Women’s unmet need of modern contraceptive in Cameroon has many gender specific health risks and development implications. This paper sought to examine the perceptions variation among men and women towards contraceptive use by employing a mixed method design to collect both quantitative and qualitative data from 248 participants using questionnaires and interview guides. The results showed that 86% of the participants had heard of contraceptives and a lesser proportion (8%) did not know the importance of contraceptives; 67% of respondents indicated that women were in greater need of contraceptives as opposed to 33 % who opined that men needed contraceptives and the relationship between gender perception and contraception use was statistically significant (p-value=0.04). This study contributes to the body of knowledge on contraceptive use and the predictors which may account for its weak uptake and the wide unmet need of contraceptives in African countries like Cameroon.

Keywords: Cameroon, contraceptives, family planning, reproductive health, perception, sustainable development goals

Population growth, the spread of Sexually Transmitted Infections (STIs), women’s autonomy over their reproductive decision making, access to education as well as issues relating to male and female reproduction and sexuality can be directly linked to access and use of Modern Contraceptives (MC) (World Health Organization [WHO], 2019).1 The significant importance of contraceptives has been highlighted by various international instruments and institutional mechanisms such as the 1994 International Conference on Population and Development (UN, 1995, 2016)2, the Sustainable Development Goals (SDGs) and the WHO which strongly advocates for access and use of MC to particularly to women and girls of reproductive age (15-49). In particular, WHO, (2019)1 states that “use of modern contraceptives in 2017 prevented an estimated 308 million unintended pregnancies’’ further highlighting that “[M]eeting all women’s need for modern methods of contraception would avert an additional 67 million unintended pregnancies annually”.¹ As an indispensable dimension of Sexual Reproductive Health (SRH), contraceptives have increasingly gained notoriety for their ability to guarantee important reproductive and development outcomes linked to birth control, family planning, and prevention of unintended and unwanted pregnancies, protection against STI and HIV/AIDS, reduction of child mortality rates among other benefits.²

Current literature suggests that access and use of contraceptives can be very significant for both men and women, even though the outcomes on women and girls of reproductive age are far greater.^3,4 Within the context of the United States of America, a longitudinal study conducted by Bailey and Lindo⁵ revealed among other things that the use of MC has reaped significant benefits for women across the board. As an illustration, Bailey and Lindo⁵ correlate women’s economic empowerment, age of childbirth and age of marriage to the uptake of MC across many decades. Similarly, in their study on attitudes surrounding contraceptive use among refugee youths in Nigeria, Okanlawon et al.,⁶ noted that refugees and displaced persons are exposed to various reproductive health risks such as STIs, prostitution, rape and early engagement in sexual activities as well as unintended and unwanted pregnancies which can be resolved with contraceptive use. In addition, the just cited authors noted that beliefs and attitudes about contraceptive use can serve as serious barriers to their effective use, thereby exacerbating an already precarious situation for refugees. Within the context of contraceptive use among displaced persons, Internally Displaced Persons (IDPs) in Cameroon are a particularly at risk community.⁷ From September 2016 till date, violence in the North West and South Regions of Cameroon have caused the displacement of hundreds of thousands of people from their homes and communities (Internal Displacement Monitoring Centre).⁸

Women and girls who have been forcefully displaced from their homes have found themselves in precarious situations as they struggle to survive. Kenimbeni⁷ notes that IDP girls from the North West seeking refuge in Bafoussam the capital of the West region of Cameroon are compelled to have sexual intercourse with their bosses in order to “secure their jobs, have higher pay, or simply earn their end of month salaries”. It is plausible to argue that in a context where predatory sexual practices are rife, women and girls have little to no voice in sexual decision making and STI’s are rife, the situation of these female IDPs could be very disastrous if interventions fail to address their reproductive health care needs. Emeh et al.,⁹ utilizing a cross-sectional research design in a study on predictors of contraceptive use among workers in Pena Mboko and Tiko CDC (Cameroon Development Corporation) plantation camps came to the conclusion that the rhythm method was the most prevalent form of contraception utilized followed by condoms. Also, the authors noted that living with a partner, getting into a union at age less than 30 years and experiencing last pregnancy in the last five years were important predictors in assessing contraceptive use among the study population. However the most statistically significant predictors were age (<35 years) and living with a partner.⁹ When coupled with a cultural context that has developed a doubtful attitude towards contraceptive use, this category of vulnerable women and girls find themselves in a bind.

