occurs. Dissemination of information about options for contraception should become a part of the routine counseling in primary health care centers and other health care institutions as any decision about contraceptive use should be based not only on contraceptive risks/benefits, but also on the efficacy of the method, individual’s life situation, and the level of risk particular to the user characteristics and the life consequences of childbearing for the mother and child [ 16 , 17 ].

Our study has a number of inherent limitations. Firstly, it is a cross-sectional study, so relationships between the predictor variables and the dependent variables can only be described as general associations not a causal relationship. Second, as an interview survey, social desirability bias cannot be eliminated, and recall bias for some events might happen. Third, our study participants were completely from the urban population, so the result cannot be extended to the rural population in the region. However, the current study provides insights to policymakers and health care providers about awareness, attitude, and barriers affecting family planning practice among women in the region to offer need-based health services and to guide health awareness efforts.

This study revealed that most women in the urban Hail community, northern Saudi Arabia, were aware about and have a positive attitude towards family planning. The majority of women ever used, and two-thirds of them were currently using any family planning method/s, which is higher than the national estimate for Saudi Arabia. However, only one in five who received counseling for the type of contraceptive method used from healthcare providers. The unavailability of family planning services in primary health care centers impedes getting professional counseling. It is imperious to consider family planning clinics to provide quality family planning services.

Availability of data and materials

Available from the corresponding author on reasonable request.

Abbreviations

Primary health care

Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J (2006) Family planning: the unfinished agenda. Lancet 368(9549):1810–1827. https://doi.org/10.1016/S0140-6736(06)69480-4 PMID: 17113431

Article   PubMed   Google Scholar  

World Health Organization Regional Office for Europe (2000) Definitions and indicators in Family Planning Maternal & Child Health and Reproductive Health used in the WHO Regional Office for Europe. [Cited 2020 August 3]; Available from: https://apps.who.int/iris/handle/10665/108284 .

Kantorová V, Wheldon MC, Ueffing P, Dasgupta ANZ (2020) Estimating progress towards meeting women’s contraceptive needs in 185 countries: a Bayesian hierarchical modelling study. PLoS Med 17(2):e1003026. https://doi.org/10.1371/journal.pmed.1003026

Article   PubMed   PubMed Central   Google Scholar  

World Health Organization. Family planning/contraception methods fact sheet (2020). Updated 22 June 2020. [cited 2020 Aug. 6]; Available from: https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception .

Family Planning Rights and Empowerment Working Group (2014) Family planning 2020: rights and empowerment principles for family planning. [cited 2020 Aug. 23]. Available from: http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2014/12/FP2020_Statement_of_Principles_FINAL.pdf .

United Nations (2019) World population prospects 2019. [cited 2020 Aug. 13]; Available from: https://population.un.org/wpp/Graphs/Probabilistic/FERT/TOT/682 .

World Health Organization, Regional Office for the Eastern Mediterranean (2013) Country cooperation strategy for WHO and Saudi Arabia 2012 - 2016. [Cited 2020 Aug. 19]; Available from: http://applications.emro.who.int/docs/CCS_Saudia_2013_EN_14914.pdf .

The World Bank (2020) Labor force, female (% of total labor force) | Data [Internet]. [cited 2020 June 21]. Available from: https://data.worldbank.org/indicator/SL.TLF.TOTL.FE.ZS .

Cochran, W. G. (1963) Sampling techniques, 2. Aufl. John Wiley and Sons, New York, London. Preis s. https://doi.org/10.1002/bimj.19650070312 .

al-Nahedh NN (1999) The effect of sociodemographic variables on child-spacing in rural Saudi Arabia. East Mediterr Health J. 5(1):136–140 PMID: 10793791

CAS   PubMed   Google Scholar  

United Nations, Department of Economic and Social Affairs, Population Division (2020) World fertility and family planning 2020: highlights. [Cited 2020 June 27]. Available from: https://www.un.org/en/development/desa/population/publications/pdf/family/World_Fertility_and_Family_Planning_2020_Highlights.pdf .

Alsaleem MA, Khalil SN, Siddiqui AF, Alzahrani MM, Alsaleem SA (2018) Contraceptive use as limiters and spacers among women of reproductive age in southwestern, Saudi Arabia. Saudi Med J 39(11):1109–1115. https://doi.org/10.15537/smj.2018.11.22817 PMID: 30397710; PMCID: PMC6274655

Centers for Disease Control and Prevention (1999) Achievements in public health, 1900–1999: family planning. MMWR Weekly 48(47):1073–1080 [cited 2020 June 18]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm

Google Scholar  

Sonfield A, Hasstedt K, Gold RB (2014) Moving forward: family planning in the era of health reform. Guttmacher Institute, New York [cited 2020 Aug 3]. Available from: https://www.guttmacher.org/sites/default/files/report_pdf/family-planning-and-health-reform.pdf

Gipson JD, Koenig MA, Hindin MJ (2008) The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Stud Fam Plann. 39(1):18–38. https://doi.org/10.1111/j.1728-4465.2008.00148.x PMID: 18540521

National Research Council (US) Committee on Population (1989) Contraception and reproduction: health consequences for women and children in the developing world. National Academies Press (US), Washington (DC) PMID: 25144060

World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge for Health Project. Family planning: a global handbook for providers (2018 update). Baltimore and Geneva: CCP and WHO, 2018. [Cited 2020 June 21]. Available from: http://www.who.int/reproductivehealth/publications/fp-global-handbook/en/ .

Download references

Acknowledgements

We thank directors and healthcare staff in maternity hospital and participated PHC centers, Hail City, Saudi Arabia, for facilitating the study. We also thank the participant mothers for their agreement, patience, and allowing the time to carry out the interview.

No funding was received.

Author information

Authors and affiliations.

Family & Community Medicine Joint Program, Hail, Saudi Arabia

Ghzl Ghazi Alenezi

Academic Affairs & Postgraduate Studies, General Directorate of Health Affairs, Najran, Saudi Arabia

Hassan Kasim Haridi

You can also search for this author in PubMed   Google Scholar

Contributions

GA conceived the study idea, participated in development of the data collection tool, carried out all interviews, and participated in interpretation of the study results. HH adapted the study idea, designed the data collection tool, carried out data analysis and interpretation of results, and wrote the manuscript. All authors have read and approved the manuscript

Authors’ information

GA: family medicine senior resident, Family & Community Medicine Joint Program, Hail, Saudi Arabia. HH: Consultant Public Health Medicine; the Designated Institutional Official (DIO) of Academic Affairs & Postgraduate Studies, Health Affairs, Najran; ex Head of the Research Department, Health Affairs, Hail Region, Saudi Arabia.

Corresponding author

Correspondence to Hassan Kasim Haridi .

Ethics declarations

Ethics approval and consent to participate.

The protocol of the study was reviewed and approved by the Regional Bioethics Committee of the General Directorate of Health Affairs, Hail region, with the approval number 2019/22 dated October 6, 2019. Agreed participants signed the study consent form. Participants were guaranteed anonymity, confidentiality of the responses, and voluntary participation, and they can withdraw for any reason and any time, without any implications.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Alenezi, G.G., Haridi, H.K. Awareness and use of family planning methods among women in Northern Saudi Arabia. Middle East Fertil Soc J 26 , 8 (2021). https://doi.org/10.1186/s43043-021-00053-8

Download citation

Received : 28 October 2020

Accepted : 22 March 2021

Published : 01 April 2021

DOI : https://doi.org/10.1186/s43043-021-00053-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Contraceptives
• Family planning
• Saudi Arabia

Americans navigate family planning amid concerns about finances and the planet’s future

Ali Rogin Ali Rogin

Satvi Sunkara Satvi Sunkara

Leave your feedback

• Copy URL https://www.pbs.org/newshour/show/americans-navigate-family-planning-amid-concerns-about-finances-and-the-planets-future

The U.S. birth rate hit a record low in 2023, but data suggests that over the past 30 years, the number of adults who want to have children has remained relatively stable. So why aren’t more Americans having children or expanding their families? Ali Rogin explores the complexities of today’s family planning and speaks with family demographer Karen Guzzo to learn more.

Read the Full Transcript

Notice: Transcripts are machine and human generated and lightly edited for accuracy. They may contain errors.

Last year, the U.S. birth rate hit a record low. But data suggests that over the past 30 years, the number of adults who want or wish they had children has remained relatively stable. So why aren't they having children or expanding their families? Ali Rogin explores some of the complexities of today's family planning.

Over the past few weeks, we've been speaking with Americans who say they want to have a child or grow their families about why they're hesitant to do so. Their answers were varied and complex, just like the solutions they said would help them change their minds.

Catherine Clark, Washington, DC:

I always wanted kids. I love kids. But economically, I don't really know of anyone who can swing it anymore. Even parents that are working full time, they can't afford childcare. They don't have a village to help them raise them.

Cecilia La Torre Ramirez, Alexandria, Virginia:

I'm grateful that we are in like, a stable financial situation. Still, it's difficult to raise a child. We don't have any family close by. We have friends who also have kids. So they are also busy taking care of their families. It's difficult. We don't have anyone.

Trevor Williams, Tulsa, Oklahoma:

Every year, there comes out a new statistic of whether or not we've hit the turning point for climate change. And that's something that I take into consideration when it comes to starting a family, because I don't want to raise a child in a world that every year gets closer and closer to becoming uninhabitable.

Cazoshay Marie, Phoenix, Arizona:

In May of 2017, I was struck by a car that was traveling 48 miles per hour while crossing the street. And as a result of that, I ended up with several long term disabilities and conditions. And really through this experience, my son actually became a caregiver to me. Our roles were kind of reversed, and so that's not something that I would willingly want to be in another position to do again. Would I be able to handle the parent teacher conferences, the transportation, making meals, changing diapers? As a disabled person, those are all considerations.

Erica Staley, Chicago, Illinois:

Pretty much as soon after having my first child, I agreed that weren't going to try and have a second with all the other uncertainties. And that was heartbreaking. We really did want to, and were kind of hoping that could be possible, but it just wasn't. We had met with a financial advisor, and he was pretty clear. You're either going to be able to afford childcare or retirement savings like, you can't. You're not really going to do both in the next five years just because of the cost.

Catherine Clark:

Everyone is incredibly stressed out. Everyone's incredibly broke. We're all trying to help each other. We're all grasping at straws. And I don't know if I want that for my future.

Trevor Williams:

My sister, I know she spends about a quarter of her salary every month on childcare expenses, even with daycare expenses and such like that. I know there's additional things such as putting extra food on the table and covering medical expenses.

Cazoshay Marie:

There are a lot of things that I think that the government, the society and community can do to kind of help with some of those concerns that are not just for me as a disabled parent, but I think for anyone who would be considering or hesitant to expand their family, that would be just offering more support, more community based support, as well as just the resources for the practical knowledge, parenting classes, things of that nature.

Erica Staley:

If universal child care was an option, and we didn't have to worry about that, if universal healthcare was an option, and I wouldn't have to wonder if I can anticipate regular maternal care, high quality maternal care, while I was pregnant, then, yeah, we absolutely would have made an effort to expand our family. For sure.

We need rent subsidies because no one can afford it. We need to be able to get the cost of food and housing under control because right now they are spiraling out.

Cecilia La Torre Ramirez:

I think we need to have paid leave for all because many families are the sandwich generation. You have to take care of your parents who are elderly, and you have to take care of your kids. People work really hard. It's not that we don't work hard, but it's not enough.

For more on this topic, I'm joined by Karen Guzzo, a family demographer and the director of the Carolina Population Center at the University of North Carolina.

Karen, thank you so much for being here. First of all, tell us about this moment that we're in. Is it different than other times in this country's history that we've seen declines in fertility?

Karen Guzzo, The University of North Carolina at Chapel Hill: That's a great question. And so what I would say is we've seen fertility fall below what we call replacement level before, and the United States has come back up above this, above that sort of mythical two children per woman level.

What's interesting now, though, is that it's been sustained declines pretty much year after year since the Great Recession. And so we're starting to think, as demographers, maybe the decision making that goes into whether people have children or going to have another one has changed.

What are the factors weighing on people's minds these days?

Karen Guzzo:

Well, people are certainly not being selfish about deciding to have kids. They're actually being really deliberate having children. And so they're worried about their ability to combine work and family, their ability to provide for their future children, their ability to afford to give sort of a lifestyle that will suggest that their kids have opportunities for success in the future. So they want to be able to afford to buy a house. They want to send their kids to safe and reliable childcare centers and then ultimately safe schools. They want a world in which they think climate change will not delay their children's chances of success.

