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Unmet need for family planning: experience in rural and urban areas of Bangladesh

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https://www.eduzhai.net Public Health Research 2013, 3(3): 37-42 DOI: 10.5923/j.phr.20130303.02 Unmet Need for Family Planning: Experience from Urban and Rural Areas in Bangladesh Rafiqul Islam, Ahmed Zohirul Islam*, Mosiur Rahman Department of Population Science and Human Resource Development, University of Rajshahi, Bangladesh Abstract One-fourth of pregnancies are either unwanted or mistimed in Bangladesh. Unwanted births not only pose risk to child health and wellbeing but also force to rapid population growth in resource strapped countries. The objectives of this study are to examine the extent of unmet need for contraception in Bangladesh and to explo re the differentials in un met need by some selected characteristics of the reproductive aged women in rural-urban Bangladesh. This study utilizes BDHS 2004 data. Chi square test and logistic regression analysis are used here. The total unmet need for fa mily planning a mong currently married wo men in Bangladesh is found to be 12%. Un met need to space births in rural area is higher than in urban area. The significant predictors of unmet need for spacing and limit ing births are found to be ever using family planning, discussing family p lanning matters with spouses, number of liv ing children, intention to have last child, age and education in the rural area whereas, age, intention of having last child, ever use of any contraception and discussing family planning matters with spouses in urban area. Rural wo men especially young married wo men deserve special consideration because unmet need to space birth is highest among them. Keywords Family Planning, Contraception, Un met Need, Spacing Birth, Limit ing Birth 1. Introduction Un met need is a powerful concept for designing family planning programmes and has important imp lications for future population growth. More than 100 million wo men in less developed countries, or about 17% of all married wo men, would prefer to avoid pregnancy but are not using any form of family p lanning[1]. Un met need for contraception can lead to unintended pregnancies, which pose risks to wo men, their families, and societies. In less developed countries, about one-fourth of pregnancies are unintended, that is, either unwanted or mistimed[2]. One particu larly harmful consequence of unintended pregnancies is unsafe abortion. An estimated 18 million unsafe abortions take place each year in less developed regions, contributing to high rates of materna l death and injury in these regions[3]. Bangladesh is a densely populated country of the world. Resource scarcity and subsistence-level econo mic conditions characterize the economy[4]. The total population is about 156 million about 36 % of the population lives on less than $1 a day[5]. Other indicators also reflect the poverty of the country: the literacy rate of the population aged five years and older is 43.1 % (males 53.9 and females 31.8 %) and life exp ectan cy is 62 years fo r both males and females[6]. * Corresponding author: zohirul.18@gmail.com (Ahmed Zohirul Islam) Published online at https://www.eduzhai.net Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved Although infant and child mortality levels have been declined, they are still h igh owing to relatively weak prenatal and postnatal services[7]. Despite these low socio-economic indicators, Bangladesh has achieved a high level of success in its family planning programme. Contraceptive use among married wo men in Bangladesh is increased gradually fro m 8% in 1975 to 61% in 2011, a greater than sevenfold increase in less than four decades. The total fert ility rate (TFR) dropped by half, fro m about six children per wo man to about three fro m 1975 to 2004. However, Bangladesh still has a long way to go to achieve the replacement level of fertility, i.e. about 2.1 children per wo man, which the government hopes, will be achieved by the year 2015. The contraceptive prevalence rate (CPR) would have to rise to over 70% for this target to be reached[8]. Most recently, contraceptive use increased by 5% points in the past four years from 56% in 2007 to 61% in 2011. Ho wever, in 2011, 12% of currently married wo men