The importance of family planning in reaching the Millennium Development Goals(MDGs) is well acknowledged as it has been shown to reduce mother and infant mortality rates(1). Maternal mortality is a crucial measure of global development, and reducing it has been an ongoing challenge in low-income countries, even with the availability of effective interventions(2). Globally increased usage of family planning has resulted in reductions in maternal and infant mortality(3) but Maternal mortality rates remain alarmingly high, with approximately 287,000 women dying during or after pregnancy and childbirth in 2020. Nearly 95% of these deaths occurred in low- and middle-income countries, and the majority were preventable(4). The preventable loss of nearly 3 million women’s lives between 2010 and 2020 is a profound global tragedy that underscores significant health disparities both between and within countries and constitutes a grave violation of human rights(5,6).

Recent estimates for 2019 reveal that sexual and reproductive health services in low- and middle-income countries (LMICs) fall short of meeting the needs of their populations. Approximately 218 million women of reproductive age (15 to 49 years old) in these countries have an unmet need for modern contraception. Additionally, nearly 49% of pregnancies in LMICs, totaling about 111 million each year, are unintended(7). In West and Central Africa, there is a troubling combination of low coverage and high unmet need for family planning services (8–11). The use of modern contraceptives offers numerous benefits, including effective birth spacing, reduction in unwanted or unintended pregnancies, prevention of unsafe abortions, improved maternal health, lower infant mortality rates, and protection against sexually transmitted diseases(12). Non-health benefits of modern contraceptives include increased educational opportunities and empowerment for women, poverty reduction, and the promotion of sustainable population growth and economic development in countries(13), despite the many benefits of modern contraceptives (MC), their use to prevent sexually transmitted infections, unwanted pregnancies, and deaths from unsafe abortions remains low in many African countries(14). Although there has been a recent rise in contraceptive use(15), Sub-Saharan Africa (SSA), of which Somaliland is a part, has the highest fertility rate in the world and also faces the greatest unmet need for family planning (16,17). According to the Somali Demographic Health Survey (SDHS), just 7% of currently married women are using any form of contraception, with only 1% utilizing modern contraceptive methods(18). Somalia has one of the lowest contraception uptake rates globally. Key factors influencing contraception use and unmet need include age, education level, number of children, exposure to family planning messages via mass media, and the region and location of residence(19). This study seeks to assess the utilization of family planning services and the factors that influence their use among women of reproductive age in Hargeisa, the capital of Somaliland.

MATERIALS AND METHODS

Study design and setting

A cross-sectional study employing a quantitative approach was conducted in Hargeisa, the capital city of Somaliland. (20), Hargeisa is the largest city in Somaliland, with an estimated population of around 1,200,000 in 2019 (21). For this study, two districts from the urban area and two small towns from the rural region of Hargeisa were selected.

Study population and sampling

The study targeted women of childbearing age (15-49) living in the selected four regions. A random sampling method was employed to choose participants from both urban and rural areas. Due to the lack of formal addresses in Somaliland, the researcher chose a house and then selected another every 30 meters to reduce sampling bias. The study included women aged 15-49 who were married, lived in the study location, and were in households that were accessible to researchers on the data collection days.

Study tool and Data collection

Data were collected primarily through face-to-face interactions using a questionnaire administered by the researcher and trained data collectors. The questionnaire, originally developed by Lilian Agesa in Western Kenya in 2016 (22), consisted of 24 questions. For this study, it was modified to remove culturally inappropriate questions and adapted to include 21 relevant questions. The questions were translated into Somali from English for use in rural areas where English is less commonly understood. Researchers received instructions on how to complete the questionnaire and explain the questions clearly to respondents. The questionnaire was divided into three sections: demographic characteristics, history of previous access to family planning services, and factors affecting the utilization of family planning services. Each interview took around 30 minutes.

Data analysis

Data were analyzed using IBM SPSS Statistics Version 25. Descriptive statistics were used to summarize participant characteristics. Associations between family planning utilization outcomes and participant characteristics were assessed using the chi-square test. A p-value of <0.05 was considered statistically significant.

Ethical consideration

To conduct this research, we obtained ethical approval from the Ankara Yildirim Beyazit University, Social and Human Sciences Ethics Committee (approval number: 2022-671) and authorization from the Ministry of Health Development of the Republic of Somaliland (reference number: 2/800/2022). All participants provided written informed consent and were fully informed about the study's purpose and rationale.

