Family planning (FP) refers to a couple’s decision to limit or space out the number of children they will have by using contraceptive methods. Contraceptive use has clear health benefits, as preventing unwanted pregnancies reduces the incidence of unsafe abortions and thus saves lives, because abortions are responsible for 7% – 9% of maternal deaths.¹ Some studies have also shown that FP helps to reduce child mortality because contraception, by lengthening the birth interval, prevents pregnancies and closely spaced, premature births, which are significant predictors of child mortality.²

Worldwide, among 1.9 billion women of reproductive age (15–49 years), an estimated 874 million women use a modern contraceptive method. Although substantial progress has been made, there are still 164 million women who want to delay or avoid pregnancy and are not using any contraceptive method and thus are considered to have an unmet need for FP.²

Despite all the benefits of FP, African countries still have low contraceptive use and very high fertility rates. The World Bank identified 10 countries in sub-Saharan Africa with fertility rates above five in 2021.³ While FP is essential throughout the reproductive lives of individuals and couples, postpartum family planning (PPFP) focuses on preventing unwanted or closely spaced pregnancies in the months following childbirth. Before and during this postpartum period, there are many contacts with health services that provide an opportunity to offer women who have recently given birth with appropriate counselling and to promote contraceptive use. These opportunities include antenatal care (ANC) appointments, delivery and the immediate postpartum period, as well as postpartum consultations at 6 days and 6 weeks, healthy infant consultations, infant immunisation sessions and consultations for maternal or infant health problems. Postpartum family planning is crucial in addressing unmet needs for FP, as postpartum women are among those most in need of these services. In addition, closely spaced pregnancies in the first year after childbirth are the most dangerous for both mother and child, as they carry an increased risk of adverse outcomes such as prematurity, low birth weight and intrauterine growth restriction.⁴

Africa has the highest fertility rate in the world, and almost a quarter of women of reproductive age – nearly 47 million – still have an unmet need for contraception.⁵ Several interventions have been tested to overcome financial barriers and increase women’s access to contraceptive methods (e.g. cash transfer programmes, distribution of free vouchers and community or performance-based financing, free FP, etc.).^6,7,8 Burkina Faso was one of the first countries in sub-Saharan Africa to adopt a free FP policy, partly justified by the success of the national FP weeks organised each year.⁹ The free policy, which was piloted in June 2019 and scaled up in July 2020, covers all sexually active people and the cost of long-acting and short-acting contraceptive methods, outpatient curative care to manage unwanted side effects and inpatient curative care in the event of complications. Six months after the implementation of the free policy, a study by Tiendrebeogo et al.¹⁰ showed that the abolition of user fees for FP led to an 86% increase in the likelihood of contraceptive use and a 13-point reduction in the prevalence of unmet need for contraception.

The non-use of modern contraceptives among young lactating mothers may cause several health problems if they become pregnant. Indeed, this group of women is exposed to the potential risk of closely spaced pregnancies, with all the possible severe complications.^11,12 This means that the non-use of contraception exposes them to a new pregnancy with a birth interval of less than 33 months, which is below the World Health Organization recommendation of at least 24 months to avoid a very high risk of morbidity and mortality for the woman and her child.^11,12

Therefore, firstly, the rationale for conducting this study among breastfeeding women is that, to the best of our knowledge, since the implementation of free FP in Burkina Faso, studies measuring contraceptive use have targeted all married and unmarried women, irrespective of their lactating status.^13,14 Few studies have examined contraceptive use specifically among young lactating mothers under the new free FP policy in Burkina Faso. Secondly, given that one of the reasons for not using contraception is the desire to have a child, this paper aims to examine the modern contraceptive use and factors associated with it among breastfeeding women with a child under 24 months in a semi-rural setting of Burkina Faso. Given that they have young children, they are unlikely to have another child at the time of the study.

Our study included 995 young lactating mothers. Figure 1 shows the recruitment process for the target population.

We identified the prevalence and factors associated with modern contraceptive use among young lactating mothers in the Kaya municipality. Overall, the prevalence of modern contraceptive use among young lactating mothers was 53.9%. This study showed that discussions within couples influenced the use of FP. It also showed that women who had used contraception before the last pregnancy used it more than those who did not. Finally, it showed that women with a higher socio-economic status used modern contraceptives more than the poorest women.

The prevalence of modern contraceptive use among young lactating women in this study was relatively high. This could be because of the national policy of free FP services, which has been in place in Burkina Faso since July 2020 in the Koulsé region, where the city of Kaya is located. Financial barriers to accessing contraception may have been reduced with free FP and may therefore have led to increased use of contraceptive methods.

In our study, condoms remained the second most commonly used contraceptive method (38.2%) after implants (41.4%). A similar result was reported by Ahissou et al. in Benin, who noted that male condoms were one of the most commonly used methods among young women.¹⁸ It is therefore important that information sessions be held for both women and men to ensure that the rules surrounding condom use are followed. Even among regular condom users, there may be cases of incorrect use, such as genital contact before or after condom use, as well as cases of breakage, as previously reported by some authors. In fact, a published study showed that the prevalence of incorrect condom use can reach 40% – 50% among condom users.¹⁹ This calls for in-depth awareness raising on the importance of using condoms correctly and thus avoiding closely spaced pregnancies in breastfeeding women.