The availability of various types of MC such as condoms, pills, implants, injectable among others, IUDs, among others offers users the ability to make informed choices which have implications on reproductive life choices. With the exception of Africa, there has been an impressive uptake in the rate of contraceptive use as well as fulfilling the unmet needs of contraceptive use across the world. According to WHO,¹ the rate of MC use across the world stood at 63 percent while in Europe, Latin and North America and the Caribbean was above 70 percent in 2017. On the contrary, across Africa, the rate of contraceptive use within the same period stood at less than 26 percent which is quite interesting considering that population growth, poorly spaced pregnancies, prevalence of HIV/AIDS and STI’s, and early unintended pregnancies are serious social problems which require immediate policy action. Edietah et al.,¹⁰ revealed in their study of contraceptive use and determinant of unmet family planning that the degree of unmet family needs in the North West region of Cameroon were quite high. Among the various factors which accounted for the unmet need was the unimpressive rate of contraceptive practice which prevailed in the region. Consequently, the low uptake of MC in Africa and by extension Cameroon cannot be totally explained by poverty, unmet needs and lack of MC options. It is plausible that attenuating socio-cultural and political factors constitute an axis of the problem which has not been amply imputed into the equation of low MC uptake in Africa and Cameroon. This paper examines the link between the ability to use as well as the perception variations which exist between men and women’s use of MC in North West and South West regions of Cameroon. Results obtained from this research will be vital in informing decision making regarding MC uptake in these 2 regions.

Study area

The study was carried out in the South West (SW) and North West (NW). The North and South West Regions constitutes the English speaking parts of Cameroon. In the SW region data for the study was collected from Buea which is the capital of the SW region. Buea is part of the Mt Cameroon and is a cosmopolitan town with over 300,000 inhabitants as per the 2013 census. In the NW region, data was collected from Bamenda which is the capital of the region. It has a total population of over 573,000 inhabitants. Since September 2016, these 2 regions been experiencing socio-political crisis which is still ongoing in Cameroon.

Study design

The study is a community based cross-sectional study. A mixed method approach was used to collect quantitative and qualitative data.

Sampling technique

The two regions for the study are the two Anglophone regions of the country. The study areas of Buea and Bamenda were purposefully selected as these are the most cosmopolitan towns of the Anglophone regions with inhabitants from all over the region, hence it will be possible to get a varied perception on contraception use. At the community level, convenient sampling was used to select participants in schools and other social gatherings.

Target population

The study targeted women of reproductive age 21 to 49 years and men 21 years and above.

Sample size

The sample size for the study was estimated using the cochrane’s formula. A proportion of 20% was used to estimate the sample size. This proportion was obtained from an earlier study done in the North West region in Cameroon that estimated the level of modern contraception use at 20%. Assuming a 95% confidence level, the sample size was estimated at 246 participants and assuming a non-response rate of 10%, the minimum sample size was estimated at 270 participants.

Data collection and management

The study collected both quantitative and qualitative data. Quantitative data was collected using a close ended semi structured questionnaire. The questionnaires were double checked on daily basis for completeness and then entered into excel. As for the qualitative data, it was collected through key informant interviews using an interview guide. These interviews were conducted among 5 men and 5 women per selected study site. The interviews were all recorded into a tape recorder.