And so they're giving these factors a lot of thought, and they're hard to measure. In sort of the typical surveys that we used to use and some of the earlier theories, we had to kind of understand fertility.

There's been a particularly steep decline in terms of births from people who are much younger to what do you attribute that?

The research really shows that for teens and those in their early 20s, traditionally, those births have largely been sort of unplanned and unintended. And so, these are births that people are able to avoid having, avoiding getting pregnant in their late teens or early 20s, when perhaps they have less stable relationships, when they have fewer economic resources. So this is good news.

The problem is that if people are avoiding having births at ages and in circumstances where we might think they are not ready to be parents, is to try to understand when they think they will be ready to have kids and make sure that we as a society have those conditions in place for them.

We need to make sure that they reach their later 20s and their 30s and feel like, okay, now I have what it takes to be a good parent, and I have the resources and life circumstances where I can, you know, go ahead and make those decisions.

Sometimes we hear of people in these categories being labeled as selfish, or they're being insinuations that they're being selfish. What do you make of those conceptions?

That's really not the case. My research and the research of many others is showing that people have the set of prerequisites in mind that they want to be able to meet, to make sure that they are able to be good parents, that they are able to provide what their kids need, that they can meet the needs of their relationships and their family and friends.

And so they're really being quite considerate about this. Being a parent is really hard in the United States, and we have declining social mobility. And so people are being very careful about this. If they think they can't give their kids good opportunities, they're willing to say, hold on, I should wait. I'll wait till I have kids and tell them in a better circumstance.

Lastly, what are some of the other solutions that other countries are trying to put in place to avoid continuously declining birth rates? And is any of it working?

Well, there are countries that are offering cash allowances or tax breaks. Those don't seem to be particularly effective. The more effective policies are those that are kind of a package of deals. So having a robust childcare infrastructure, one that people can find easily, they can afford it is high quality that's important. Having parental leave for both mothers and fathers is important.

Most policies that are effective are the ones that grow the economy for everybody, but also have a strong social safety net that really makes sure that young people and young families have access to the resources they need, like childcare, like paid leave, but also aren't overburdened by housing costs or student loan costs.

Doctor Karen Guzzo at the University of North Carolina, thank you so much for joining us.

Thank you for having me.

Listen to this Segment

Watch the Full Episode

Ali Rogin is a correspondent for the PBS News Hour and PBS News Weekend, reporting on a number of topics including foreign affairs, health care and arts and culture. She received a Peabody Award in 2021 for her work on News Hour’s series on the COVID-19 pandemic’s effect worldwide. Rogin is also the recipient of two Edward R. Murrow Awards from the Radio Television Digital News Association and has been a part of several teams nominated for an Emmy, including for her work covering the fall of ISIS in 2020, the Las Vegas mass shooting in 2017, the inauguration of President Barack Obama in 2014, and the 2010 midterm elections.

Satvi Sunkara is an associate producer for PBS News Weekend.

Support Provided By: Learn more

More Ways to Watch

Educate your inbox.

Subscribe to Here’s the Deal, our politics newsletter for analysis you won’t find anywhere else.

Thank you. Please check your inbox to confirm.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Perceptions of family planning services and its key barriers among adolescents and young people in Eastern Nepal: A qualitative study

Navin bhatt.

1 B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Bandana Bhatt

2 Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal

Bandana Neupane

3 Nepal Health Sector Support Programme (NHSSP)/DFID/Ministry of Health and Population, Kathmandu, Nepal

Ashmita Karki

4 Central Department of Public Health, Institute of Medicine, Kathmandu, Nepal

Tribhuwan Bhatta

5 Department of Electronics and Computer Engineering, Institute of Engineering, Tribhuvan University, Lalitpur, Nepal

Jeevan Thapa

6 Department of Community Health Sciences, School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal

Lila Bahadur Basnet

7 School of Public Health and Community Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Shyam Sundar Budhathoki

8 Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom

Associated Data

All relevant data are within the manuscript and its Supporting Information files.

Introduction

Family planning methods are used to promote safer sexual practices, reduce unintended pregnancies and unsafe abortion, and control population. Young people aged 15–24 years belong to a key reproductive age group. However, little is known about their engagement with the family planning services in Nepal. Our study aimed to identify the perceptions of and barriers to the use of family planning among youth in Nepal.

A qualitative explorative study was done among adolescents and young people aged 15–24 years from the Hattimuda village in eastern Nepal. Six focus group discussions and 25 in-depth interviews were conducted with both male and female participants in the community using a maximum variation sampling method. Data were analyzed using a thematic framework approach.

Many individuals were aware that family planning measures postpone pregnancy. However, some young participants were not fully aware of the available family planning services. Some married couples who preferred ’birth spacing’ received negative judgments from their family members for not starting a family. The perceived barriers to the use of family planning included lack of knowledge about family planning use, fear of side effects of modern family planning methods, lack of access/affordability due to familial and religious beliefs/myths/misconceptions. On an individual level, some couples’ timid nature also negatively influenced the uptake of family planning measures.

Women predominantly take the responsibility for using family planning measures in male-dominated decision-making societies. Moreover, young men feel that the current family planning programs have very little space for men to engage even if they were willing to participate. Communication in the community and in between the couples seem to be influenced by the presence of strong societal and cultural norms and practices. These practices seem to affect family planning related teaching at schools as well. This research shows that both young men and women are keen on getting involved with initiatives and campaigns for supporting local governments in strengthening the family planning programs in Nepal.

An unmet need for family planning results in unintended pregnancies and illegal abortions. This has major health and social implications and is often the leading cause of maternal and child mortality in low-income countries [ 1 , 2 ]. An estimated 214 million women of reproductive age lack access to contraception resulting in an estimated 67 million unintended pregnancies, 36 million induced abortions, and 76,000 maternal deaths each year [ 3 ]. Family planning (FP) is a key intervention to limit these adverse health outcomes [ 4 – 6 ]. Such interventions can prevent 90% of abortions, 32% of maternal deaths, 20% of pregnancy-related morbidity globally, and reduce 44% of maternal mortality in low-income countries [ 1 , 7 ]. FP reduces adolescent pregnancies, prevents pregnancy-related health risks, and helps to prevent HIV/AIDS [ 8 ]. Access to contraception promotes education, raises the economic status of women, and gradually empowers them resulting in improved health outcomes and better quality of life [ 3 , 5 , 9 , 10 ].

Global data show that only 32% of married women from low-income countries currently use modern contraceptives [ 9 ]. According to the Nepal Demographic Health Survey 2016, the total fertility rate was 2.3 births per woman, which is declining and approaching replacement fertility. This is an important achievement. However, the modern contraceptive prevalence rate (mCPR), which is 43%, is still below the target in Nepal [ 11 ]. Nepal has consistently failed to reach the target of mCPR for the past 20 years. The future projection of mCPR for 2030 is 60% [ 5 ], which may be a distant dream if the barriers and enablers are not identified on time to strengthen the current efforts.

Expanding the coverage and access to effective contraceptive methods are essential to meet the Sustainable Development Goals and to achieve universal access to reproductive healthcare services by 2030 [ 11 , 12 ]. For this, the government of Nepal has started a FP program with a focus on increasing the use of FP services and reducing the unmet need [ 5 , 11 ]. However, various factors negatively influence the delivery of FP services including lack of information, limited awareness of dissemination activities, lack of trained staff, and various cultural and religious factors [ 13 ].

Family planning is a choice for many youth, but they often experience barriers such as negative provider attitudes, long distances to healthcare facilities, and inadequate stock of preferred contraceptives [ 13 , 14 ]. Nepali youth are reluctant to use modern contraceptives due to misconceptions about long-term fertility risks, fear of side effects and overall lack of deeper knowledge [ 15 , 16 ]. Besides, FP decisions are mostly dependent on male household members, including husbands and other elder members [ 17 , 18 ]. Married women whose husbands are away as migrant workers face unique contraceptive challenges. When their husbands return home for a few weeks in a year, these women are not prepared with their contraceptives, which can result in unwanted pregnancies [ 18 ].

The extrapolation of the available literature on FP use among adults from Nepal and elsewhere suggests that youth is an under-researched population when it comes to FP There is also a dearth of evidence on perception and key barriers to the use of FP measures in this population. Hence, this study aims to identify the perceptions of the FP services and barriers to the use of FP among the youth in Nepal to assist policymakers in designing appropriate interventions to strengthen the family planning programs in Nepal.

Material and methods

Ethical considerations.

The study received ethical approval from the Institutional Review Committee of B.P. Koirala Institute of Health Sciences, Dharan, Nepal as per the Undergraduate Research Proposal review process (URPRB/01/015). We obtained informed written consent from all participants aged 18 and above. For minors, we obtained assent from the parents of the participants with the participants’ permission. For those who could not read, the information sheet was read aloud by a volunteer, verbal consent was given, and a thumbprint, in the presence of a witness, was used in place of a signature. To maintain the confidentiality of the information and the privacy of the participants, only selected participants and the moderators attended the sessions. Personal identifiers and locator information were not collected, and any identifying information accidentally mentioned was removed from the text before the analysis.

Study setting

The study was conducted among the participants from Hattimuda village of Morang district in Province One of Nepal. Hattimuda village is a community service area of B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. BPKIHS is a public-funded health sciences university, which follows a teaching district concept adopted as a part of its community-based medical education curriculum. BPKIHS also runs a tertiary hospital service for the population of eastern Nepal [ 19 ]. There is a public health facility in Hattimuda village that provides primary health care services including FP services such as the distribution of contraceptives. The nearest secondary and tertiary levels of healthcare services are available 18 kilometers away in Biratnagar, which is the provincial capital and the headquarters of Morang district. According to the 2017/18 annual report of the Department of Health Services, the contraceptive prevalence rate of Morang district is 54.6% [ 5 ] whereas the unmet need for FP in Province One as per the Nepal Demographic Health Survey 2016 is 25% [ 11 ].

Study design

This was a qualitative study with an exploratory design to gather a deeper understanding of the perception of FP and its barriers. Focus group discussions (FGD) and in-depth interview (IDI) methods were used. The overall study lasted from November 2017 to October 2018.

Study population and sampling technique

Adolescents and young people between 15 and 24 years of age from Hattimuda were included in the study. We used the maximum variation sampling method to enroll participants. Pretesting, including one FGD and four IDIs, was conducted among residents in another village of the same district. The pretesting guided the selection of participants for FGDs and IDIs. Accordingly, FGDs were conducted among adolescents and young people, separately for male and female participants to allow for free expression of views during the discussion of potentially sensitive issues. Moreover, the respondents recommended that people at the forefront of the community such as the village leaders, schoolteachers, community health volunteers, religious leaders, youth leaders, and students be selected for the interviews to gather more information. Along with the recommendations from the pretesting, brainstorming was done with community volunteers to generate a list of people who understood the issues of adolescents and young people. More volunteers were added to the list upon the recommendation of the initial respondents. Thus, participants representing diverse backgrounds in terms of gender, profession, education, and social status, were selected. The IDIs were done among 25 prominent people in the community, which included leaders, school teachers, female community health volunteers, healthcare professionals working at the health post and FP service centers, and youth leaders from youth clubs. Health care providers were included in the interviews as their views would be invaluable due to their experience as FP service providers and as witnessing the health issues faced by youth. The teachers are regarded highly for their knowledge and opinions in Nepali communities. So, they were selected for the IDI to provide more insight into the educational barriers to FP and to help in youth mobilization for FP activities. Considering the vital role of local leaders in influencing the implementation and regulation of population-level activities in the village, they were selected for IDI. Six focus groups were conducted with a total of 48 respondents ( Fig 1 ).

Data collection

The Focus Group Discussions (FGD) and In-depth interviews (IDI) were conducted by the researchers within the team with prior experience in qualitative research methods. The interview team included an undergraduate medical student, two postgraduate resident doctors, a public health graduate, and a public health academic researcher. Before data collection, an orientation session was conducted for the interviewers using the interview schedule and the topic guide. The IDI guidelines and interview schedules were developed from the literature review and were modified after pretesting. Validation of the tools was ensured by using the Item Objective Congruence (IOC) index and consultation with academics with experience in FP research. Using a semi-structured open-ended questionnaire, the participants were assessed on their knowledge and perceptions regarding sexual and reproductive health (SRH) and FP, SRH problems faced by youth, challenges and barriers to use of FP services, the role of youth in combating the perceived challenges, and suggestions for enhancing the use of services. Data were considered to have reached saturation when the responses from participants became repetitive and/or no new responses were received.