in Bangladesh have an unmet need for family planning services [9]. The CPR could be raised by 12% if the programme is able to bring with in its fo ld that segment of the population described as having an unmet contraceptive need. Recently 63% of wo men in developing countries use a method of family planning[10]. In 1960, that number was just 10%[11]. Despite this dramatic increase, about one in six married wo men still has an unmet need for family p lanning, that is, she wants to postpone her next pregnancy or stop having children altogether but, for whatever reason, is not using contraception[12]. As a consequence, 76 million 38 Rafiqul Islam et al.: Unmet Need for Family Planning: Experience from Urban and Rural Areas in Bangladesh wo men in developing countries still experience unintended pregnancies each year[13], and 19 million resort to unsafe abortions[14]. Therefore, the objectives of this study are to observe the extent of unmet need for contraception in Bangladesh and to explore the differentials in unmet need by some selected characteristics of the respondents between urban and rural areas. 1.1. Unmet Need: The B asic Concept Many women, who are sexually active would p refer to avoid becoming pregnant but nevertheless are not using any method of contraception, are considered to have an “unmet need” for family planning[15]. Th is concept basically points to the gap between some wo men’s reproductive intention and their contraceptive behavior. The standard formula of unmet need group includes all fecund wo men who are married or living union and thus presumed to be sexually active but are not using any method of contraception and who either do not want to have any more children (un met need for limit ing births) or want to postpone their next b irth for at least two more years (unmet need for spacing births); the unmet need group also includes all pregnant married wo men whose pregnancies are mistimed or unwanted. 2. Sources of Data This study utilizes the data extracted fro m Bangladesh Demographic and Health Survey (BDHS) 2004, which emp loyed nationally representative survey from 11,440 ever married wo men of age 10-49 covering 361 sample points’ of 122 urban areas and 239 ru ral areas throughout Bangladesh. Out of 11,440 ever-married samples 2586 and 8854 wo men are taken fro m urban and rural areas respectively. 3. Methodology In this study, unmet need is classified into t wo categories such as unmet need for spacing births and unmet need for limit ing births. Un met need for spacing birth includes pregnant women whose pregnancy was mistimed, amenorrheic wo men who are not using family planning and whose last birth was mistimed, and fecund women who are neither pregnant nor amenorrheic and who are not using any method of family planning and say they want to wait two or more years for their next birth. Moreover, unmet need for spacing birth includes fecund wo men who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the next birth. On the other hand, un met need for limit ing birth refers to pregnant women whose pregnancy was unwanted, amenorrheic wo men whose last child was unwanted, and fecund women who are neither pregnant nor amenorrheic, who are not using any method of family planning, and who want no more ch ildren. Excluded fro m the unmet need category are pregnant and amenorrheic wo men who became pregnant while using a method (these women are in need of a better method of contraception). Chi square test and logistic regression analysis are used to observe the effects of different covariates on unmet contraceptive need for spacing and limiting births. For this purpose two binary logistic models have been fitted for unmet need regard ing spacing and limiting b irths separately for each urban, rural and all wo men of Bangladesh category. The response variable for the first model has two categories: unmet need for spacing (coded 1) and no unmet need for spacing (coded 0) and the response variable for the second model has also two categories: unmet need for limiting (coded 1) and no unmet need for limiting (coded 0). 