Data analysis

Data from the questionnaires was entered into excel and then exported into STATA 15 for analysis. Univariate analysis through proportions and means was used to summarize the demographic data as well to ascertain the level of contraceptive use. Bivariate and multivariate analysis was used to assess the possible factors causing differences in perceptions between men and women on contraception use. Both tables and graphs have been used to present the results as needed. For the KIIs, the interviews were recorded, then transcribed verbatim. This was followed by coding and then analysis through content analysis.

The objective of this study was to assess perception variation on contraception use among men and women. A total of 270 questionnaires were given out and a total of 248 were retained giving a response rate of 92%. Data was collected on the demographic distribution of the participants and a majority of the participants (61%) were from the South West region. Most of the participants were female and a majority had completed tertiary level of education. Over half (58%) of the participants were female. Table 1 summarizes all the demographic characteristics considered for the study.

Perceptions on contraceptives use

Regarding perceptions on contraceptive use, 86% of the participants had heard of contraceptives and majority (33%) knew about contraceptives from the hospitals and schools. As for the perception on the importance of contraceptives, a greater proportion of the participants agreed that contraceptives were used to prevent both pregnancy and STIs. A lesser proportion (8%) did not know the importance of contraceptives. With regards to the perception on who needs contraceptives more, 67% of respondents indicated that women were in greater need of contraceptives as opposed to 33 % who opined that men needed contraceptives. The perceptions on contraceptive use have been summarized in Table 2.

The views expressed in Table 2 were also corroborated with qualitative results collected from key informants. A key informant (KI2) who works as a nurse in a clinic in Mile 16 Buea noted that contraceptives were indispensable for both women and men particularly with the advent of Sexually Transmissible Infections (STI’s) such as Hepatitis B, Gonorrhea, and Syphilis among others which seemed to be experiencing a resurgence in Cameroonian society. Regarding the source from which information on contraceptive use was most prevalent, the just mentioned key informant (KI2) confirmed that hospitals and health centres are prolific in terms of sensitization campaign and messages such as banners, posters, tracks and others on contraceptive use. Similarly, another female respondent (KI4) who serves as a secondary school teacher in Mile Four Nkwen in Bamenda noted that through health clubs and other avenues students with an emphasis on female students are consistently grilled on the need to use contraceptives and request information regarding contraceptives in schools.

In terms of the importance of contraceptive use, most key informants were of the opinion that they were most effective in preventing pregnancies and the spread of STIs. In situations where young girls were inexperienced and in the early stages of sexual curiosity, one the Key Informant (KI3) in Molyko Buea noted that: “Contraceptives such as condoms could be very helpful to inexperienced girls in preventing both the spread of HIV/AIDS and also early unwanted pregnancies” (KI3, Nurse Molyko, Buea).

Other key informants such as a male community leader (quarter head) in New Lay Out Nkwen noted that: “Contraceptives such as condoms can be very helpful for women who are very fertile and easily get pregnant. They can easily purchase them [condoms] and through dialogue and persuasion encourage their partners to use them during intercourse. An added advantage to condom use is that it is affordable and readily available in almost all stores in the community” (KI4 community leader New Lay Out Nkwen). In addition, there was overwhelming agreement regarding the view that contraceptives had a greater impact on women’s reproductive health care than it did for men. The views also noted that, unlike men, women’s biology exposes them to various risk factors linked to sexual intercourse and reproduction. A key informant noted that due to their Biology, women are more vulnerable to STI’s, HIV and other venereal diseases. Coupled with the risk of early, unwanted and unintended pregnancies, women’s access to and use of contraceptives is of greater significance as opposed to men who are not capable of getting pregnant (KI2).

Level of contraceptive use

One of the study’s objectives was to assess the level of contraceptive use. As shown on Table 3 a majority of the participants (62%) had ever used or using contraceptives. Condoms were the most used contraceptives and were not used on every sexual encounter. The least used contraceptive was the injectable type. As for the purchase of contraceptives, they were mostly obtained from pharmacies and drug shops. About half of the respondents indicate that they had no challenges with contraceptives while 16% reported side effects as the major challenge with the use of contraceptives (Table 3).