Focus group discussions

A representative group of youth from diverse backgrounds who could provide credible information about practices and factors affecting the use of FP in the community was selected. Separate FGDs were held for girls and boys to allow for free expression. A moderator was responsible for guiding the discussion and a note-taker for taking the notes, including recording non-verbal responses and ensuring the audio recording. A total of 6 FGDs, each containing 8 homogenous participants, were conducted. Each individual participated once in the FGD. Every member of the group could make their contribution to any question posed before proceeding to another question. Each FGD lasted for 60–90 minutes on average. The discussion was done in the Nepali language as preferred by participants and later translated into English during transcription.

In-depth interviews

In-depth interviews with the key stakeholders were conducted using the Interview Schedule after obtaining the informed consent and audio-recorded with participant permission. A total of 25 IDIs were conducted for the average duration of 30–45 minutes, at a location convenient to the participant, which included their homes and offices.

Data management and analysis

A framework method of thematic analysis was used. The analysis included stages of transcription, familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting the data into the framework matrix, and interpretation of the data. The data collected from the focus groups and interviews were transcribed verbatim. The notes taken were used as a guide to segregate the responses by different respondents during the discussion. An independent researcher conversant in the Nepali and English languages cross-checked the transcripts for accuracy and preservation of original meaning during translation. Preliminary codes were assigned to the available data and then organized into thematic units that were continually revisited and revised as necessary. To ensure consistency of data and findings, two authors were involved in data analysis and reporting. The recordings were stored and accessed by the research team only and were destroyed after the analysis and final report preparation.

Operational definition

According to UNFPA, all persons within the age of 15–24 years are considered youth [ 20 ].

The baseline characteristics of the participants can be seen in Table 1 .

The responses from the IDIs and FGDs revealed four broad themes. Within each broad theme were several substantive sub-themes that emerged from the data. The themes and subthemes are summarized in Table 2 below.

Theme 1: Knowledge and perceptions of FP

A) knowledge and sources of information on fp.

Participants demonstrated awareness of some form of FP. However, some knew nothing about it. Health workers were commonly referred to as the sources of information, while some also mentioned peers, radio, television, and books. Male participants openly disclosed their sources of information on FP while some female participants were reluctant to share their sources.

b) Perceptions of FP

Perceptions of FP varied among participants. Some male participants inferred FP measures as women’s business and did not show any interest in talking more about it. Some referred to FP as using condoms during intercourse, while others referred to oral pills and injectable hormones as FP. Some female participants looked at FP as a way of avoiding unwanted pregnancies.

“My sister used to say that she has been using injection (Depo-Provera) to control unwanted pregnancy . I think FP is about the same . ”- 19 years Female , FGD participant

Theme 2: Preference for FP methods and decision-making

Some female participants reported preference for traditional methods of contraception such as coitus interruptus and calendar method over modern methods. These people used modern methods of FP to start with, which they discontinued later due to the side effects. Participants also stated that the health facilities that provide FP services were far, and hence they had no alternative other than natural methods. Male participants hardly mentioned visiting any health facilities for FP purposes.

“Most of our clients who come for it (FP) are women. Even condoms are collected by women. Men rarely come alone or as couples for FP services.” - 35 years old Female, FP service provider, IDI participant

Yet husbands were responsible for the decision-making about FP and choices of methods for most couples. Some participants (both male and females) mentioned that women rather than men should use permanent FP measures. They believed that men being the breadwinner of the family, should not undergo sterilization, for example, as it would make them physically weak.

“Though I love my wife and I am concerned about her. But I have no options. I must work in a factory. I need to lift heavy weights there. All the major house chores are also done by me. These things (sterilization) would make me weak. How can I earn my livelihood then?”- 22 years Male, FGD participant

Some female participants expressed their concerns regarding the use of permanent FP methods. They mentioned that they had already been through various phases of pain, be it during menstruation, pregnancy, or delivery which has made them weak. Thus, they prefer their husbands to undertake any measures.

In contrast, unmarried participants stated that they would rather discuss and decide together with their partners regarding which method to choose in the future. Despite this interest, women were not sure how to engage their husbands in discussion. Some female participants said that they could not persuade their future husbands to use contraceptives as it would be disrespectful, whereas a few male participants believed it was a woman’s responsibility to use FP methods.

“It (FP) is stuff to be done by the women . So , there is no doubt about who would be doing it . Moreover , people would laugh at me if I do it -20 years Male , FGD participant “ Women have already gone through much pain in bringing up and taking care of the children and again keeping this stuff (FP) in their head is unjustifiable . As such, in comparison to the female operative procedure, I have heard that the male one is simple, less time consuming, and does not bring many complications . So, why not we men take the lead on this? ” -25 years Male, Youth leader, IDI participant

Theme 3: Barriers and challenges in the use of FP

A) supply-side barriers and challenges.

Participants indicated that contraceptive services are not always accessible nor affordable in rural areas. Health facilities are far, and many people feel reluctant to travel in a hot climate. Participants who were reluctant to travel said they were doubtful that the health facilities would have the methods in stock even if they managed to walk the distance. Others who were reluctant said they would be unable to afford the contraceptives from a private medical store regularly. A few participants raised the issue of privacy and unavailability of all services at the health centers. Similarly, young males from the community complained that the services at the health post were focused only on mothers and married couples, while the boys and the unmarried people were not given much attention. For this, they suggested changing the term to something other than FP because they believed that FP should include not only those who had families.

Participants expressed their frustration that FP and SRH services in their village had not been running well for more than a year. They felt that the government was not doing anything about it either. Some students expressed the need for an integrated curriculum at school covering every aspect of SRH and FP that would ensure adequate and proper knowledge of such crucial subjects. Despite the students’ desire to learn and understand FP, their teachers are often reluctant to talk about FP in detail. The participants also indicated that family members, in general, forbid girls and women from getting involved in FP awareness activities.

“Though we are eager to learn about those lessons (reproductive organs and health), our teacher skips them. They tell us to read it by ourselves.” -18 years Female, FGD participant

b) Demand-side barriers and challenges

A few participants were confused about which method to choose, how to use it properly and did not even know where to seek FP services locally.

“My husband works abroad. Last year, when he came home during Dashain (festival), we had (intercourse). Later, he returned to his workplace. Meanwhile, I came to know that I was pregnant, after 3 months. I was shocked to hear that. We already had 3 children; 2 of them were unplanned. I did not have enough information about contraceptive measures in this situation. Had I known about them; I would have used them. I had serious trouble travelling to get it aborted.” - 24 years Female, FGD participant

Some female participants expressed their reluctance to use FP methods due to their own or other people’s past experiences and the fear of side effects, including vaginal bleeding, spotting, abdominal pain, nausea, vomiting, headache, acne, and infertility. These female participants expressed the need for a single-use FP method with fewer side effects for women which could be used without their husbands’ consent. The male participants were worried about the risk of unwanted pregnancy due to the breaking of condoms and a few participants also expressed concern that they experienced allergic reactions after the use of condoms. Moreover, they were concerned about not having any alternative methods of contraception other than condoms.

“I have a much bitter experience. I was using Depo injection before. But I started having over bleeding for which I was admitted to the hospital for a few days. Later, I was switched to implants but they also did not suit me. In between I also used pills, but they aggravated my acne and I was feeling nauseated every day. Uff…. I am fed up now. I swear, I won’t ever use any methods.” - 19 years Female, FGD participant “I have heard that keeping these things (Copper-T) in the uterus can cause cancer. Better to avoid it.” - 20 years Female, FGD participant “There aren’t many choices for men. I think using a condom during sex is like tying plastic around the tongue and eating food.” - 21 years Male, IDI participant

Religious and ethnic variation affected use of FP. Participants reported that people belonging to upper caste groups used FP measures more than lower caste groups. Likewise, people who had migrated from the hilly areas used FP services, whereas people from the local ethnic community did not use as they were less aware of it. FP decisions among young people seem to be influenced largely by religious beliefs, stigma, and the perceived role of men and women based on existing social norms. Some participants regarded children as a gift from God and denied using any FP methods. Some believed using FP was going against the law of nature, religion, and culture; thus, they would not avoid childbirth, but rather celebrate every birth. Some indicated that if couples did not have children within 1–2 years of marriage, then people would question the woman’s fertility. Most couples preferred sons to daughters as they believed sons would look after them and their property, while the daughters would be married and sent away, resulting in avoidance of FP measures until they have a son. Some couples even wished to have two sons because if anything unfortunate happened to one, the other son would still be with them to carry the generation forward.

“My aunt gave birth to a son after 5 successive daughters. She is pregnant again this time in the hope to have a son. She says that she cannot trust to have only one son because if anything happens to their only son, then she will have no one to pay tribute after her death.”- 22 years Female, FGD participant

Participants also said that people felt shy talking about FP openly. Female participants also felt uncomfortable asking for contraceptives with male health personnel at the health post. Similarly, teachers felt uncomfortable teaching about reproductive health and FP as their children and relatives could be present as students in the classroom. Participants indicated that some students would laugh and smile, making it difficult for the teachers to run the classroom sessions smoothly.

It was reported by a FP service provider that some men opposed their wives using any FP measures as they perceived that the use of FP measures allowed their wives to become promiscuous when they go abroad for work.

“Some husbands working abroad forbid their wives from using any FP measures because they fear the use of FP measures may provoke a sexual relationship with someone else in their absence”- 30 years Female, Health professional providing medical abortion services, IDI participant

Theme 4: Role of youth and suggestions to improve FP

The youth were interested in getting involved in a “peer to peer education” approach to increase awareness among the community about FP use. This approach would include peer training programs, role-plays/dramas, and counseling sessions to break the key barriers linked with such services. Activities ranging from redesigning the school’s curriculum to strengthening FP services in primary care centers, and from launching mobile outreach clinics to facilitating “spousal communication” were intended to change attitudes and support gender equality in sexual and reproductive health. Participants emphasized forming youth centers and collaborating with other youth clubs in the village. Furthermore, they suggested bringing religious leaders, teachers, doctors, and politicians as advisors of the youth centers would be beneficial as they are influential members of the community.

“I feel bad for my sister who is not given much importance from my parents. She got married against her choice due to her parents’ pressure. Now, they are forcing her to have kids. She is just 15 and if she gets pregnant, what will happen to her health and her child, how can she take care of a baby? I had a long debate with my father yesterday. I have now decided to start a youth club to promote awareness regarding FP and preventing early marriage and teenage pregnancies.” - 23 years Male, FGD participant

Male participants indicated that family planning programs are effective only when men prioritize women’s autonomy. Moreover, they expressed disappointment with the local government for not encouraging the involvement of men in FP programs in their village. To help address this issue, they expressed their interest in supporting the local government in bringing inclusive FP programs to their village.

“For a long time, women have been using those (Contraceptives) by hiding. We are always in fear about what others would say if they came to know about us using it. This can be addressed through male involvement and support.” -24 years Female, FGD participant

This qualitative study provides in-depth information on the understanding and perceptions of youth in Eastern Nepal regarding FP. This study generated findings regarding knowledge and perceptions of rural residents regarding FP and its methods; decision-making and preference among participants; supply-side and demand-side barriers and challenges regarding the use of FP measures; steps that can be taken to improve their use; and the role of youth in increasing FP coverage. Although most participants knew something about FP, a few female participants were completely unaware of it. And while some participants agreed that all married couples should be using FP measures, some unmarried male participants believed that those measures should be exclusively for women. These men said that they would let their wives use them after getting married. Current FP methods for men are either coitus-dependent, such as condoms or withdrawal, or permanent, such as vasectomy. Limited choices for men may have resulted in misconceptions that contraceptives are mostly for women.

Men often claimed to be the sole decision-maker of the family on important matters, including those related to family health and contraception. In most circumstances, men solely decide the FP measure to be used without having a discussion with their partner. This might be one of the reasons why women are bound to adopt a FP method that is not necessarily their choice. Besides, this problem is further reinforced by the limited options of FP methods available for men other than condoms and permanent sterilization. These findings are supported by other studies in South Asia, where family planning measures are mostly considered women’s responsibility [ 21 – 24 ]. Health workers, peers, and mass media were the most common sources of information regarding FP similar to prior studies in India [ 21 , 24 ] and Nepal [ 22 ]. Participants in this study seemed to assign FP responsibility to the other gender in terms of using FP. This could mean that there is a gap in communication within the couples when deciding about FP. There is a need for further research to identify ways to improve communication among couples.