4. Results The Table 1 elucidates that the total unmet need for family planning among currently married wo men in Bangladesh is 12.2 % out of which 5.9 % have unmet need for spacing births and 6.3 % want to limit births. However, un met need to space births in the rural area is higher than that in the urban area. On the other hand unmet need to limit births is almost same for both urban (6.2 %) and rural (6.3 %) wo men. Table 1. Distribution of currently married women according to their demand for contraception Contraceptive use status Unmet need to space Unmet need to limit Using contraceptivesto space Using contraceptivesto limit Spacing failure Limiting failure Desire birt h < 2 yrs Infecund, menopausal Total Urban Number of women % 89 3.8 146 6.2 450 19.0 1042 44.1 28 1.2 18 0.8 341 14.4 250 10.6 2364 100.0 Rural Number of women % 531 6.5 516 6.3 1267 15.5 3386 41.3 96 1.2 68 .8 1416 17.3 912 11.1 8192 100.0 Ban gla desh Number of women % 620 5.9 662 6.3 1717 16.3 4427 41.9 124 1.2 86 .8 1757 16.6 1162 11.0 10556 100.0 Public Health Research 2013, 3(3): 37-42 39 Table 2. Percentage distribution of currently married women with unmet need for contraception according to some background characteristics Characte ristics Urban Unmet need to Space Limit Rural Unmet need to Space Limit Ban gla desh Unmet need to Space Limit Women’s age <20 20-34 35-49 Women’s e ducation Illit erat e Primary Secondary Higher Husband’s e ducation Illit erat e Primary Secondary Higher Women’s occupation Did not work Work Husband's occupation Manual Non manual Did not work Religion Non Muslim Muslim Numbe r of living children None 1-2 3-4 5+ Fe rtility Pre ference W ant s Undecided Doesn't want Mass me dia exposure Yes No Eve r use of any contrace ption No Yes Discussed about FP wi th husband Never Once or twice More often Region Barisal Ch itt agon g Dhaka Khulna Rajshahi Sylhet Wealth index Poor Middle Rich *** 10.9 1.0 3.5 8.8 0.1 4.9 *** 2.1 8.6 3.9 6.7 5.7 4.5 3.2 2.9 *** 2.6 6.7 3.8 8.4 4.9 5.9 3.6 3.4 *** 4.5 6.4 1.3 5.3 *** 4.8 7.0 2.1 5.2 4.5 4.5 - 2.4 4.7 4.0 6.3 *** 8.2 0.3 5.2 4.5 1.0 9.8 0.0 9.9 *** 8.0 0.0 15.2 2.2 1.0 9.8 *** 3.8 5.2 3.4 12.3 *** 13.1 5.9 2.5 6.3 *** 4.3 8.1 3.5 4.1 1.5 3.0 - 3.1 7.2 5.7 7.8 3.5 6.2 2.8 6.0 2.5 3.3 5.1 8.1 ** 4.6 8.7 4.2 6.8 3.5 5.4 *** 17.5 1.2 5.4 7.7 0.5 7.5 *** 4.6 7.5 5.9 7.3 10.0 3.9 10.0 0.7 *** 5.0 6.5 7.0 6.8 8.7 6.6 5.6 3.0 *** 7.4 6.1 2.8 7.3 *** 7.0 6.7 4.9 4.9 4.5 6.1 *** 3.3 3.2 6.8 6.7 *** 13.5 0.0 9.0 3.8 3.2 9.2 1.0 12.2 *** 13.0 0.0 28.5 .6 2.1 10.0 *** 6.6 5.4 6.2 8.0 *** 17.9 7.8 3.9 6.0 *** 7.7 7.7 4.8 4.4 3.1 3.1 *** 6.8 7.3 11.2 9.6 5.1 6.7 4.1 4.7 4.8 3.2 12.1 12.2 *** 6.1 6.8 7.3 5.8 6.5 5.9 Note: Significant level: ***, ** and * indicate p<0.001, p<0.01 and p<0.05 respectively *** 16.3 1.2 4.9 8.0 0.4 6.9 *** 4.1 7.7 5.5 7.2 8.9 4.0 6.6 1.8 *** 4.6 6.5 6.4 7.1 7.7 6.4 4.8 3.2 *** 6.8 6.2 2.4 6.8 *** 6.6 6.7 3.9 5.0 4.5 5.3 *** 3.1 3.5 6.2 6.6 *** 12.2 0.1 8.0 3.9 2.8 9.3 0.9 11.8 *** 11.9 0.0 25.8 0.9 1.9 9.9 *** 5.8 5.3 5.9 8.4 *** 17.2 7.5 3.5 6.0 *** 7.1 7.7 4.5 4.4 2.6 3.0 *** 6.3 7.2 9.8 9.1 4.6 6.6 3.8 4.9 4.5 3.2 11.1 11.4 *** 5.9 7.0 6.8 5.9 5.3 5.7 40 Rafiqul Islam et al.: Unmet Need for Family Planning: Experience from Urban and Rural Areas in Bangladesh Table 3. The odds ratio of logistic regression models for the determinants of unmet need for contraception Characte ristics Women’s age <20 (Ref) 20-34 35-49 Re spondent’s e ducation Illiterate (Ref) Primary Secondary Higher Women’s occupation Did not work (Ref) Work Husband's occupation Manual (Ref) Non manual Did not work Religion Non Muslim (Ref) Muslim Numbe r of living children None (Ref) 1-2 3-4 5+ Wante d last chil d Yes (Ref) No Eve r use of any contrace ption No (Ref) Yes Discussed about FP wi th husband Never (Ref) Once or twice More often Co n st ant Urban Spacing Limiting 1.000 0.970 0.002 1.000 2.037e 1.232 e 1.000 1.268 1.848 1.890 1.000 1.375 1.138 0.705 1.000 0.516 1.000 0.787 1.000 0.586 0.536 1.000 0.700 2.358 1.000 3.010 1.000 1.605 1.000 3.177 2.078 0.017 1.000 0.003 0.003 0.002 1.000 0.224 1.000 2.341e 1.000 0.178e 1.000 0.126 e 1.000 0.559 0.446 0.051c 1.000 0.387 e 0.217c 0.015 Odds Ratio Rural Spacing Limiting Ban gla desh Spacing Limiting 1.000 0.511 e 0.275 e 1.000 1.263d 1.557e 1.000 0.560e 0.264d 1.000 1.412e 1.518d 1.000 1.504e 1.870e 1.590e 1.000 1.376c 1.242 1.387 1.000 1.444d 1.804e 1.601c 1.000 1.384c 1.268 1.162 1.000 0.708 1.000 1.109 1.000 0.676c 1.000 1.025 1.000 0.676c 0.862 1.000 0.815 1.699 1.000 0.654d 0.857 1.000 0.797 1.826 1.000 1.824c 1.000 2.146c 1.000 1.895d 1.000 2.009d 1.000 2.260e 3.295d 