In the same vein, the qualitative findings also confirmed these results. It was gleaned from field interviews that there was an increasing acceptance of contraceptive use even though perceptions from some individuals do not favor the use of the latter. Results revealed that since male condoms were affordable, available and knowledge on their effective use was widespread, this type of contraceptive emerged as the most popular. In the same light, two key informants who run small drug stores in neighborhoods in Buea and Bamenda observed that condoms were the most widespread contraceptives they had observed their customers consistently purchases. Interestingly, there was a preference for male condoms as opposed to female condoms as noted by the key informants Buea.

Further investigation revealed that female condoms are not easily available in the market, knowledge on its use is lacking and suspicion surrounding their effectiveness is not guaranteed particularly considering the amount of time required to use them on by women. Results revealed that knowledge and use of pills was mostly restricted to a small population, mostly composed of young girls and boys who having engaged in at risk sexual activities, took pills as a counter and corrective measures to avoid unintended and unwanted pregnancies. Key informant KI1 observed that pills popularly referred to as ‘Morning After’ were mostly purchased from drugstores in Molyko a neighborhood hosting the University of Buea by a predominantly female audience. This results also coincides with the quantitative findings in which the majority of respondents noted that their usage of contraceptive was not consistent but rather happened on occasion. As noted by KI4, “if adolescents and women used contraceptives consistently, the advent of unwanted and unintended pregnancies, spread of STIs, and other related issues which can be resolved by contraceptive use will not be as widespread as we have them today”. It was also understood from the results that some respondents usually preferred sex without protection citing that it prevented a wholesome appreciation of the sexual experience.

Additionally, the qualitative results revealed that women and girls who had mastered their menstrual cycles and knew their windows of conception could easily engage in sex without the use of condoms and other available contraceptives. This was despite the understanding that access to and cost of MC such as condoms was not a challenge. As previously mentioned, condoms are affordable, easily accessible and are sometimes distributed for free by benevolent associations and medical personnel. In the same vein, a wide range of different MC varieties and types are offered by hospitals and pharmacies popular among which are condoms. This implies that despite the availability of a range of MC at their disposal, condoms have been selected as the contraceptive of choice by users in the context of this study. This could probably be explained by the fact that there are barely any challenges associated with their use; they have little to no side effects and hardly ever fail. The challenges associated with the use of condoms and other MCs in the context of this study are linked rather to socio-cultural and religious considerations rather than to the effectiveness of the products. From field results, it was observed by KI4 noted that: “Catholic Christians in particular and devout Christians in general tend to believe that the use of contraceptive goes against Christian doctrine” and “culturally, discussions between children and parents on issues related to sex hardly ever take place and in the rare cases that they do, emphasis usually focuses on abstinence. As such, children grow up with very limited knowledge on safe sex approaches inclusive of which is the role of MC”(KI4 Community Leader, New Lay out Nkwen).

Demographic factors and contraception use

The study also sought to examine the relationship between demographic factors and use of contraceptives. Most of the demographic factors such as gender, marital status, and religion did not show any significant association with contraceptive use except for level of education that reported a p-value of 0.01 (Table 4).

Comparing perception and use of contraceptives

The participants’ perception of contraceptives were compared with their level of contraceptives use and the findings showed that most of the participants who were using contraceptives believe contraceptives prevent both pregnancy and STIs and this relationship was significant with p-value 0.03 (Table 5).