Religious and ethnic variation influence FP use. People belonging to privileged ethnic groups used FP measures more than underprivileged groups. This is despite family planning services being free for all citizens in Nepal. In this study, people who had migrated from hilly regions knew about and used FP services more than those belonging to the ethnic community in the local region. This is an area for further research to understand differences in knowledge and perceptions regarding FP between the population groups. This can be argued as a limitation of the current FP promotion programs, which may not have considered the different needs of people from different religious and ethnic backgrounds [ 25 ]. A few participants reported that their holy scriptures forbade them from using FP methods as they viewed children as a gift from God; any artificial process interrupting pregnancy or preventing the possibility of life is a religious offense for them [ 26 ]. Previous studies from Nepal have shown that this belief has long been rooted in some communities [ 27 – 29 ].

Apart from religious beliefs, fear of side effects, having experienced adverse health consequences after using hormonal contraceptives, and fear of potential infertility in the future are reasons for reluctance using FP methods among women [ 30 ]. Besides, we can speculate that language and cultural barriers, and fear of discrimination especially by male counterparts negatively influence the use of FP measures among some women despite their strong interest in using them. The use of IEC materials in raising awareness and empowering married couples for shared decision-making could help generate demand [ 28 , 29 ]. Local cultural taboos restrict open communication about safer sex measures and sexual health in Nepal, prohibiting young girls and boys from receiving adequate information and guidance regarding sexual and reproductive health and FP [ 31 ].

Most of the married women and men stated that the decision-makers of the family are men. The husband decides whether or not to use contraception, or more specifically, whether or not to let their wives use it. However, unmarried participants expressed their willingness to decide mutually with their spouse regarding FP use in the future [ 21 , 32 ]. Most women in this study seemed comfortable letting their male partners decide on contraceptives. This attitude could be explained by the patriarchal dominance in decision-making [ 19 , 33 , 34 ].

Some men mentioned that condoms inhibit their sexual pleasure, which is why they prefer women to use other methods instead. A study conducted in Far West Nepal and another nationwide study reported similar concerns among men [ 31 , 35 ]. Adolescent girls stated that they were not comfortable talking to a male health worker about FP or to a female worker in the presence of a male health worker, which has also been reported elsewhere [ 36 ]. Some women said that their husbands forbade the use of contraceptives because they thought that contraceptives would allow their wives to become promiscuous and that using FP was a sign of infidelity. This issue, however, was not raised by any men in the study. Some women reported violence as a consequence of using contraceptives without their husband’s consent. Prior qualitative studies also reported that women may suffer domestic violence for opposing their husbands. Studies suggest that a multi-sectoral action involving stakeholders from health, women’s rights, and education sectors is imperative to further research and address this issue [ 29 , 36 , 37 ].

Supply constraints (distance to a provider for getting contraceptives, out of stock, limited choices of contraceptives, unaffordable methods, etc.) could aggravate the unmet need for contraception. These constraints are similar to all regular supplies faced by the health system in Nepal. However, supply-side interventions such as increasing the number of health facilities distributing FP services, policy focusing on consistent operating hours, and full stock of a wide variety of FP methods could largely improve uptake and increase contraceptive coverage [ 18 , 38 ].

Most female participants did not speak up when asked about their perception of the role of men in FP. On the other hand, male participants explained that the role of the youth could be disseminating FP information, conducting awareness campaigns, organizing dramas and role-plays to educate people about the religious and cultural barriers of FP use, etc. With appropriate training, the young men said they would be willing to work for FP advocacy in the community.

Reproductive health leaders and planners should identify men who are willing to share decision-making authority with their wives and devise behavioral change interventions [ 39 ]. Male participation could support the FP programs and also help empower women [ 40 ]. The participants in the study expressed the need for the current FP programs to consider the community members as key stakeholders in planning FP programs. There is a need to further explore possible ways of working with the rural, marginalized communities and hard-to-reach or specific ethnic groups to improve their update of FP services [ 41 ]. There is evidence that mass media messages increase the likelihood of FP use, which could be considered by advocacy and dissemination programs [ 42 ]. Evidence from maternal and newborn health care research shows that interventions that engage men result in more equitable couple communication and shared decision-making. This may be a relatable concept to be considered for FP programs as well [ 43 ].

We urge those in charge of the health and sexual education curriculum to find ways to encourage teachers to give equal attention to these topics, including FP education, as they would to any other. It was reported that teachers were reluctant to teach about FP as they perceived the young students felt discomfort around this topic. Further research to identify innovative youth-friendly methods to teach sexual and reproductive health topics to students may be helpful. Youth groups should be regarded as important stakeholders in the redesign of school health curricula, particularly for their insight into culturally sensitive and otherwise effective ways for delivery. Health professionals, members of local organizations, and community leaders pointed to the necessity of addressing unmet FP needs and the stigma associated with FP use through community education approaches that take into account cultural norms and beliefs [ 44 ]. Interventions focusing on reproductive health education curricula involving school teachers could be considered [ 45 ]. Strengthening health systems, bridging service gaps, improving the integration of contraceptive services and counseling with routine health care are important strategies for increasing contraceptive uptake in eastern Nepal [ 22 ].

Among the study’s limitations was the fact that it was conducted in a single village in eastern Nepal. Our findings might differ if the sample had been drawn from other parts of the country. Although participants spoke fluent Nepali, some phrases used in local dialects could not be perfectly translated into Nepali or English. These responses could have been affected by social desirability as the participants may have felt constrained from speaking freely with people from health institutions. To help reduce these obstacles we held open meetings and drop-in sessions with the support of community youth to disseminate the purpose of the study and build rapport with the young people in the village before we approached them for the study. Moreover, participants were assured anonymity and confidentiality, which may have increased their willingness to participate in the research.

Conclusions

There appear to be information and communication gaps between women and men regarding FP services and programs. The information gap could be addressed by exploring ways to increase information uptake in schools through redesigning the curriculum delivery. Mass media may be used to disseminate appropriate health education regarding FP. Health institutions could consider approaches to create FP information and service centers that are male-friendly. The communication gap may be more deeply rooted in the culture and traditions of Nepalese society. In a mostly patriarchal society, further identification of motivations for men to participate in FP related activities could be challenging. However, it is promising that men may be willing to support their partners for FP decision-making and engage in strengthening FP programs through the “peer to peer” approach via youth-led centers and community clubs. Program managers and policy makers need to take into account the fact that youth are willing to contribute to ongoing FP programs. Doing so would help bridge the information and communication gaps between school education and practice. Innovative research to further explore perceived benefits by youth on the uptake of family planning, sexual and reproductive health services is needed.

Supporting information

Acknowledgments.

We extend our sincere thanks and regards to Dr. Agata Parfieniuk, Kirsty Lunney, and Anu Regmi for their invaluable contributions to the manuscript. We acknowledge the support received from Dr. Meika Bhattachan, Dr. Avinash Kumar Sunny, and Dr. Pawan Upadhyaya during data collection. The authors acknowledge the support received from the BPKIHS and participants for their participation in the study. Special thanks to Dr. Bibisha Baaniya, Dr. Garima Pudasaini, Dr. Soniya Gurung, Dr. Shristi Nepal, Bisha Baaniya, and Arshpreet Kaur for their generous support throughout the study.

Abbreviations

Funding Statement

The author(s) received no specific funding for this work.

Data Availability

• Intelligence
• Artificial Intelligence
• Data Intelligence
• Device Innovation
• Next Generation Digital Appliances
• Communications & Media
• Next Generation Communications
• Next Generation Display & Media
• Soc Architecture
• Security & Privacy
• Software Engineering

Publications

• R&D Centers
• Samsung Research America
• Samsung R&D Institute Canada
• Samsung R&D Institute United Kingdom
• Samsung R&D Institute Poland
• Samsung R&D Institute Ukraine
• Samsung R&D Institute Russia
• Samsung R&D Institute Israel
• Samsung R&D Institute Jordan
• Samsung R&D Institute India-Bangalore
• Samsung R&D Institute Philippines
• Samsung R&D Institute Indonesia
• Samsung R&D Institute Bangladesh
• Samsung R&D Institute China-Beijing
• Samsung R&D Institute China-Nanjing
• Samsung R&D Institute Japan
• Samsung R&D Institute Japan-Yokohama
• Samsung Research
• Meet Our Researchers
• Life at Samsung Research
• Vision & Mission

Bayesian Prompt Learning for Image-Language Model Generalization

Research areas, view publication.

• Follow University of Limerick on Facebook
• Follow University of Limerick on X/Twitter
• Follow University of Limerick on Instagram
• Follow University of Limerick on LinkedIn
• Follow University of Limerick on YouTube
• Follow University of Limerick on TikTok
• Search University of Limerick website

Ireland’s youngest female councillor graduates from University of Limerick

Newly elected Clare County Councillor, Rachel Hartigan credits her success to working twice as hard as the average candidate, as she graduated from University of Limerick today (Thursday) with a Bachelor of Arts in European Studies . 

Aged 22, Cllr Hartigan might be the youngest female councillor in the country, but she is no stranger to politics, having studied it in UL, been an active member of Ógra Fianna Fáil, and interned for Clare TD Cathal Crowe. 

It was during her summer internship with Deputy Crowe that Rachel first considered running in the local elections.  

“I never would have seen myself running for elected politics”, she explained, “but working in Cathal's office, a lot of the queries coming in were what I would imagine a local councillor should really be dealing with. 

“And that's when I realised I didn't know who my local councillor was, which seemed bizarre because I'm a politics student, interning in my TD's office, so I'm politically engaged.  

“And there's a lot that a local councillor deals with that has a huge impact on people's day-to-day lives, and I felt like we were really missing that strong voice.” 

Cllr Hartigan also credits a lack of representation amongst local councillors as a key factor that “spurred” her to action: “I think the median age of a councillor in Ireland is somewhere in the 70s bracket and I felt like that was extremely unfair. 

“When we look at why younger people don't come out in droves to vote a lot of the time, what stood out to me was we can't identify with our politicians. 

“We don't feel like they speak for us and they don't take the time to get to know what our issues are and what's important to us. 

“We're kind of written off and cast aside a lot of the time, and that really spurred me to action as well.” 

Rachel was one of more than 3,600 students to graduate at UL this week, and as a first-time local representative, she said her degree in European Studies has “without a doubt” helped to prepare her for her new role.  

“I could probably go through reams of actual content and papers and academic research that I did, I could give you exact examples that will come into play now in my role, but the main thing is critical thinking. It is the ability to be open minded and have the skills to do your own research, that is the biggest thing. 

“Because there is no guidebook, there is no induction to becoming a councillor, so I'm dealing with queries on housing, medical cards, roads, and footpaths, it's a broad range of issues and I've just started, so having the skills to be able to research properly and effectively and efficiently is huge and I genuinely wouldn't be able to do what I'm doing now had I not learned those really important research skills in UL. 

“Obviously studying politics comes into it but in terms of the other subjects I studied, my time studying marketing was hugely helpful, particularly in planning the campaign. 

“It was massively beneficial to have an understanding of consumer culture and behavior and being able to approach social media strategically, not just throwing something up for the sake of it. And they're all skills and habits that I picked up in my time as a student in UL.” 

Commenting on the landscape for a young woman running an election campaign, Cllr Hartigan said: “I did get a lot of ‘Oh you'll get elected because you're a woman, so you'll get the woman vote or you'll get elected because you're a young person.’ 

“I got elected because I worked my ass off, that's why I got elected.  

“There wasn't an army of young people or an army of women heading to the polling station for me, that's just not what happened, as much as that would have been really cool to see. 

“I got elected because I was canvassing for six or seven hours a day, I was on top of my social media, I was planning and hosting public meetings. 

“I was doing all of the things that you need to do to win, but I was working twice as hard as the average candidate because I had a lot to prove because I am a young woman, so it doesn't make it easier to run as a woman or a young person like some people suggest. 

“You actually have to prove yourself twice as much, and that's not fair, but I think the only way that that will change is if we get more women in and more young people in.” 

Cllr Hartigan credits the support of her family and lecturers in helping her throughout her election campaign.  

“My lecturer Dr Scott Fitzsimmons was very supportive, as was course director Dr Xosé Boan, who advised me to watch myself and my own mental health and well-being as well.  