1.543e 1.000 24.661 28.392d 35.485 1.000 2.428d 3.238c 1.559 1.000 0.991 1.157 1.283 1.000 0.132e 1.000 1.806e 1.000 0.136e 1.000 1.908e 1.000 0.196 e 1.000 0.104 e 1.000 0.190 e 1.000 0.111 e 1.000 0.517 e 0.243 e 0.198d 1.000 0.484 e 0.433d 0.000 1.000 0.521 e 0.277 e 0.170 e 1.000 0.463 e 0.381d 0.001d Note: Ref = Reference Category and c=p<0.05; d=p<0.01 and e=p<0.001 4.1. Urban - Rural Differentials in Unmet Need for Contracepti on Table 2 shows the percentage distribution of the women in the sample with an un met contraceptive need. Un met need for spacing births is higher among younger women, wh ile unmet need for limiting childbearing is higher among older wo men. In each age group the level of un met need among rural wo men is higher than that of urban wo men. But un met need to limit births among urban women (8.8%) is higher than that of rural wo men (7.7%) only in the age group 20-34 y ears . Both urban and rural area as the education level increases the unmet need to limit birth decreases. Women who work for cash have less unmet need to space (1.3%) and to limit (5.3 %) births than their counterparts who do not work for cash in the urban area. Whereas rural wo men who work for cash have less unmet need to space (2.8%) but more un met need to limit (7.3%) births than those women who do not work for cash. In the urban area women whose husband are non-manual workers ( Serv ice man, business man etc., ) have less unmet need to space (2.1%) and limit (5.2%) births co mpared with those women whose husbands are manual workers (Day labours, farmers etc.,). This result is also true for the rural wo men and wo men allover the country. Muslim wo men have more unmet need (space and limit) for FP than their non-muslim counterparts both in the urban and rural a rea. As the number of living child ren increases the unmet need to space births is decreased but unmet need to limit births is increased among both urban and rural wo men. Women who access to mass media have 3.8% and 6.6% unmet need to space births among urban and rural wo men respectively, but unmet need to limit births is almost same for urban (5.2%) and rural (5.4%) wo men. Wo men who never use any contraception have higher unmet need for FP than those wo men who ever use any contraception allover the country. This is also true for both urban and rural women. Wo men who never discuss about FP with their husband have higher unmet need than their counterparts who discuss with their husband both in the urban and rural area. Un met need (space and limit) is highest among women in Chittagong and Sylhet divisions (13.5% and 13.1% respectively) in the urban area and (20.8 % and 24.3 % respectively) in the rura l area . Public Health Research 2013, 3(3): 37-42 41 4.2. Determinants of Unmet Need for Contraception We now wanted to see if there was any factors associated with unmet need in the urban and rural areas, and if any, how much did those factors contribute to unmet need. The ten predictor variables used are the same in both models. The results are presented in table 3. Un met contraceptive need for spacing birth was concentrated among women in the under 20 year’s age group. In both urban and rural areas and for the country as a whole, the data shows that as the age increased unmet need to space birth gradually declined. For urban areas, there is no association between mother’s education and unmet need to space and limit birth. However in rural areas, wo men with primary schooling and those with a secondary and higher education had significantly higher (p<0.001) un met need to space births. The probability of having an unmet need (Both space and limit) was significantly lower (p <0.001) where husbands and wife discussed family planning method and this was true for both urban and rural areas. Also it was significantly lo wer (p<0.001) among the ever users of any contraception. The no. of liv ing children emerged as the best predictor of un met contraceptive need in the rural areas. In the rural a reas unmet need to space births was more than 1.5 times higher among wo men who had five or mo re children than those who had no children. By contrast, in the urban areas women who had five or more ch ildren un met need to space births was 0.017 times lo wer than those who had no children and the difference was not statistically significant. 