RESULT

A total of 1,152 women of reproductive age participated in the study, with an equal distribution between urban and rural areas (50.0% each). Nearly half of the participants (47.0%) were aged 25–34 years, and the majority were married monogamously (75.5%). In terms of education, over one-quarter of participants had university-level education (26.4%), while 12.7% were illiterate. Most respondents were housewives (72.7%), and a large proportion (75.1%) reported having no personal income, indicating a high level of economic dependency among women. Among spouses (n = 1,128), the majority were aged 31–40 years (46.6%) and had university-level education (43.7%). Most spouses were employed (73.1%), and a considerable proportion contributed regular income, with 26.5% earning between $100–200 per month. Overall, these findings suggest a socioeconomic imbalance between women and their partners, with men generally having higher employment and income levels, which may influence decision-making dynamics, including the utilization of family planning services (table 1).

Table 1. Socio-demographic characteristics of the participants (n = 1,152)

Family planning (FP) services were generally more accessible and affordable in urban areas compared to rural settings. A higher proportion of urban participants reported that FP methods were always available and affordable. Health centers were the primary source of FP services in both urban and rural areas. However, rural participants reported greater structural barriers, including longer distances to FP service points and higher transportation costs. Despite these challenges, the majority of respondents in both settings indicated that FP services were obtained from health facilities and that counseling was provided prior to use. The prevalence of reported side effects from FP use was low. In contrast, myths and misconceptions regarding FP were highly prevalent across both urban and rural populations, with similar proportions in each group. Common beliefs included concerns about infertility, illness, and social consequences such as partner remarriage. Communication with partners regarding FP use was limited, particularly in rural areas, and partner approval was generally low among those who discussed FP. Cultural and social factors, including preferences for larger families and religious or societal beliefs, were commonly reported as influencing FP utilization (Table 2).

Table 2. Factors related to family planning utilization by place of residence

Note: Percentages for family planning service characteristics were calculated among respondents who reported previous or current family planning utilization; therefore, totals may not equal the full study sample.

Bivariate analysis using the chi-square test was conducted to assess the association between socio-demographic characteristics of participants and their spouses and family planning (FP) utilization outcomes, including previous use, current use, and intention to use FP services. A significance level of p ≤ 0.05 was considered. In the bivariate analysis, education level, occupation, place of residence, and several spouse-related characteristics were significantly associated with previous family planning (FP) utilization (p ≤ 0.05). Women with higher levels of education showed higher proportions of FP use. Occupation was also significantly associated, with employed women reporting greater FP utilization compared to other occupational groups. Place of residence demonstrated a strong association, as women living in urban areas reported substantially higher FP use than those in rural areas (p < 0.001). Among spouse-related variables, education level, occupation, and income were significantly associated with FP utilization, indicating the influence of partner socioeconomic characteristics. In contrast, age group, marital status, income status of the participants, and spouse age were not significantly associated with previous FP utilization (table 3)

Table 3. Factors associated with previous family planning utilization

In the bivariate analysis, education level, occupation, place of residence, and income status were significantly associated with current family planning (FP) utilization (p ≤ 0.05). Women with higher education, particularly those with university-level education, reported higher proportions of FP use. Occupation was also significant, with employed women demonstrating higher FP utilization compared to other occupational groups. Place of residence showed a strong association, with urban women reporting substantially higher FP use than rural women (p < 0.001). Income status was also significantly associated with FP utilization. Among spouse-related characteristics, age, education level, occupation, and income were significantly associated with current FP utilization, indicating the important role of partner-related socioeconomic factors. In contrast, age group and marital status of participants were not significantly associated with current FP use (table 4).

Table 4. Factors associated with current family planning utilization

In the bivariate analysis, occupation, place of residence, and income status were significantly associated with the intention to use family planning (FP) services (p ≤ 0.05). Women residing in urban areas reported a higher intention to use FP compared to those in rural areas (p < 0.001). Income status was also significant, with women who were economically dependent showing a greater intention to use FP. Occupation demonstrated a significant association, with housewives reporting higher intention to use FP compared to employed women. Among spouse-related characteristics, education level, occupation, and income were significantly associated with intention to use FP, suggesting that partner socioeconomic factors influence future FP decisions. In contrast, age group, education level, marital status of participants, and spouse age were not significantly associated with intention to use FP (Table 5).

Table 5. Factors associated with intention to use family planning services

DISCUSSION

This study examined the factors associated with family planning (FP) utilization, including previous use, current use, and intention to use FP services. The findings highlight the important role of socio-demographic and socioeconomic factors, particularly place of residence, education level, and income status, in shaping FP-related behaviors.