“Sometimes you get these grand ideas and you're just all go, all the time and you forget to take the time to mind yourself, so I was really glad to have been told that.” 

Rachel does not hail from a political family, with her mother Rosaleen working as a medical secretary and her father Paul the Chief Information Officer for Electric Ireland Superhomes. However, that did not stop Paul from taking on the role of campaign manager.  

“We both learned together and he came out with me every single night, as did my mom. I could not have done it without them,” explained Rachel. 

“Obviously, the focus and the attention is on the candidate, but behind the scenes nobody does it alone, your family has to be on board.  

“It's a huge, massive team effort and for all the work that I was doing with my final year in UL and campaigning, they were out canvassing with me just as much, spending just as many hours at the doors.” 

A native of Parteen, Co. Clare, Rachel attended Parteen National School and now represents the Shannon Electoral Area.  

Reflecting on achieving the two major milestones of graduating university and winning her first election, she said it hasn’t fully sunk in yet. 

“I really felt like I was a campaign/Final Year Project robot, and it’s only the last few weeks I've had time to sit and process and reflect. 

“You never really look at your own accomplishments and achievements and say ‘oh my God, that was really good’. I think Irish people in particular, and women too, are really bad at giving themselves a pat on the back, even when it's well deserved. 

“I'm trying to take in the huge accomplishment, but it's hard to come out and say that and to even feel it, so that's something I'm working on at the moment, giving myself a little pat on the back.” 

• Human Reproduction
• Reproductive Medicine
• Family Planning

family planning final thesis.

• February 2020
• Thesis for: Bachelor Science Of Public Health Officer
• Advisor: SUPERVISOR BY: Dr. Hamze Ali Abdulahi, Hoodo Ziad Yousuf Hudda A/rahman Mire Hoodo Ahmed Hashi Haliima Mohamed Isma’el Fihiima Osman Mohamud

• Medical lecturer.

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations
• Mbalu Conteh
• Isata T C Kamara
• Kadiatu Conteh

• Indian J Prev Soc Med
• Rajesh Reddy

• Akshaya Kumar Mishra
• B WORLD HEALTH ORGAN

• Eliya M. Zulu

• Gunnar Thorvaldsen

• Rober M Kei

• Elizabeth J Mason

• Dawit Adane
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Recommended Articles
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

Impact of artificial intelligence on the planning and operation of distributed energy systems in smart grids.

1. Introduction

• Comprehensive analysis of AI applications: This review offers a thorough examination of artificial intelligence (AI) techniques across the key phases of power systems: generation, transmission, and distribution. We explore the specific roles AI plays in optimizing operations, enhancing efficiency, and improving system resilience.
• Identification of research gaps and challenges: We identify significant research gaps in the application of AI to power systems, particularly in areas such as the integration of renewable energy sources, the development of robust predictive models, and the interoperability of diverse energy systems. The paper discusses the current challenges in deploying AI, including technical, cybersecurity, and regulatory hurdles.
• Future perspectives and opportunities: This paper outlines future research directions and opportunities for further development of AI applications in power systems. We propose strategies for advancing AI integration, such as combining AI with emerging technologies like blockchain and IoT, and emphasize the need for interdisciplinary research to address the complex challenges of modern energy systems.
• Holistic framework for AI in power systems: We introduce a new holistic framework that illustrates the application of AI techniques across all phases of the power system, providing a structured approach to understand AI’s impact and guiding future research and development efforts.

2. Methodology

2.1. literature review process, 2.1.1. selection criteria.

• Publication date range: The review focused on articles published between 2014 and 2024 to capture the most recent advancements and trends in AI applications within smart grids. This range reflects the rapid development of AI technologies and their growing integration into energy systems.
• Journal quality: Only peer-reviewed journal articles were included to ensure the credibility and scientific rigor of the literature reviewed. Journals were selected based on their impact factor and relevance to the fields of energy, AI, and smart grid technology.
• Language: Only articles published in English were considered, as it is the predominant language of scientific discourse in this field.
• Keywords: The review focused on articles that included specific keywords and phrases, such as “artificial intelligence,” “smart grids,” “distributed energy resources,” “machine learning,” and “renewable energy integration.” These keywords were essential to capturing studies relevant to the research objectives.
• Relevance to research objectives: Studies were included if they addressed key themes such as AI-driven energy management, integration of DERs, challenges and opportunities in AI adoption, and regulatory and ethical considerations related to AI in energy systems.

2.1.2. Search Strategy

• Scopus: Known for its extensive collection of scientific publications, Scopus was used to identify articles across a wide range of disciplines, ensuring coverage of both technical and interdisciplinary studies.
• Web of Science: This database was selected for its comprehensive indexing of high-impact journals and its ability to track citation networks, allowing for the identification of influential studies and emerging trends.
• Search terms: A combination of specific search terms and Boolean operators was used to refine the search and capture relevant studies. The primary search terms included “artificial intelligence AND smart grids,” “AI AND distributed energy systems,” “machine learning AND energy management,” “AI AND renewable energy integration,” and “AI challenges AND opportunities in smart grids.”

2.2. Analytical Framework

2.2.1. methodological approach.

• Literature synthesis: A thorough synthesis of the selected literature was conducted to identify common themes, trends, and gaps in the research. This synthesis provides a foundational understanding of how AI is being applied across various aspects of smart grids, including demand forecasting, load management, and renewable energy integration.
• Case study analysis: Case studies of AI implementations in real-world energy systems were examined to provide practical insights into the challenges and successes of AI adoption. These case studies highlight specific applications of AI, such as predictive maintenance, virtual power plant optimization, and microgrid management, offering detailed examples of AI’s impact on system performance.
• Comparative analysis: A comparative analysis was performed to evaluate different AI techniques and algorithms used in energy systems. This analysis compares the effectiveness, scalability, and adaptability of various AI approaches, such as machine learning models, neural networks, and optimization algorithms, in addressing key challenges in smart grid operations.
• Thematic categorization: The literature and case study findings were categorized into thematic areas such as technical challenges, economic impacts, regulatory considerations, and ethical implications. This categorization enables a comprehensive understanding of the multidimensional aspects of AI applications in distributed energy systems.

2.2.2. Evaluation Criteria

• Performance improvement: The extent to which AI applications enhance the performance of energy systems, measured by improvements in efficiency, reliability, and grid stability. Key performance indicators include reductions in energy losses, increased accuracy of demand forecasts, and enhanced integration of renewable energy sources.
• Scalability: The ability of AI solutions to be scaled across different sizes and types of energy systems, from small microgrids to large interconnected networks. Scalability is assessed by examining the adaptability of AI technologies to varying levels of complexity and infrastructure.
• Cost-effectiveness: The economic viability of AI applications, including cost savings achieved through operational efficiencies and reductions in energy costs. Cost-effectiveness is evaluated by comparing the implementation and maintenance costs of AI solutions against the financial benefits realized.
• Regulatory compliance: The degree to which AI applications align with existing regulatory frameworks and policies, including considerations for data privacy, security, and ethical standards. Compliance is assessed by reviewing regulatory guidelines and identifying areas where AI solutions may need to adapt to meet policy requirements.
• Stakeholder acceptance: The level of acceptance and support from key stakeholders, including utility companies, policymakers, and consumers. Stakeholder acceptance is measured through qualitative assessments of stakeholder engagement and feedback on AI implementations.

3. AI Applications in Distributed Energy Systems

3.1. ai techniques and innovations, 3.1.1. overview of ai techniques, 3.1.2. innovations in ai, 3.1.3. ai techniques for planning and operation of distributed energy systems in smart grids.

• Artificial intelligence (AI) techniques have become foundational in transforming distributed energy systems by enhancing operational efficiency and optimizing resource utilization. Key AI techniques include machine learning (ML), deep learning, genetic algorithms, and multi-agent systems.
• Machine learning (ML): ML algorithms are widely used for predictive analytics and demand forecasting in smart grids, particularly in demand response applications where they help utilities predict and manage peak load scenarios [ 3 , 7 , 67 ]. These models excel at handling large datasets and learning from historical data to make accurate predictions, though they may require significant computational resources, limiting real-time applicability due to their complexity [ 70 ].
• Deep learning (DL): DL techniques, especially neural networks, are effective for complex pattern recognition and fault detection within power systems. They are used for real-time monitoring and power flow analysis, making them invaluable for managing unbalanced distribution grids [ 8 , 15 , 77 ]. However, their high computational demands and need for extensive training data can pose challenges in certain applications [ 61 ].
• Genetic algorithms (GA): GA are optimization techniques effective for solving complex problems related to energy distribution and resource allocation, such as in microgrids. These algorithms enable efficient energy management and operation of both renewable and conventional energy sources [ 75 , 76 , 78 ]. While highly adaptable, GA often require many iterations to converge to an optimal solution, which can be time-consuming [ 61 ].
• Multi-agent systems (MAS): MAS involve multiple intelligent agents that interact to achieve a common goal, such as load balancing or fault management. These systems are highly flexible and can operate in decentralized environments, making them suitable for distributed energy resources (DERs) integration and grid stability enhancement [ 78 , 88 , 89 ]. However, their implementation can be complex, requiring robust communication protocols and coordination mechanisms [ 78 ].

3.1.4. AI Techniques for Regression and Classification in Smart Grids

• AI techniques play a crucial role in smart grids and distributed energy systems by providing advanced methods for regression and classification tasks. These tasks are fundamental in analyzing and predicting various parameters critical for the efficient operation and planning of energy systems.
• Regression techniques: Regression is used in smart grids to predict continuous variables, such as energy consumption, power generation from renewable sources, or electricity prices. Machine learning algorithms, like linear regression, support vector regression (SVR), and neural networks, are commonly employed for these purposes. For example, linear regression can be used to model the relationship between electricity demand and influencing factors such as weather conditions or time of day, which helps utilities in load forecasting and demand management [ 45 , 53 ]. Another example is using support vector regression to predict solar power generation based on historical weather data, which enhances the accuracy of energy management in solar farms [ 69 ].
• Classification techniques: Classification techniques are used to categorize data into discrete classes, making them essential for fault detection, power quality assessment, and demand response strategies in smart grids. Algorithms such as decision trees, random forests, and deep learning classifiers are applied to classify power system states, detect faults, and manage grid stability. For instance, decision trees can be used to classify whether a transformer is likely to fail based on sensor data, allowing for proactive maintenance and reducing downtime [ 74 , 90 ]. Additionally, deep learning classifiers can analyze patterns in grid data to predict and classify potential grid anomalies, enhancing the reliability and security of energy distribution systems [ 82 , 91 ].

3.1.5. Advanced AI Techniques for Smart Grids

• Generative Adversarial Networks (GANs): GANs are a class of machine learning frameworks where two neural networks, the generator and the discriminator, are trained simultaneously. GANs have been widely used in image generation and data augmentation, but their potential extends to smart grids as well. For instance, GANs can generate realistic synthetic data to enhance the training of AI models used in demand forecasting and anomaly detection. This synthetic data can simulate various scenarios of energy consumption and generation, helping improve the robustness and generalizability of predictive models [ 43 , 69 ]. Moreover, GANs can aid in the detection and mitigation of cyber threats by generating adversarial examples to test the resilience of smart grid cybersecurity systems, as discussed by Wang et al. [ 70 ]. This technique helps in identifying potential vulnerabilities in AI models deployed within the grid, ensuring that they are well-prepared to handle real-world adversarial attacks.
• Graph Neural Networks (GNNs): GNNs are designed to perform inference on data represented as graphs, making them particularly suitable for applications in smart grids, which can be naturally modeled as graphs of interconnected nodes and edges (e.g., substations, transmission lines, and distributed energy resources). GNNs can effectively capture the spatial dependencies and topological characteristics of the grid, enabling enhanced grid management and fault detection capabilities. For example, GNNs can be used to predict the optimal flow of electricity in the grid by analyzing the dynamic relationships between different components, thereby improving energy distribution efficiency and reducing losses [ 49 , 76 ]. Additionally, GNNs are instrumental in identifying critical nodes and potential vulnerabilities in the network, which is crucial for maintaining grid stability and preventing cascading failures [ 50 , 80 ]. This is particularly valuable in scenarios involving complex interdependencies, such as those seen in large-scale integration of renewable energy sources.