Results from interviews were also in consonance with the quantitative findings on the perception of contraceptive use. In the first instance, the health workers who served as key informants (KI2 and KI3) unequivocally stated that the major misconception about MC such as condoms is that the majority of people equate them with the prevention of pregnancies neglecting the important role they play in preventing the transmission of STI’s and HIV/AIDs. Evidently, the association between the effective role of MCs such as condoms in preventing pregnancies and the spread of STI’s is one that cannot be underestimated. Similarly, the overall perception is that women and girls are in greater need of contraceptive than men and boys. The main point of emphasis from the interviews was that women and girls were in greater need as opposed to men and boys because of biological and cultural factors which tended to disfavor the former and favor the latter. As an illustration, during the interview sessions, one key informant (KI4) noted that: “Previously when a boy impregnated a girl in school, the girl was sent away until she put to birth before she could return. In most instances, the girl never returned considering that she felt shame and stigma due to the cultural context which tends to frown on single mothers as well as the extra duties the mother accumulates. While pregnant girls as per school rules and regulations were compelled to stay away from school, boys on the other hand, continued school with little to no repercussion. Even though this practice has been abolished by a recent circular from the ministry of secondary education, teen mothers still bear the brunt of the socio-cultural stigmas and challenges of early pregnancies, which could have been avoided if they understood the importance of and made use of contraceptives.”

Gender differences in perception and use of contraceptives

The study showed that the use of contraception among females was higher than in males but this difference was not statistically significant (p-value=0.3). The results presented in Table 6, reveal that more women than men need contraceptives, and the relationship between gender perception and contraception use statistically significant (p-value=0.04) (Table 6).

The statistically significant relationship between gender perception and use of contraceptives could be associated with quite a good number of factors according to the qualitative findings of this study. Firstly, the fact that women are more likely to encounter challenges with dire consequences if they discard the role and importance of contraceptives in so far as their reproductive health is concerned on the one hand and on the other their life expectancy implies that women will obviously accord MC more importance than men. Secondly, cultural pressures on women such as those evident in communities in Cameroon hardly give women any agency or decision making in so far as the spacing and number of children they can have while not jeopardizing their health. Thirdly, and of the most part, men tend to control women’s bodies in so far as sex is concerned which tends to expose them to vulnerabilities such as HIV/AIDs and other STIs. Finally, women tend to accord more attention to their healthcare and wellbeing and will evidently use MC as a means to guarantee that need. While the tendency has been to control the reproductive rights and choices of women and girls by a society that is still highly patriarchal, the results reveal that the perception differential between women and men regarding the use of MC can be explained by the different implications which accrue to either men and/or women in the specific context in question.

This study sought to understand perception variation on contraception use among men and women. The findings suggested that a majority of the participants had ever used or using contraceptives. This was possible given that most of the respondents were very educated and were residing in urban areas, hence they had knowledge on modern contraceptives as well as access to them. The results were similar to those of a study in Ghana that reported contraceptive use among women at 60%.¹¹ These results were however higher than those from a study in Uganda by Nsubuga et al.,¹² that reported uptake of contraceptives among students at 42%.¹² This difference could be because the study in Uganda was conducted only among females. The use contraceptives especially condoms is lower in females than males as was the case in the present study even though the difference was not statistically significant. The results also contradict those reported in a study in Nigeria with a modern contraceptive use of (31.6%). The study in Nigeria was done among youth in a refugee camp who indicated that they had difficulty gaining access to contraceptives hence it was likely to have a lower uptake of contraceptives among them.⁶

Findings from the study also revealed that condoms were the most used contraceptives. This was not surprising as they are more available, easier to use and according to one of the female respondents’ do not present side effects. Due to the availability, easy access (both cost and proximity) they can be easily procured even when sex was unplanned. This was confirmed by one male participant who indicated that he always gets a condom from a nearby shop especially when visited surprisingly by the girlfriend. This could also be partly attributed to campaigns that distribute condoms and to the fact that most provision shops in the study areas always sell male condoms.