5. Discussion In this paper an attempt has been made to examine the proportion of wo men who are exposed to the risk of unwanted pregnancy but are not practicing contraception. In most societies this has been a very serious problem since the impact of un met need on fertility over a period of time may be very significant even if the magnitude of un met need at any point in time is small. The total unmet need for family planning among currently married wo men in Bangladesh is 12.2% out of which 5.9% have unmet need for spacing births and 6.3% want to limit b irths. Statistics on unmet need may understate the true demand for family planning. They often exclude unmarried wo men because it is difficult to collect reliable information[16,17]. Yet un married young people face great barriers to services and may have higher levels of unmet need than married wo men [18]. The standard definit ion of unmet need also fails to consider wo men who are using contraception but need a method that is mo re effective, safer, or a better fit with their personal circu mstances[19]. However, Ferdousi et al. found in their study conducted at Sreepur upazila under Gazipur district in Bangladesh that 22.4% among rural wo men have un met need of family p lanning[20]. In another study, among the married fecund wo men 7% have un met need for contraceptive with 5% for spacing and 2% for limiting b irth in kolkata, India[21]. Bhattacharya et al. observed that 42% unmet need of wh ich 26 % % were limiters and 16% were spacers[22] and Sain i et al. observed 26 % total un met need with, 7% and 19% un met need for spacing and limiting respectively[23]. Present study also represents that the unmet need to limit b irths is almost same for both urban and rural wo men; on the other hand, unmet need to space births in the rural area is higher than that in the urban area. Cost and accessibility have been identified as barriers to use of family planning services for poor, rural wo men[24]. In another study, Haque showed that about 16.03% of currently ma rried adolescent women had an unmet need for contraceptive in Bangladesh it was higher in rura l areas (17.4%) than in urban areas (12.6%). He also found that husband’s opposition and fear of side effects were the most cited causes for not using contraceptives[25]. Other research in sub-Saharan Africa has found that use of contraception increases if a wo man has previously discussed contraception, been exposed to mass med ia about family planning, or approves of family planning [26, 27, 28]. The main predictors of unmet need for spacing and limit ing births were found to be ever use of family p lanning, husband-wife communication on family planning matters, number of living children and respondents age. It is quite evident that, if the 12% gap between ever use of contraception (70%) and cu rrent use (58%) could be b ridged, the CPR would be close to 70% and the country might reach the replacement level of fertility. Therefore, in order of priority, the population programme should aim at motivating "drop-outs" to resume practicing contraception. The programme can do so through appropriate IEC (informat ion, education and communicat ion) measures, imp roved supervision, as well as by ensuring that the major reason for dropping out (half of the users in Bangladesh stop using contraceptive methods within the first 12 months of use), namely, side-effects, is duly addressed through better counseling as well as better management of side-effects. The programme certainly needs to give due consideration to improvements in the quality of care being offered to acceptors. This issue can be better addressed under the new service delivery strategy of providing services fro m static clin ics, attended by paramedics in addition to field-workers. Also, the providers need to be given adequate training on counseling, screening and management of side-effects. Co mmunicat ion between husbands and wives on family planning matters is an important intermed iate step along the path to their eventual adoption and the sustained use of family planning methods. The programme should be further strengthened and intensified in rural areas, where un met need is highest. Co mmun ity leaders should be more act ively involved in the programme and it should give greater emphasis to longer-acting methods in order to address the