The study revealed that family planning has historically been underused among women in Hargeisa, Somaliland, with only 23.9% having utilized it in the past. This rate has since decreased slightly to 22.5%, indicating that family planning use remains relatively low in the region. This finding aligns with previous studies that have reported similarly low utilization rates for family planning services in sub-Saharan Africa(14,23–27). Several factors contribute to the low usage of family planning in this study. One significant reason is the lack of husband support; many women do not utilize family planning services due to pressure from their husband, who often desire more children. Additionally, the study found that Somali men might marry additional wives if their current wives seek to use modern family planning methods. This issue is consistent with other research, which also highlights the role of husbands' approval in influencing family planning usage(28–33). Another significant factor is the widespread myths and misconceptions about family planning within the community, which likely contribute to the underutilization of these services by women. This finding is supported by other studies that highlight similar barriers(34–37). Additionally, Somali culture strongly discourages the use of family planning services. A similar issue is observed in other African countries like South Sudan, where deeply ingrained socio-cultural factors that promote larger families and discourage family planning contribute to the lowest contraceptive use in the East and Southern Africa region(38), in South West Nigeria(39). In developing countries, particularly in Africa, cultural and traditional factors are recognized as significant barriers to the acceptance and use of contraception. Many family planning programs fail to be effective because providers do not fully understand or address the cultural obstacles present in traditional communities(40). One of the most consistent findings of this study was the significant association between place of residence and family planning utilization outcomes. Women residing in urban areas reported significantly higher previous utilization, current utilization, and intention to use family planning services compared with women residing in rural areas. This finding underscores the persistent geographic disparities in access to and utilization of reproductive health services. Previous studies in low- and middle-income settings have similarly reported that residence is a key determinant of FP uptake, often reflecting differences in service availability, accessibility, and health system infrastructure(41–43) The observed association may also be influenced by variations in cultural norms, awareness, and health-seeking behaviors between urban and rural populations.

Education level was significantly associated with previous and current family planning utilization. Women with higher educational attainment were more likely to report using family planning services than less educated women. Higher levels of education may improve access to health information, increase awareness of contraceptive options, and enhance women's ability to make informed reproductive health decisions. Similar associations have been reported in previous studies conducted in low- and middle-income countries.(44,45).

 Income status was significantly associated with intention to use family planning services. Economically dependent women reported different levels of intention to use FP compared with women who had independent income. This suggests that economic empowerment plays a crucial role in shaping women’s reproductive autonomy and decision-making. Women with independent income may have greater control over health-related decisions and better access to services, which may increase their likelihood of considering FP in the future. This finding aligns with existing evidence emphasizing the importance of financial independence in improving reproductive health outcomes(46–48). Overall, the findings of this study highlight the multifaceted nature of FP utilization and the importance of addressing both structural and socioeconomic determinants. Geographic disparities, economic dependency, and variations in education-related effects suggest that FP interventions should be tailored to local contexts. Policies aimed at improving equitable access to FP services should prioritize underserved populations, particularly those in disadvantaged geographic and socioeconomic positions.

Strengths and limitations

This study has several strengths. It includes a relatively large sample size and examines multiple dimensions of FP utilization, including past behavior, current use, and future intention, providing a comprehensive understanding of FP dynamics in urban and rural areas. However, some limitations should be considered. First, the cross-sectional design limits the ability to establish causal relationships. Second, the study relied on self-reported data, which may be subject to recall bias and social desirability bias, particularly given the sensitive nature of FP use. Third, some variables, such as occupation, had small sample sizes in certain categories, resulting in unstable estimates that should be interpreted with caution. Finally, potential measurement limitations related to the cultural adaptation of the questionnaire may affect the reliability and validity of the findings. Although the study included both urban and rural participants, it was conducted within a single geographic area, which may limit the generalizability of the findings to all women in Somaliland or to other settings with different socio-cultural and health system contexts

Conclusion

 Family planning (FP) utilization remains low among women in Hargeisa, Somaliland. Place of residence, education level, occupation, income status, and spouse-related socioeconomic characteristics were significantly associated with FP utilization. In addition, cultural factors, including a preference for larger families, spousal influence, and misconceptions about modern contraceptive methods, continue to affect FP use. Efforts to improve FP uptake should focus on increasing community awareness, addressing myths and misconceptions, promoting women’s empowerment, and improving access to services, particularly in underserved areas. Future studies should explore FP utilization in other regions of Somaliland and further examine the socio-cultural factors influencing reproductive health behaviors.

Acknowledgments

We sincerely appreciate all the participants and data collectors for their valuable contributions.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

No funding