Findings on modifiable determinants are particularly important because they could inform the design of programmes and interventions. Our results showed that one of the major determinants of current method use was whether the woman had already used at least one modern contraceptive method. Indeed, the experience can increase women’s knowledge, encouraging them to use contraceptive methods more regularly. This result indicates that the most crucial step is convincing women to adopt a method for the first time. This may be one of the best ways to combat fears about side effects. Previous studies have already shown that the experience of contraceptive use is associated with the reuse of contraceptive methods. For example, Saizonou et al. in Benin found an increased likelihood of contraceptive use among participants who had already used a contraceptive.²⁰ Previous use of contraceptive methods can also help women to better understand side effects and stimulate the search for more proactive advice to manage them, ensuring continued use and satisfaction with a new method. Programmes should be designed to provide guidance tailored to correct and consistent use, based on a person’s past challenges. Indeed, understanding past experiences can not only inform the design of planning programmes to ensure that a full range of methods are available and accessible, but it can also prompt a review of the way counselling is delivered to health service users. For example, counselling sessions may specifically target the reasons for changing or discontinuing a method or dissatisfaction with previous use, proactively addressing these barriers, such as side effects, to improve long-term use and continuity of use.

In addition, the study showed that there is still a significant difference in the likelihood of using a modern contraceptive method between rich and poor women, even though contraceptives are currently accessible in Burkina Faso. It may be that people are not sufficiently aware of this measure and therefore do not use the free methods. Although the study by Tiendrebeogo et al.,¹⁰ conducted in Burkina Faso 6 months after the implementation of the free policy, supports this hypothesis, it is less likely because free FP services were expanded in July 2020, almost 4 years after implementation. Indeed, Tiendrebeogo et al. showed that, of the 1471 women of reproductive age surveyed 6 months after the abolition of user fees for FP services, 56% were aware of the policy, and knowledge of the fee abolition policy was associated with a 46% increase in the likelihood of contraceptive use among women aged 15–49 years. Most likely, the policy of free contraception has limits in its application, with residual expenditure by women on contraception, thus creating disparities between rich and poor women. The findings of Browne et al. also support this.²¹ These authors reported, in their evaluation of the free contraceptive policy in Burkina Faso 6 months after its introduction, that barriers to implementation included inadequate communication about the policy, shortages of supplies and contraceptive methods and delays in government reimbursement. Indeed, in their study, 39% of participants continued to pay for FP services despite the new policy, mainly because of stock-outs that forced them to buy their contraceptives elsewhere. These findings may explain the persistent difference in contraceptive use between rich and poor women. Furthermore, there could be differential information needs between the richest and poorest quintiles. For example, the rich may require more specific information, while women in low-income households may need programmes that simultaneously address financial barriers and stigma through targeted awareness-raising, accessible services and culturally appropriate communication.

Finally, discussions within couples have a significant impact on women’s contraceptive use. Many authors have reported this in different contexts. For example, a systematic review of 14 articles on the role of men in the uptake of contraceptive methods reported a highly significant association between non-opposition by partners and a higher likelihood of contraceptive use among women.²² Another study showed that approximately 59.2% of couples who had discussed FP in the 12 months prior to the survey date were using contraceptives, while only 39.2% of couples who had not discussed it were using contraceptives.²³ In Niger, similar results were also found.²⁴ Efforts should be made to better communicate the fact that FP is a woman’s right, on the one hand, and also to involve men more in sexual and reproductive health policies, so as to improve their knowledge of FP and promote discussion within couples. Indeed, these results provide data to target interventions that facilitate joint decision-making, including the use of mass media to encourage private discussions within couples about FP. Also, it may be important to offer, for example, counselling to couples (both partners together) rather than focusing only on women or men, as already recommended by Fantaye et al. in Ethiopia.²⁵ This includes giving both partners the opportunity to learn together about the different methods and goals of FP. This can include group sessions, home visits or other community-based approaches that bring couples together and can be particularly important in African contexts where traditional gender roles can impede communication.

This study found that a significant proportion of women did not use modern contraceptives because of side effects. This finding has been reported in previous studies. Indeed, a literature review of factors influencing contraceptive use in sub-Saharan Africa between 2005 and 2015, published in 2017, found that the negative factors reducing contraceptive use were women’s misconceptions about the side effects of contraception.²⁶ Awareness campaigns should be conducted to minimise the extent of these misconceptions about contraception. Our results also showed that men and other family members are reluctant to use modern contraceptives by lactating women (5% for men’s refusal and 4% for other family members’ refusal). Several studies have found similar results.^27,28 It is therefore necessary to develop awareness-raising and information campaigns aimed at men so that they accept their wives’ use of contraceptive methods.

The prevalence of modern contraceptive use among young lactating mothers in the Kaya municipality, Koulsé, Burkina Faso, is relatively high. As our study population consists of young lactating mothers, the use of modern contraceptives among these women should be higher because they are at risk of having a short birth interval, with its consequences for women’s health and pregnancy outcomes, should they become pregnant. It is, therefore, necessary to continue to raise awareness among women and men in general and young lactating mothers in particular, so that they adopt more modern contraceptive methods to improve their health and well-being. These awareness-raising campaigns and interventions should focus on strengthening counselling for lactating mothers at every contact with health centres, improving free access policies by fully removing financial barriers to accessing FP services and involving men.