3.2. Impact on Energy Management

3.2.1. demand forecasting, 3.2.2. energy flow optimization, 3.3. coordination and integration of ders, 3.3.1. battery diagnostics and predictive maintenance, 3.3.2. dynamic grid response and decision support systems, 3.3.3. integration of ders, 3.3.4. enhancing system flexibility, 4. challenges and opportunities, 4.1. technical, economic, and regulatory challenges, 4.1.1. technical barriers, 4.1.2. economic impacts, 4.1.3. regulatory and policy issues, 4.2. integration of renewable energies, 4.2.1. intermittent renewable integration, 4.2.2. demand response enhancement, 4.3. cybersecurity in ai applications for distributed energy systems, 4.4. holistic framework for ai applications in energy systems, 4.4.1. overview of ai applications across power system phases.

• Power generation: AI techniques are extensively used in optimizing power generation, particularly from renewable sources such as solar and wind energy. Machine learning algorithms, for instance, have been developed to predict solar irradiance and wind speeds with greater accuracy, thus allowing for more precise energy output forecasts and better scheduling of dispatchable resources [ 10 , 108 ]. Moreover, AI is applied to enhance the operational efficiency of power plants by utilizing predictive maintenance algorithms that can anticipate equipment failures before they occur. This reduces downtime and maintenance costs while ensuring continuous power generation [ 8 ]. Research has shown that AI-based predictive maintenance strategies extend the lifespan of grid components by anticipating failures and scheduling proactive maintenance.
• Power transmission: In the transmission phase, AI technologies are pivotal in optimizing the flow of electricity across vast networks, ensuring stability and reliability. Deep learning techniques are employed for real-time anomaly detection and fault diagnosis in transmission lines, which helps in early identification and rectification of potential issues [ 15 ]. AI-driven optimization algorithms are also used to dynamically adjust power flows and maintain voltage levels within optimal ranges, preventing grid failures and enhancing overall grid resilience [ 14 ]. A multi-agent system can be implemented to enhance situational awareness and provide adaptive responses to unexpected grid events, further improving transmission reliability and security [ 18 ].
• Power distribution: AI’s role in the distribution phase is critical for managing the complexity of modern electrical grids, especially with the increasing penetration of distributed energy resources (DERs) such as solar panels and wind turbines. AI techniques, such as reinforcement learning, optimize load management by predicting consumption patterns and adjusting supply in real-time to match demand [ 7 ]. This not only enhances demand response strategies but also facilitates the seamless integration of DERs into the grid, ensuring stability and minimizing disruptions [ 3 ]. Furthermore, AI-based predictive analytics are used for voltage regulation and to reduce energy losses during distribution, which improves the efficiency and reliability of energy delivery to end-users [ 9 ].

4.4.2. Research Gaps, Challenges, and Future Perspectives

• Research gaps: While AI has significantly advanced power systems, several research gaps still exist. One notable gap is the need for more robust models that can handle the variability and uncertainty of renewable energy sources. Current AI models are often limited in their ability to predict extreme weather events or sudden changes in generation, which can impact grid stability [ 5 ]. Additionally, there is a lack of comprehensive solutions for the interoperability of diverse energy resources and systems, which is crucial for the seamless integration of renewable energies and the overall efficiency of the power grid [ 13 ]. Further research is needed to develop AI algorithms capable of managing the complex interactions between various energy sources and storage systems.
• Challenges: The deployment of AI in power systems faces several challenges. Technically, there is a need for advanced infrastructure, such as high-speed communication networks and powerful computational resources, to support AI applications [ 4 ]. Cybersecurity remains a significant concern, as the integration of AI and digital technologies exposes power systems to potential cyber threats, including data breaches and cyber-attacks [ 12 ]. Developing robust cybersecurity measures, such as blockchain-enabled frameworks, is essential to protect these systems and ensure their reliable operation. Additionally, regulatory and policy challenges need to be addressed to create standardized frameworks that govern the use of AI in power systems, ensuring data privacy, security, and ethical use [ 11 ].
• Future perspectives: Looking forward, the future of AI in power systems lies in the development of more adaptive and scalable AI models that can manage the dynamic nature of energy systems. Integrating AI with emerging technologies like blockchain can enhance security and transparency, while IoT can provide real-time data collection and analytics, further improving system resilience and efficiency [ 16 ]. There is also a need for interdisciplinary research that combines expertise from energy, computer science, and regulatory fields to address the multifaceted challenges of AI integration in power systems. Exploring these future directions will help in building smarter, more efficient, and resilient power systems that can adapt to the evolving demands of the modern energy landscape.

4.5. Future Trends in AI Impact on the Planning and Operation of Distributed Energy Systems in Smart Grids

4.5.1. increased integration of advanced ai techniques:, 4.5.2. enhanced cybersecurity measures, 4.5.3. autonomous and decentralized energy management, integration with emerging technologies, focus on sustainable and resilient energy systems, 5. discussions, 6. conclusions, author contributions, data availability statement, acknowledgments, conflicts of interest.

