Path analysis for the adoption of modern contraception in morocco: an evaluation of women's status, husband's approval and mass media on the use of modern contraception among the moroccan married women
Background: Despite the contraceptive prevalence of 67.4% in Morocco, one woman out of 10 has unmet need for birth spacing or limiting and, only one woman out of two is using modern contraception. Although, Moroccan national family program [FP] was launched in the sixties and aimed to increase use of FP among married Moroccan women; the program is still facing some limits to improve coupleâ€™s contraceptive care. This paper examines to what extent womenâ€™s status, husbandâ€™s FP approval and mass media positive exposure to FP messages translate into increased modern contraceptive uptake. This study uses the socio ecological framework to assess factors that influence FP use among married women in Morocco. In this model factors from individual, interpersonal and programmatic levels were identified based on a review of the literature as having an effect on contraception use. Objectives: The main objectives of this study are to: (1) explore the effect of womenâ€™s status including their education, their occupation and, their FP decision making on womenâ€™s desire for more children, (2) examine if husbandsâ€™ FP approval impacts womenâ€™s fertility desire, (3) assess how positive mass media FP messages â€˜exposure influences womenâ€™s desire for children, (4) explore the effect of womenâ€™s fertility desire on womenâ€™s FP approval and,(5) assess if womenâ€™s FP approval increases modern contraception adoption. Methods: This analysis is based on secondary data from the 2004 Demographic Health Survey and, 2011 Morocco National Survey on Population and Family Health which were conducted among married women aged between 15 and 49 years old. Data were collected using a two-stage sampling scheme and the study population was 8,106 women in 2004 and 9,317 women in 2011. Path analysis, using series of multiple regression modeling analyses, was conducted to investigate the relationship between womenâ€™s desire for more children and predictors related to womenâ€™s status, husbandsâ€™ FP approval and, womenâ€™s exposure to FP messages via mass media. Full models were fitted to test the relationships between womenâ€™s desire for more children and womenâ€™s FP approval; womenâ€™s approval of FP and modern contraception use. Results: Descriptive analysis between 2004 data and 2011 data analysis showed similar results for womenâ€™s and husbandsâ€™ predictors. Women in 2011 who used modern contraception were mostly aged more than 35 years old (51%), lived in urban areas (56%), mostly rich (40.3%), educated (46%), with no occupation (89%), did not decide FP use alone (73.3%), whose husbands discussed FP with them (62%) and, approved contraceptive use (98%). Positive exposures to FP messages on mass media were measured only in 2004 data and showed that among women who adopted modern contraception, only 2.9% read FP messages in newspapers, 12.6% heard them in the radio and 25.5% heard them on television. Path analyses showed some differences between 2004 data and 2011data. In 2011 data educated women were 1.42 (O.R. = 1.42, C.I. 1.26â€“1.6) more likely to desire more children than those with no education. Women with occupation were 1.25 (O.R. = 1.25, C.I. 1.01â€“1.47) times more likely to desire children than those with no occupation. However, womenâ€™s education and womenâ€™s occupation factors were not related to womenâ€™s fertility desire in 2004 data. Husbandsâ€™ FP approval was not significantly associated to womenâ€™s fertility desire in both 2004 and 2011 data analyses. Mass media exposure to FP messages was examined only in 2004 and showed no significant association with womenâ€™s fertility desire. Similar results were observed between 2004 data and 2011 data and showed that women who decided for FP were 0.75 (O.R. = 0.75, C.I. 1.01â€“1.47) times less likely to desire more children than those who were not FP decision makers. Moreover, in 2004 women who decided for FP were 2, 32 times more likely to use modern contraception than women who were not FP decision makers [O.R. 2, 31 (CI 1.79-3.01)]. In 2011 data analysis, women who approved FP were 5.72 (O.R. = 5.72, C.I. 3.06â€“10.7) more likely to use modern contraception than those who did not approve FP. Furthermore, women whose husbands approved FP were 2.55 times more likely to adopt modern contraception (O.R. = 2.55, CI 1.845-3.513). Conclusions: This study results indicated womenâ€™s and, husbandâ€™s factors affecting womenâ€™s fertility desire and womenâ€™s contraceptive use. The factors effects varied between 2004 data and 2011 data. In 2011 data womenâ€™s education, womenâ€™s occupation, womenâ€™s FP decision making and, husbandsâ€™ FP discussion variables, had a significant effect on womenâ€™s fertility desire. However, in 2004 data only husbandâ€™s FP discussion had a positive effect on womenâ€™s fertility desire which had a positive effect on womenâ€™s FP approval. Womenâ€™s exposure to mass media FP messages did not have a significant effect on both womenâ€™s fertility desire and womenâ€™s contraceptive outcomes. Husbandsâ€™ FP approval and husbandsâ€™ FP discussion with their wives were highly predictive for womenâ€™s contraceptive use and remained essential factors for which Moroccan health policy makers should take into consideration in order to reduce unmet needs and improve coupleâ€™s contraceptive care in Morocco.