Injectable contraceptives, intrauterine devices and implants were shown to be the least used, which could be because they are only administered in health facility and by a skilled medical provider. These results also corroborate with findings from other studies were male condoms are the most used contraceptives.^12–14

As for the frequency of use of contraceptives, most participants do not use condoms for every sexual encounter. According to a female respondent, condoms are used during ovulation “safe period”. Furthermore, most times some of the sexual encounters are unplanned and hence there is hardly time to look for a condom. Moreover, it also becomes difficult to purchase a condom when in a shop in the midst of other customers. Users of condoms do not feel comfortable buying condoms in public due to the cultural barriers and stigma associated with condoms. This is because of the uneasy feeling condom buyers get each time they request for a condom in a shop as everyone else in the shop stares at you or make uncomfortable comments as there is still some stigma associated with the purchase of condoms.

With regard to purchase of contraceptives, the study showed that contraceptives were most often obtained from pharmacies and drug shops. This was quite expected as the most used MC was condoms since they can be easily purchased from shops and pharmacies at any time. As per the challenges encountered with use of contraceptive, half of the participants encountered little to no challenges with contraceptives. Further analysis of the results showed that over 90 percent of the participants who reported no challenges were those using condoms. Participants using other methods were reported some side effects, failure rates and the fact that some partners did not want to use contraceptives. One of the male participants noted that his partner had refused taking any pills or implants due to Christian beliefs and the perception that contraceptives use triggered negative side effects.

In another dimension, the study was able to ascertain that the variations between how contraceptives were perceived and used did not significantly vary between women and men. Interestingly, the findings revealed that the predominant perception held by men and women indicated that contraceptive were effective in preventing both STI’s and unintended pregnancies. Hence, there was a strong perceptual association of contraceptives with STI and pregnancy prevention. This finding tends to correspond with the literature particularly as it pertains to the fact that more than 800 million women of reproductive age in Low Income Countries (LICs) like Cameroon urgently need contraceptives to avoid pregnancy (International Federation of Gynecology and Obstetrics.¹⁵ This goes to highlight the important role that contraceptive use can have in terms of leveraging development objectives and ensuring that women and girls of reproductive age are guaranteed access to affordable and efficient contraception options. Similarly, the importance of contraceptive towards preventing STIs also emerged as an important finding of this study. Previous studies have established that, contraceptives such as condoms can be linked to the prevention and/or reduction in the transmission rate of STI’s¹⁶ and HIV.¹⁷ Therefore, the findings of this study are in line with previous research which shows that contraceptives such as condoms are instrumental in preventing unintended pregnancies and STI’s.

Another important finding which was statistically significant pertained to the gender variation in the use of contraceptive between men and women. These findings are consistent with those of Njotang et al.,¹⁸ who highlighted the influence of men on women’s (particularly in relationships) ability to use contraceptives in Yaoundé Cameroon. Also, Namasivayam et al.,¹⁹ in their qualitative study in the patriarchal context of Uganda revealed that women’s access to and use of contraceptives was determined to a very large extent by men and the wider society’s negative perception about women who use contraceptives. In addition, Mkwananzi⁴ noted that significant gender differences exist with regards to contraceptive use between men and women of reproductive age in selected sub-Saharan African countries. However unlike our study which observed that perceptions of both women and men tended to view women as more likely to use contraceptive, Mkwananzi's,⁴ findings revealed that the reality was layered. For example, his findings revealed that age as a predictor of contraceptive use tended to increase for women as they aged while this was not quite the same for men. Furthermore, another important finding of this study observed that there was a strong perception about the role of socio-cultural beliefs on women’s access to and use of contraceptives which men did not experience.

This study contributes to the body of knowledge on contraceptive use and the predictors which may account for its weak uptake and the wide unmet need of contraceptives in African countries like Cameroon. One such predictor are perceptions which have been documented to play an important role in how people interact between and among themselves. From this study, it is clear that perception clearly affects the how women and men understand and use contraceptives within the context in which the study was conducted.

We wish to appreciate the intervention of the Universities of Buea and Bamenda as well as Cameroon’s Ministry of Higher Education for providing seed research grants which permitted the conduct of this study.

None.

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