• Szczepaniuk, H.; Szczepaniuk, E.K. Applications of Artificial Intelligence Algorithms in the Energy Sector. Energies 2023 , 16 , 347. [ Google Scholar ] [ CrossRef ]
• Kumar, A.; Alaraj, M.; Rizwan, M.; Nangia, U. Novel AI Based Energy Management System for Smart Grid With RES Integration. IEEE Access 2021 , 9 , 162530–162542. [ Google Scholar ] [ CrossRef ]
• Ibrahim, M.S.; Dong, W.; Yang, Q. Machine learning driven smart electric power systems: Current trends and new perspectives. Appl. Energy 2020 , 272 , 115237. [ Google Scholar ] [ CrossRef ]
• Ali, S.S.; Choi, B.J. State-of-the-Art Artificial Intelligence Techniques for Distributed Smart Grids: A Review. Electronics 2020 , 9 , 1030. [ Google Scholar ] [ CrossRef ]
• Hua, W.; Chen, Y.; Qadrdan, M.; Jiang, J.; Sun, H.; Wu, J. Applications of blockchain and artificial intelligence technologies for enabling prosumers in smart grids: A review. Renew. Sustain. Energy Rev. 2022 , 161 , 112308. [ Google Scholar ] [ CrossRef ]
• Singh, S.; Singh, S. Advancements and Challenges in Integrating Renewable Energy Sources Into Distribution Grid Systems: A Comprehensive Review. J. Energy Resour. Technol. 2024 , 146 , 090801. [ Google Scholar ] [ CrossRef ]
• Kumar, M.; Pal, N. Machine Learning-based Electric Load Forecasting for Peak Demand Control in Smart Grid. CMC: Comput. Mater. Continua 2023 , 74 , 4785–4799. [ Google Scholar ] [ CrossRef ]
• Durairaj, D.; Wroblewski, L.; Sheela, A.; Hariharasudan, A.; Urbanski, M. Random forest based power sustainability and cost optimization in smart grid. Prod. Eng. Arch. 2022 , 28 , 82–92. [ Google Scholar ] [ CrossRef ]
• Nair, D.R.; Nair, M.G.; Thakur, T. A Smart Microgrid System with Artificial Intelligence for Power-Sharing and Power Quality Improvement. Energies 2022 , 15 , 5409. [ Google Scholar ] [ CrossRef ]
• Rojek, I.; Mroziński, A.; Kotlarz, P.; Macko, M.; Mikołajewski, D.; Rojek, I.; Mroziński, A.; Kotlarz, P.; Macko, M.; Mikołajewski, D. AI-Based Computational Model in Sustainable Transformation of Energy Markets. Energies 2023 , 16 , 8059. [ Google Scholar ] [ CrossRef ]
• Ferrández-Pastor, F.J.; García-Chamizo, J.M.; Gomez-Trillo, S.; Valdivieso-Sarabia, R.; Nieto-Hidalgo, M. Smart Management Consumption in Renewable Energy Fed Ecosystems. Sensors 2019 , 19 , 2967. [ Google Scholar ] [ CrossRef ]
• Beniwal, R.K.; Saini, M.K.; Nayyar, A.; Qureshi, B.; Aggarwal, A. A Critical Analysis of Methodologies for Detection and Classification of Power Quality Events in Smart Grid. IEEE Access 2021 , 9 , 83507–83534. [ Google Scholar ] [ CrossRef ]
• Seema, P.N.; Nair, M.G. The key modules involved in the evolution of an effective instrumentation and communication network in smart grids: A review. Smart Sci. 2023 , 11 , 519–537. [ Google Scholar ] [ CrossRef ]
• Velasquez, W.; Moreira-Moreira, G.Z.; Alvarez-Alvarado, M.S. Smart Grids Empowered by Software-Defined Network: A Comprehensive Review of Advancements and Challenges. IEEE Access 2024 , 12 , 63400–63416. [ Google Scholar ] [ CrossRef ]
• Perger, A.V.; Gamper, P.; Witzmann, R. Behavior Trees for Smart Grid Control. IFAC-PapersOnLine 2022 , 55 , 122–127. [ Google Scholar ] [ CrossRef ]
• Chandrasekaran, K.; Selvaraj, J.; Amaladoss, C.R.; Veerapan, L. Hybrid renewable energy based smart grid system for reactive power management and voltage profile enhancement using artificial neural network. Energy Sources Part A Recover. Utiliz. Environ. Effects. 2021 , 43 , 2419–2442. [ Google Scholar ] [ CrossRef ]
• Bin Kamilin, M.H.; Yamaguchi, S. Resilient Electricity Load Forecasting Network with Collective Intelligence Predictor for Smart Cities. Electronics 2024 , 13 , 718. [ Google Scholar ] [ CrossRef ]
• Soares, J.; Pinto, T.; Lezama, F.; Morais, H. Survey on Complex Optimization and Simulation for the New Power Systems Paradigm. Complexity 2018 , 32 , 2340628. [ Google Scholar ] [ CrossRef ]
• Colak, M.; Balci, S. Photovoltaic System Parameter Estimation Using Marine Predators Optimization Algorithm Based on Multilayer Perceptron. Electr. Power Comp. Syst. 2022 , 50 , 1087–1099. [ Google Scholar ] [ CrossRef ]
• Wesley, B.J.; Babu, G.S.; Kumar, P.S. Design and control of LSTM-ANN controllers for an efficient energy management system in a smart grid based on hybrid renewable energy sources. Eng. Res. Express 2024 , 6 , 015074. [ Google Scholar ] [ CrossRef ]
• Khayyat, M.M.; Sami, B. Energy Community Management Based on Artificial Intelligence for the Implementation of Renewable Energy Systems in Smart Homes. Electronics 2024 , 13 , 380. [ Google Scholar ] [ CrossRef ]
• Garcia Medina, M.S.; Aguilar, J.; Rodriguez-Moreno, M.D. A Bioinspired Emergent Control for Smart Grids. IEEE Access 2023 , 11 , 7503–7520. [ Google Scholar ] [ CrossRef ]
• Anthony Jnr, B. Decentralized AIoT based intelligence for sustainable energy prosumption in local energy communities: A citizen-centric prosumer approach. Cities 2024 , 152 , 105198. [ Google Scholar ] [ CrossRef ]
• Rimal, B.P.; Kong, C.; Poudel, B.; Wang, Y.; Shahi, P. Smart Electric Vehicle Charging in the Era of Internet of Vehicles, Emerging Trends, and Open Issues. Energies 2022 , 15 , 1908. [ Google Scholar ] [ CrossRef ]
• Ahmad, T.; Madonski, R.; Zhang, D.; Huang, C.; Mujeeb, A. Data-driven probabilistic machine learning in sustainable smart energy/smart energy systems: Key developments, challenges, and future research opportunities in the context of smart grid paradigm. Renew. Sustain. Energy Rev. 2022 , 160 , 112128. [ Google Scholar ] [ CrossRef ]
• Khalid, M. Energy 4.0: AI-enabled digital transformation for sustainable power networks. Comput. Ind. Eng. 2024 , 193 , 110253. [ Google Scholar ] [ CrossRef ]
• Payne, E.K.; Qian, W.; Lu, S.; Wu, L. Technical risk synthesis and mitigation strategies of distributed energy resources integration with wireless sensor networks and internet of things—Review. J. Eng. 2019 , 18 , 4830–4835. [ Google Scholar ] [ CrossRef ]
• Georgilakis, P.S. Review of Computational Intelligence Methods for Local Energy Markets at the Power Distribution Level to Facilitate the Integration of Distributed Energy Resources: State-of-the-art and Future Research. Energies 2020 , 13 , 186. [ Google Scholar ] [ CrossRef ]
• Ma, H.; Zhang, H.; Tian, D.; Yue, D.; Hancke, G.P. Optimal demand response based dynamic pricing strategy via Multi-Agent Federated Twin Delayed Deep Deterministic policy gradient algorithm. Eng. Appl. Artif. Intell. 2024 , 133 , 108012. [ Google Scholar ] [ CrossRef ]
• Banales, S. The enabling impact of digital technologies on distributed energy resources integration. J. Renew. Sustain. Energy. 2020 , 12 , 045301. [ Google Scholar ] [ CrossRef ]
• Cicceri, G.; Tricomi, G.; D’Agati, L.; Longo, F.; Merlino, G.; Puliafito, A. A Deep Learning-Driven Self-Conscious Distributed Cyber-Physical System for Renewable Energy Communities. Sensors 2023 , 23 , 4549. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Bindi, M.; Piccirilli, M.C.; Luchetta, A.; Grasso, F. A Comprehensive Review of Fault Diagnosis and Prognosis Techniques in High Voltage and Medium Voltage Electrical Power Lines. Energies 2023 , 16 , 7317. [ Google Scholar ] [ CrossRef ]
• Ghasemi, A.; Shojaeighadikolaei, A.; Hashemi, M. Combating Uncertainties in Smart Grid Decision Networks: Multiagent Reinforcement Learning With Imperfect State Information. IEEE Internet Things J. 2024 , 11 , 23985–23997. [ Google Scholar ] [ CrossRef ]
• Boato, B.; Sueldo, C.S.; Avila, L.; de Paula, M. An improved Soft Actor-Critic strategy for optimal energy management. IEEE Lat. Am. Trans. 2023 , 21 , 958–965. [ Google Scholar ] [ CrossRef ]
• Pandiyan, P.; Saravanan, S.; Kannadasan, R.; Krishnaveni, S.; Alsharif, M.H.; Kim, M.-K. A comprehensive review of advancements in green IoT for smart grids: Paving the path to sustainability. Energy Rep. 2024 , 11 , 5504–5531. [ Google Scholar ] [ CrossRef ]
• Karanfil, M.; Rebbah, D.E.; Debbabi, M.; Kassouf, M.; Ghafouri, M.; Youssef, E.-N.S.; Hanna, A. Detection of Microgrid Cyberattacks Using Network and System Management. IEEE Trans. Smart Grid 2023 , 14 , 2390–2405. [ Google Scholar ] [ CrossRef ]
• Xi, L.; Chen, J.; Huang, Y.; Xu, Y.; Liu, L.; Zhou, Y.; Li, Y. Smart generation control based on multi-agent reinforcement learning with the idea of the time tunnel. Energy 2018 , 153 , 977–987. [ Google Scholar ] [ CrossRef ]
• Ma, R.; Yi, Z.; Xiang, Y.; Shi, D.; Xu, C.; Wu, H. A Blockchain-Enabled Demand Management and Control Framework Driven by Deep Reinforcement Learning. IEEE Trans. Ind. Electron 2023 , 70 , 430–440. [ Google Scholar ] [ CrossRef ]
• Abdullah, H.M.; Gastli, A.; Ben-Brahim, L. Reinforcement Learning Based EV Charging Management Systems-A Review. IEEE Access 2021 , 9 , 41506–41531. [ Google Scholar ] [ CrossRef ]
• Taik, A.; Nour, B.; Cherkaoui, S. Empowering prosumer communities in smart grid with wireless communications and federated edge learning. IEEE Wireless Commun. 2021 , 28 , 26–33. [ Google Scholar ] [ CrossRef ]
• Afzali, P.; Yeganeh, A.; Derakhshan, F. A novel socio-economic-environmental model to maximize prosumer satisfaction in smart residential complexes. Energy Build. 2024 , 308 , 114023. [ Google Scholar ] [ CrossRef ]
• Rosato, A.; Panella, M.; Araneo, R.; Andreotti, A. A Neural Network Based Prediction System of Distributed Generation for the Management of Microgrids. IEEE Trans. Ind. Appl. 2019 , 55 , 7092–7102. [ Google Scholar ] [ CrossRef ]
• Succetti, F.; Rosato, A.; Araneo, R.; Panella, M. Deep Neural Networks for Multivariate Prediction of Photovoltaic Power Time Series. IEEE Access 2020 , 8 , 211490–211505. [ Google Scholar ] [ CrossRef ]
• Aleem, S.A.; Hussain, S.M.S.; Ustun, T.S. A Review of Strategies to Increase PV Penetration Level in Smart Grids. Energies 2020 , 13 , 636. [ Google Scholar ] [ CrossRef ]
• Nabavi, S.A.; Motlagh, N.H.; Zaidan, M.A.; Aslani, A.; Zakeri, B. Deep Learning in Energy Modeling: Application in Smart Buildings With Distributed Energy Generation. IEEE Access 2021 , 9 , 125439–125461. [ Google Scholar ] [ CrossRef ]
• Okampo, E.J.; Nwulu, N.; Bokoro, P.N. Optimal Placement and Operation of FACTS Technologies in a Cyber-Physical Power System: Critical Review and Future Outlook. Sustainability 2022 , 14 , 7707. [ Google Scholar ] [ CrossRef ]
• Ucer, E.; Kisacikoglu, M.C.; Yuksel, M. Decentralized Additive Increase and Multiplicative Decrease-Based Electric Vehicle Charging. IEEE Syst. J. 2021 , 15 , 4272–4280. [ Google Scholar ] [ CrossRef ]
• Zhang, Y.; Krishnan, V.V.G.; Pi, J.; Kaur, K.; Srivastava, A.; Hahn, A.; Suresh, S. Cyber Physical Security Analytics for Transactive Energy Systems. IEEE Trans. Smart Grid 2020 , 11 , 931–941. [ Google Scholar ] [ CrossRef ]
• Shaqour, A.; Hagishima, A. Systematic Review on Deep Reinforcement Learning-Based Energy Management for Different Building Types. Energies 2022 , 15 , 8663. [ Google Scholar ] [ CrossRef ]
• Rabie, A.H.; Ali, S.H.; Saleh, A.I.; Ali, H.A. A new outlier rejection methodology for supporting load forecasting in smart grids based on big data. Cluster Comput. 2020 , 23 , 509–535. [ Google Scholar ] [ CrossRef ]
• Adnan, M.; Ghadi, Y.; Ahmed, I.; Ali, M. Transmission Network Planning in Super Smart Grids: A Survey. IEEE Access 2023 , 11 , 77163–77227. [ Google Scholar ] [ CrossRef ]
• Zhou, Y. A regression learner-based approach for battery cycling ageing predictiondadvances in energy management strategy and techno- economic analysis. Energy 2022 , 256 , 124668. [ Google Scholar ] [ CrossRef ]
• Tiwari, D.; Zideh, M.J.; Talreja, V.; Verma, V.; Solanki, S.K.; Solanki, J. Power Flow Analysis Using Deep Neural Networks in Three-Phase Unbalanced Smart Distribution Grids. IEEE Access 2024 , 12 , 29959–29970. [ Google Scholar ] [ CrossRef ]
• Al-Gabalawy, M. Reinforcement learning for the optimization of electric vehicle virtual power plants. Int. Trans. Electr. Energy Syst. 2021 , 31 , 12951. [ Google Scholar ] [ CrossRef ]
• Yap, K.Y.; Chin, H.H.; Klemes, J.J. Future outlook on 6G technology for renewable energy sources (RES). Renew. Sustain. Energy Rev. 2022 , 167 , 112722. [ Google Scholar ] [ CrossRef ]
• Qiu, D.; Xue, J.; Zhang, T.; Wang, J.; Sun, M. Federated reinforcement learning for smart building joint peer-to-peer energy and carbon allowance trading. Appl. Energy 2023 , 333 , 120526. [ Google Scholar ] [ CrossRef ]
• Dabbaghjamanesh, M.; Kavousi-Fard, A.; Zhang, J. Stochastic Modeling and Integration of Plug-In Hybrid Electric Vehicles in Reconfigurable Microgrids With Deep Learning-Based Forecasting. IEEE Trans. Intell. Transp. Syst. 2021 , 22 , 4394–4403. [ Google Scholar ] [ CrossRef ]
• Alhussein, M.; Haider, S.I.; Aurangzeb, K. Microgrid-Level Energy Management Approach Based on Short-Term Forecasting of Wind Speed and Solar Irradiance. Energies 2019 , 12 , 1487. [ Google Scholar ] [ CrossRef ]