unmet needs of high parity women. Higher parity wo men, using temporary methods or not practicing contraception at all, are potential candidates for permanent methods. The providers should motivate such women to accept permanent methods by explaining to them the relat ive advantages of permanent methods. The programme should intensify its 42 Rafiqul Islam et al.: Unmet Need for Family Planning: Experience from Urban and Rural Areas in Bangladesh efforts in the rural areas of the country in order to enhance accessibility to, and availability of, family planning methods. Young married wo men (less than 20 years of age) deserve special consideration because unmet need is highest among them, and their fert ility is high. The programme should attach high priority to addressing the needs of these women by appropriate IEC measures and selective home visits. REFERENCES [1] John A. R. and William L. W. (2002), “Unmet Need for Contraception in the Developing World and the Former Soviet Union: An Updated Estimate,” International Family Planning Perspectives 28( 3) [2] Carl, H. and Britt, H. (2002), Family Planning Worldwide 2002 Data Sheet (Washington, DC: Population Reference Bureau, 2002). [3] Christopher, M . and Alan, L.(1998) eds., Health Dimensions of Sex and Reproduction. Vol. 3, Global Burden of Disease. Boston: Harvard University Press, 280. [4] Hadi, A. and Gani, M .S. (2005) Socio-economic and regional disparity in the utilization of reproductive health Services in Bangladesh. M easuring Health Equity in Small Areas (ed. In-depth network), London, Asgate Publishers. [5] United Nations Children’s Fund (2004) Under-five and infant mortality rates-UNICEF, United Nations Population Division and United Nations Statistics Division Dhaka, Bangladesh: UNICEF Bangladesh Country Office. [6] Bangladesh Bureau of Statistic (2003) Bangladesh Population Census 2001. 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[12] Levine, R., Langer, A., Birdsall, N., M atheny, G., Wright, M . and Bayer, A. (2006) Contraception. In: Jamison, D.T., Breman, J.G., M easham, A.R., et al., eds. Disease Control Priorities in Developing Countries. New York: Oxford University Press:1075–1090. [13] Singh, S., Darroch, J.E., Vlassof, M . and Nadeau, J. (2003) Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: Alan Guttmacher Institute [14] World Health Organization (2004). Unsafe Abortion. Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000. Geneva: WHO. [15] Robey, B., Ross, J. & Bhushan, I. (1996) M eeting unmet need: New strategies in Population Reoprts, Johns Hopkins school of Public Health, Population Information Programme, Baltimore, 43-48 [16] Casterline, J.B. and Sinding, S.W. (2000) Unmet need for family planning in developing countries and implications for population policy. 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(2011) Bridging the unmet need in contraceptive practive with natural methods: a study from Kolkata, India. theHealth 2 (3), 78-81. [22] Bhattacharya, S.K., Ram, R., Goswami, D.N., Gupta, U.D., Bhattacharyya, K., & Ray, S. (2006) Study of unmet need for family planning among women of reproductive age group attending immunization clinic in a medical college of Kolkata. Indian Journal of Community M edicine. Vol. 31 (2), 73-75 [23] Saini, N.K., Bhasin, S.K., Sharma, R. & Yadav, G. (2007) Study of unmet need for family planning in a resettlement colony of east Delhi. Health Pop Perspect Issues 30, 124-133 [24] Tuoane, M ., M adise, N.J. and Diamond, I. (2004) Provision of family planning services in Lesotho. International Family Planning Perspectives 30(2): 77-86. [25] Haque, M . N. (2010) Unmet Need for Contraceptive: The Case of M arried Adolescent Women in Bangladesh, Internati onal Journal of Current Research Vol. 9, 029-035 [26] Tawiah, E.O. (1997) Factors affecting contraceptive use in Ghana. Journal of Biosocial Science29(2): 141-149. [27] Gupta, N., Katenda, C. and Bessinger, R. ( 2003) Associations of mass media exposure with family planning ttitudes and practices in U ganda. Studies in Family Planning 34(1): 19-31. [28] Kayembe, P.K., Fatuma, A.B. M apatano, M .A. and M ambu, T. (2006) Prevalence and determinants of the use of modern contraceptive methods in Kinshsa, Democratic Republic of Congo. Contraception 74(5): 400-406.

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