• Yavuz, M.; Kivanc, O.C. Optimization of a Cluster-Based Energy Management System Using Deep Reinforcement Learning Without Affecting Prosumer Comfort: V2X Technologies and Peer-to-Peer Energy Trading. IEEE Access 2024 , 12 , 31551–31575. [ Google Scholar ] [ CrossRef ]
• Oyucu, S.; Polat, O.; Turkoglu, M.; Polat, H.; Aksoz, A.; Agdas, M.T. Ensemble Learning Framework for DDoS Detection in SDN-Based SCADA Systems. Sensors 2024 , 24 , 155. [ Google Scholar ] [ CrossRef ]
• Mohamed, M.A.E.; Mahmoud, A.M.; Saied, E.M.M.; Hadi, H.A. Hybrid cheetah particle swarm optimization based optimal hierarchical control of multiple microgrids. Sci. Rep. 2024 , 14 , 9313. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Yaprakdal, F.; Yilmaz, M.B.; Baysal, M.; Anvari-Moghaddam, A. A Deep Neural Network-Assisted Approach to Enhance Short-Term Optimal Operational Scheduling of a Microgrid. Sustainability 2020 , 12 , 1653. [ Google Scholar ] [ CrossRef ]
• Sinha, A.; Singh, S.; Verma, H.K. AI-Driven Task Scheduling Strategy with Blockchain Integration for Edge Computing. J. Grid Comput. 2024 , 22 , 9743. [ Google Scholar ] [ CrossRef ]
• Alsharif, M.H.; Jahid, A.; Kannadasan, R.; Kim, M.-K. Unleashing the potential of sixth generation (6G) wireless networks in smart energy grid management: A comprehensive review. Energy Rep. 2024 , 11 , 1376–1398. [ Google Scholar ] [ CrossRef ]
• Asif, M.; Naeem, G.; Khalid, M. Digitalization for sustainable buildings: Technologies, applications, potential, and challenges. J. Cleaner Prod. 2024 , 450 , 141814. [ Google Scholar ] [ CrossRef ]
• Alrubayyi, H.; Alshareef, M.S.; Nadeem, Z.; Abdelmoniem, A.M.; Jaber, M. Security Threats and Promising Solutions Arising from the Intersection of AI and IoT: A Study of IoMT and IoET Applications. Futur. Internet 2024 , 16 , 85. [ Google Scholar ] [ CrossRef ]
• Wu, H.; Wang, X.; Liao, H.; Jiao, X.; Liu, Y.; Shu, X.; Wang, J.; Rao, Y. Signal Processing in Smart Fiber-Optic Distributed Acoustic Sensor. Acta Opt. Sin. 2024 , 44 , 231384. [ Google Scholar ] [ CrossRef ]
• Xiong, Y.; Liu, Y.; Yang, J.; Wang, Y.; Xu, N.; Wang, Z.L.; Sun, Q. Machine learning enhanced rigiflex pillar-membrane triboelectric nanogenerator for universal stereoscopic recognition. Nano Energy 2024 , 129 , 109956. [ Google Scholar ] [ CrossRef ]
• Quy, V.K.; Nguyen, D.C.; Van Anh, D.; Quy, N.M. Federated learning for green and sustainable 6G IIoT applications. Internet Things 2024 , 25 , 101061. [ Google Scholar ] [ CrossRef ]
• Wang, Q.; Yin, Y.; Chen, Y.; Liu, Y. Carbon peak management strategies for achieving net-zero emissions in smart buildings: Advances and modeling in digital twin. Sustainable Energy Technol. Assess. 2024 , 64 , 103661. [ Google Scholar ] [ CrossRef ]
• Udayaprasad, P.K.; Shreyas, J.; Srinidhi, N.N.; Kumar, S.M.D.; Dayananda, P.; Askar, S.S.; Abouhawwash, M. Energy Efficient Optimized Routing Technique With Distributed SDN-AI to Large Scale I-IoT Networks. IEEE Access 2024 , 12 , 2742–2759. [ Google Scholar ] [ CrossRef ]
• Zeng, L.; Ye, S.; Chen, X.; Yang, Y. Implementation of Big Ai Models for Wireless Networks with Collaborative Edge Computing. IEEE Wireless Commun. 2024 , 31 , 50–58. [ Google Scholar ] [ CrossRef ]
• Somantri, A.; Surendro, K. Greenhouse Gas Emission Reduction Architecture in Computer Science: A Systematic Review. IEEE Access 2024 , 12 , 36239–36256. [ Google Scholar ] [ CrossRef ]
• Gou, H.; Zhang, G.; Medeiros, E.P.; Jagatheesaperumal, S.K.; de Albuquerque, V.H.C. A Cognitive Medical Decision Support System for IoT-Based Human-Computer Interface in Pervasive Computing Environment. Cogn. Comput. 2024 , 16 , 2471–2486. [ Google Scholar ] [ CrossRef ]
• Rajora, G.L.; Sanz-Bobi, M.A.; Tjernberg, L.B.; Urrea Cabus, J.E. A review of asset management using artificial intelligence-based machine learning models: Applications for the electric power and energy system. IET Gener. Transm. Distrib. 2024 , 18 , 2155–2170. [ Google Scholar ] [ CrossRef ]
• Cairone, S.; Hasan, S.W.; Choo, K.-H.; Lekkas, D.F.; Fortunato, L.; Zorpas, A.A.; Korshin, G.; Zarra, T.; Belgiorno, V.; Naddeo, V. Revolutionizing wastewater treatment toward circular economy and carbon neutrality goals: Pioneering sustainable and efficient solutions for automation and advanced process control with smart and cutting-edge technologies. J. Water Process Eng. 2024 , 63 , 105486. [ Google Scholar ] [ CrossRef ]
• Wang, X.; Guo, Y.; Gao, Y. Unmanned Autonomous Intelligent System in 6G Non-Terrestrial Network. Information 2024 , 15 , 38. [ Google Scholar ] [ CrossRef ]
• Huang, Y.; Li, M.; Yu, F.R.; Si, P.; Zhang, H.; Qiao, J. Resources Scheduling for Ambient Backscatter Communication-Based Intelligent IIoT: A Collective Deep Reinforcement Learning Method. IEEE Trans. Cogn. Commun. Netw. 2024 , 10 , 634–648. [ Google Scholar ] [ CrossRef ]
• Diefenthaler, M.; Fanelli, C.; Gerlach, L.O.; Guan, W.; Horn, T.; Jentsch, A.; Lin, M.; Nagai, K.; Nayak, H.; Pecar, C.; et al. AI-assisted detector design for the EIC (AID(2)E). J. Instrum. 2024 , 19 , 07001. [ Google Scholar ] [ CrossRef ]
• Luo, T.; Wong, W.-F.; Goh, R.S.M.; Do, A.T.; Chen, Z.; Li, H.; Jiang, W.; Yau, W. Achieving Green AI with Energy-Efficient Deep Learning Using Neuromorphic Computing. Commun. ACM 2023 , 66 , 52–57. [ Google Scholar ] [ CrossRef ]
• Zhang, H.; Fang, B.; He, P.; Gao, W. The asymmetric impacts of artificial intelligence and oil shocks on clean energy industries by considering COVID-19. Energy 2024 , 291 , 130197. [ Google Scholar ] [ CrossRef ]
• Onile, A.E.; Petlenkov, E.; Levron, Y.; Belikov, J. Smartgrid-based hybrid digital twins framework for demand side recommendation service provision in distributed power systems. Future Gener. Comput. Syst. 2024 , 156 , 142–156. [ Google Scholar ] [ CrossRef ]
• Du, J.; Lin, T.; Jiang, C.; Yang, Q.; Bader, C.F.; Han, Z. Distributed Foundation Models for Multi-Modal Learning in 6g Wireless Networks. IEEE Wireless Commun. 2024 , 31 , 20–30. [ Google Scholar ] [ CrossRef ]
• Jouini, O.; Sethom, K.; Namoun, A.; Aljohani, N.; Alanazi, M.H.; Alanazi, M.N. A Survey of Machine Learning in Edge Computing: Techniques, Frameworks, Applications, Issues, and Research Directions. Technologies 2024 , 12 , 81. [ Google Scholar ] [ CrossRef ]
• Mwangi, A.; Sahay, R.; Fumagalli, E.; Gryning, M.; Gibescu, M. Towards a Software-Defined Industrial IoT-Edge Network for Next-Generation Offshore Wind Farms: State of the Art, Resilience, and Self-X Network and Service Management. Energies 2024 , 17 , 2897. [ Google Scholar ] [ CrossRef ]
• Naseh, D.; Shinde, S.S.; Tarchi, D. Network Sliced Distributed Learning-as-a-Service for Internet of Vehicles Applications in 6G Non-Terrestrial Network Scenarios. J. Sens. Actuator Netw. 2024 , 13 , 14. [ Google Scholar ] [ CrossRef ]
• Lin, Y.-H.; Ciou, J.-C. A privacy-preserving distributed energy management framework based on vertical federated learning-based smart data cleaning for smart home electricity data. Internet Things 2024 , 26 , 101222. [ Google Scholar ] [ CrossRef ]
• Sun, Q.; Li, N.; I, C.-L.; Huang, J.; Xu, X.; Xie, Y. Intelligent RAN Automation for 5G and Beyond. IEEE Wireless Commun. 2024 , 31 , 94–102. [ Google Scholar ] [ CrossRef ]
• Rajesh, M.; Ramachandran, S.; Vengatesan, K.; Dhanabalan, S.S.; Nataraj, S.K. Federated Learning for Personalized Recommendation in Securing Power Traces in Smart Grid Systems. IEEE Trans. Consum. Electron. 2024 , 70 , 88–95. [ Google Scholar ] [ CrossRef ]
• Rani, S.; Jining, D.; Shoukat, K.; Shoukat, M.U.; Nawaz, S.A. A Human-Machine Interaction Mechanism: Additive Manufacturing for Industry 5.0-Design and Management. Sustainability 2024 , 16 , 4158. [ Google Scholar ] [ CrossRef ]
• Aslanpour, M.S.; Toosi, A.N.; Cheema, M.A.; Chhetri, M.B.; Salehi, M.A. Load balancing for heterogeneous serverless edge computing: A performance-driven and empirical approach. Future Gener. Comput. Syst. 2024 , 154 , 266–280. [ Google Scholar ] [ CrossRef ]
• Zhang, X.; Wu, Z.; Sun, Q.; Gu, W.; Zheng, S.; Zhao, J. Application and progress of artificial intelligence technology in the field of distribution network voltage Control:A review. Renew. Sustain. Energy Rev. 2024 , 192 , 114282. [ Google Scholar ] [ CrossRef ]
• Zhang, X.; Zhang, Z.; Liu, Y.; Xu, Z.; Qu, X. A review of machine learning approaches for electric vehicle energy consumption modelling in urban transportation. Renew. Energy 2024 , 234 , 121243. [ Google Scholar ] [ CrossRef ]
• Cheng, F.; Liu, H. Multi-step electric vehicles charging loads forecasting: An autoformer variant with feature extraction, frequency enhancement, and error correction blocks. Appl. Energy 2024 , 376 , 124308. [ Google Scholar ] [ CrossRef ]
• Shaamala, A.; Yigitcanlar, T.; Nili, A.; Nyandega, D. Algorithmic green infrastructure optimisation: Review of artificial intelligence driven approaches for tackling climate change. Sustainable Cities Soc. 2024 , 101 , 105182. [ Google Scholar ] [ CrossRef ]
• Santos, P.; Cervantes, G.C.; Zaragoza-Benzal, A.; Byrne, A.; Karaca, F.; Ferrandez, D.; Salles, A.; Braganca, L. Circular Material Usage Strategies and Principles in Buildings: A Review. Buildings 2024 , 14 , 281. [ Google Scholar ] [ CrossRef ]
• Soori, M.; Karimi Ghaleh Jough, F.; Dastres, R.; Arezoo, B. AI-Based Decision Support Systems in Industry 4.0, A Review. J. Econ. Technol. 2024; in press . [ Google Scholar ] [ CrossRef ]
• Wang, X.; Cui, B.; Jing, L.; Wang, X.; Wu, M.; Wen, Y.; Wu, Y.; Liu, J.; Zhang, F.; Lin, Z.; et al. Enabling Low-Power Charge-Domain Nonvolatile Computing-in-Memory (CIM) With Ferroelectric Memcapacitor. IEEE Trans. Electron Devices 2024 , 71 , 2404–2410. [ Google Scholar ] [ CrossRef ]
• Li, W.; Zhou, H.; Lu, Z.; Kamarthi, S. Navigating the Evolution of Digital Twins Research through Keyword Co-Occurence Network Analysis. Sensors 2024 , 24 , 1202. [ Google Scholar ] [ CrossRef ]
• Ruan, H.; Wei, Z.; Shang, W.; Wang, X.; He, H. Artificial Intelligence-based health diagnostic of Lithium-ion battery leveraging transient stage of constant current and constant voltage charging. Appl. Energy 2023 , 336 , 120751. [ Google Scholar ] [ CrossRef ]
• Liu, Y.; Ren, Y.; Lin, Q.; Yu, W.; Pan, W.; Su, A.; Zhao, Y. A digital twin-based assembly model for multi-source variation fusion on vision transformer. J. Manuf. Syst. 2024 , 76 , 478–501. [ Google Scholar ] [ CrossRef ]
• Xu, B.; Bhatti, U.A.; Tang, H.; Yan, J.; Wu, S.; Sarhan, N.; Awwad, E.M.; Syam, S.M.; Ghadi, Y.Y. Towards explainability for AI-based edge wireless signal automatic modulation classification. J. Cloud Comput. Adv. Syst. Appl. 2024 , 13 , 10. [ Google Scholar ] [ CrossRef ]
• Han, Y.; Yang, D.; Zhang, J.; Min, B.; Liang, Z.-W. Using Al Technology to Optimize Distribution Networks. J. Electr. Syst. 2024 , 20 , 1259–1264. [ Google Scholar ]
• Ishteyaq, I.; Muzaffar, K.; Shafi, N.; Alathbah, M.A. Unleashing the Power of Tomorrow: Exploration of Next Frontier With 6G Networks and Cutting Edge Technologies. IEEE Access 2024 , 12 , 29445–29463. [ Google Scholar ] [ CrossRef ]
• Mokhtar, B. AI-Enabled Collaborative Distributed Computing in Networked UAVs. IEEE Access 2024 , 12 , 96515–96526. [ Google Scholar ] [ CrossRef ]
• Rodriguez, E.; Masip-Bruin, X.; Martrat, J.; Diaz, R.; Jukan, A.; Granelli, F.; Trakadas, P.; Xilouris, G. A Security Services Management Architecture Toward Resilient 6G Wireless and Computing Ecosystems. IEEE Access 2024 , 12 , 98046–98058. [ Google Scholar ] [ CrossRef ]
• Walia, G.K.; Kumar, M.; Gill, S.S. AI-Empowered Fog/Edge Resource Management for IoT Applications: A Comprehensive Review, Research Challenges, and Future Perspectives. IEEE Commun. Surv. Tutor. 2024 , 26 , 619–669. [ Google Scholar ] [ CrossRef ]
• Qu, X.; Shi, D.; Zhao, J.; Tran, M.-K.; Wang, Z.; Fowler, M.; Lian, Y.; Burke, A.F. Insights and reviews on battery lifetime prediction from research to practice. J. Energy Chem. 2024 , 94 , 716–739. [ Google Scholar ] [ CrossRef ]

Click here to enlarge figure

Share and Cite

Arévalo, P.; Jurado, F. Impact of Artificial Intelligence on the Planning and Operation of Distributed Energy Systems in Smart Grids. Energies 2024 , 17 , 4501. https://doi.org/10.3390/en17174501

Arévalo P, Jurado F. Impact of Artificial Intelligence on the Planning and Operation of Distributed Energy Systems in Smart Grids. Energies . 2024; 17(17):4501. https://doi.org/10.3390/en17174501

Arévalo, Paul, and Francisco Jurado. 2024. "Impact of Artificial Intelligence on the Planning and Operation of Distributed Energy Systems in Smart Grids" Energies 17, no. 17: 4501. https://doi.org/10.3390/en17174501

Article Metrics

Article access statistics, further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals