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Prevalence and factors associated with the intention to use contraception among women of reproductive age who are not already using a contraceptive method in Liberia: findings from a secondary analysis of the 2019–2020 Liberia Demographic Health Survey
  1. Daudi Yeboah1,
  2. Abdul-Nasir Issah2,
  3. Mary Rachael Kpordoxah3,
  4. Caselia Akiti4,5,
  5. Michael Boah1
  1. 1Department of Epidemiology, Biostatistics, and Disease Control, University for Development Studies, Tamale, Ghana
  2. 2Department of Health Services, Policy, Planning Management, and Economics, University for Development Studies, Tamale, Ghana
  3. 3Department of Global and International Health, University for Development Studies, Tamale, Ghana
  4. 4Department of Bilogical Sciences, University of Liberia, Monrovia, Liberia
  5. 5Monitoring and Evaluation Unit, Ministry of Health, Congo Town, Monrovia, Liberia
  1. Correspondence to Dr Michael Boah; boahmichael{at}


Objective Contraception constitutes a vital aspect of sexual and reproductive healthcare. However, the high prevalence of non-use has become a great public health concern globally. This study examined the intention to use contraceptives and its associated factors among women of reproductive age who were not using any method in Liberia.

Design and setting A cross-sectional population-based study was conducted. We used data from the 2019–2020 Liberia Demographic and Health Survey. The research framework used the theory of planned behaviour to identify the factors that influence women’s intention to use contraception.

Participants The study analysed a weighted sample of 4504 women aged 15–49 who were not currently using any form of contraception.

Data analysis The outcome variable was the intention to use a contraceptive method. A binary logistic regression was used to identify factors associated with the intention to use contraceptives in Stata V.13.0.

Results Of the 4504 women, 39.42% intended to use contraception. Contraception intention was significantly lower in married women than in never married women (adjusted OR (aOR) 0.78; 95% CI 0.62 to 0.98). Additionally, women aged 25–34 (aOR 0.434; 95% CI 0.339 to 0.556) and 35–49 (aOR 0.120; 95% CI 0.088 to 0.163) had a reduced intent to use contraceptives than those aged 15–24. However, women with at least one child, those with prior contraception experience and those who had their first sexual encounter at the age of 13 or older were more likely to intend to use contraception. Notably, Muslim and wealthy women displayed a lower likelihood of intending to use contraception.

Conclusion These findings highlight that attitudes, subjective norms and perceived behavioural control significantly influence women’s intentions to use contraception. Understanding and addressing these factors are crucial for promoting effective contraceptive use among women, facilitating informed reproductive choices.

  • Health policy

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • The study used nationally representative population-based data.

  • The results are applicable to all women aged 15–49 in the study population.

  • Because the results of this study are based on a cross-sectional survey, it is impossible to establish causal relationships.

  • The use of secondary data for analysis limited the study’s variable selection.

  • There is a possibility of reporting bias on the part of women when responding to the survey question on contraceptive use.


Contraception has been regarded as an essential component of sexual and reproductive healthcare since it allows individuals to decide when to have children or not.1 Using contraception is essential to achieving Sustainable Development Goal (SDG) 3’s target 3.7, which emphasises that by 2030, the world should ensure universal access to sexual and reproductive healthcare services.2 The utilisation of contraception carries significant health implications, including the prevention of unplanned pregnancies, promoting optimal birth spacing, reducing the lifetime risk of maternal mortality and contributing to the attainment of SDG 3.3 4 Notably, a considerable number of unplanned pregnancies lead to unsafe abortions. Approximately 50% of the 42 million unwanted pregnancies end in unsafe abortion settings, resulting in the tragic loss of approximately 68 000 women’s lives and causing long-term health complications for around 5 million women.5

Maternal mortality in Liberia has been reported to reach 1072 deaths per 100 000 live births, according to the 2019–2020 Liberia Demographic and Health Survey (LDHS), placing it among the highest rates globally.6 7 This significant rate underscores the urgent need for effective interventions to reduce maternal mortality. Encouraging and promoting the use of contraceptives could play a pivotal role in drastically reducing these numbers.8 Unintended pregnancies pose a significant challenge in low-income and middle-income countries (LMICs), accounting for approximately 49% of all pregnancies.9 However, the impact of modern contraception on curbing unwanted pregnancies is noteworthy. In 2017 alone, 308 million unwanted pregnancies were averted globally due to the widespread use of modern contraception.10 Despite this progress, sexual and reproductive health services in LMICs continue to face substantial shortcomings. In 2019, these nations reported that 218 million women aged 15–49 had an unmet need for contraception, indicating their desire to prevent pregnancy but lacking access to modern contraceptive methods.9

Over the past four decades, the use of contraceptives has risen steeply throughout the world as more couples opt to have fewer children, and the use of contraceptive methods is now widely accessible through government-funded family planning programmes, non-governmental organisations, and private sector pharmacies and clinics.11 However, a sizeable portion of women who want to delay, space out, or stop having children do not employ a modern method.9 That is, the quality and accessibility of contraceptive services are still lacking in some of the world’s most impoverished nations.12 In developing nations, the high unmet need for contraception is primarily due to a lack of access to family planning services and concerns regarding the side effects of contraceptive methods.13 14

Liberia is among the African nations that pledged to enhance their indicators of sexual and reproductive health in 2012 in London at the Summit on Family Planning.15 Subsequently, Liberia devised a 5-year costed implementation plan (CIP) to increase the use of contraceptives and reduce the high incidence of maternal mortality and obstetric complications.16 The CIP outlines the primary initiatives that will be carried out to raise the contraceptive prevalence rate nationally from 30.7% in 2016 to 39.7% in 2022.17 By implementing this plan, it is predicted that more than 600 000 unwanted pregnancies, approximately 216 000 abortions, and more than 3300 maternal deaths will be avoided.18 In this study, the theory of planned behaviour (TPB) was employed as a framework to identify the factors influencing the intention to use contraception among women.

The TPB posits that strong perceived behavioural intentions significantly account for variations in behavioural intentions, which, in turn, relate to actual behaviour. Positive attitudes towards the behaviour, supportive subjective norms, and a high sense of perceived behavioural control are key determinants of behavioural intentions.19 The concept of perceived behavioural control comprises multiple factors that are essential for understanding its influence. With regard to the intention to use contraception, factors such as self-efficacy, barriers and facilitators can either impede or promote the intended behaviour.20 Self-efficacy pertains to the level of confidence women possess in their ability to navigate and overcome obstacles and challenges that may arise when making decisions regarding contraception usage.19

In addition to self-efficacy, external factors also significantly contribute to perceived behavioural control in contraception decisions. These external factors include the availability of contraceptive options, the extent to which a woman may rely on her partner’s cooperation and support, and the influence of time constraints and access to healthcare services.21–23 These factors can either increase or decrease a woman’s perception of control over her contraceptive decisions. Notably, a woman’s perceived control over her contraceptive decisions is a critical determinant of her intentions and actual contraceptive use. Research has demonstrated that perceived behavioural control can explain a substantial portion of the variation in women’s intentions to use contraception and their subsequent contraceptive behaviours. In fact, it has been found to explain approximately 65% of the differences in women’s intentions or plans and 27% of the differences in their actual contraceptive behaviours.24 Meanwhile, in Uganda, research focused on reproductive health revealed that the TPB explained 26% of the variation in contraceptive use.25 Additionally, a meta-analysis was conducted to explore whether the components of TPB could explain condom use behaviour. The study findings demonstrated that subjective norms, attitudes and perceived behavioural control emerged as significant predictors of condom use intention, collectively accounting for 24.0% of the variance in condom use behaviour.26

Despite family planning and other fertility regulation programmes being implemented in many LMICs to give women the opportunity to control childbearing, the proportion of women who do not intend to use them remains high.27 For instance, data from the 5 years leading up to the 2019–2020 LDHS revealed that 41% of women who initiated contraceptive use discontinued it within a year, while approximately 76% of women were not using any contraceptives. The most commonly cited reason for discontinuation was negative health effects.7 These statistics highlight the concerning prevalence of non-acceptance of contraceptive use in Liberia. The issue has become increasingly serious, as indicated by reports from DKT International.28 Contrary to this, research in Liberia has focused on contraception use.15 16 29 30 There is no such study focusing on the intention of non-users of contraceptives to use them.

As a result, this study aimed to assess the prevalence of contraceptive intent and identify the factors associated with such intentions among women of reproductive age in Liberia who are not currently using any contraceptive method.


Our study was conducted using the 2019–2020 Liberia Demographic Health Survey (LDHS), a nationally representative cross-sectional survey carried out in Liberia from 16 October 2019 to 12 February 2020. The 2008 National Population and Housing Census (NPHC), carried out by the LISGIS, served as the basis for the sampling frame used for the 2019–2020 LDHS. The 15 counties that make up Liberia are arranged into five distinct geographical regions, each of which consists of three counties. Every county has districts, and each district has clans. Each clan was divided into enumeration zones for the 2008 NPHC. According to the Liberian census frame, each enumeration area has an average of 100 households.7

A stratified two-stage cluster design was employed for the 2019–2020 LDHS; the first stage involved clusters, while the second stage involved a systematic sampling of households. The West African nation of Liberia is bordered to the northwest by Sierra Leone; to the north by Guinea; to the east by Côte d'Ivoire; and to the south and west by the Atlantic Ocean. The sampling details for the 2019–2020 LDHS, data collection methods and tools, as well as the quality control measures, have been documented in the full report.7


This study used the individual recode file for analysis. A total of 4504 women aged 15–49 who were not using a contraceptive method were included in this study. We excluded women who had not had sex at all and those who were pregnant at the time of the interview.

Dependent variable

In this study, the dependent variable was the intention to use a contraceptive method. The variable ‘contraceptive use and intention’ was used to extract the intention to use contraception. The responses were ‘using a modern method’, ‘using a traditional method’, ‘intends to use later’ and ‘does not intend to use’. In this study, the focus was exclusively directed towards non-contraceptive users, as the current contraceptive users were excluded from the sample. The responses of the current non-users were subsequently transformed into binary form, where the option ‘does not intend to use’ was coded as ‘0,’ and the option ‘intends to use’ was coded as ‘1’.


The following sociodemographic and economic characteristics were included in the study as covariates: respondents’ age group; the highest level of education; the number of children ever born; region; place of residence; religion; wealth index; marital status; having ever had a terminated pregnancy; desire for more children; knowledge of any contraceptive method; having ever used anything or tried to delay or avoid getting pregnant; and age at first sex.31–35 Within the context of TPB, the covariates were classified into three groups. The first category, subjective norms, included variables such as religion, marital status and the experience of having a pregnancy terminated, all of which could potentially influence family planning decisions due to their association with religious beliefs, social expectations and prevalent attitudes. The second category was attitude towards contraception, which encompassed both the desire for additional children and familiarity with available contraceptive methods. Finally, the third category, perceived behavioural control, incorporated multiple variables, including the respondents’ age, highest level of education, number of children, region, place of residence, ever used anything or tried to delay or avoid getting pregnant, age at first sex and wealth index. These variables were deemed significant because they may influence decision-making abilities, access to information and resources, perceived control over family planning, geographical accessibility of services and information, and the impact of socioeconomic status on access to family planning services.

Statistical analysis

Both descriptive and inferential statistical analyses were performed in the study. The study employed descriptive statistics and a χ2 test to assess the prevalence of women’s contraceptive intentions and determine the presence of any significant associations between contraceptive intention and women’s sociodemographic and obstetric characteristics. To determine the relationship between women who intend to use contraception and their sociodemographic and obstetric features, we performed an adjusted binary logistic regression. The adjusted model was fitted by including all the independent variables simultaneously. In other words, all potential predictors were included in the analysis, and the logistic regression model estimated the association of each independent variable with the outcome while adjusting for the effects of all other variables in the model. Sample weight was employed in all analyses to account for the 2019–2020 LDHS’ multifaceted survey design. All statistical analyses were conducted using Stata V.13.0 (StataCorp). The results are presented as adjusted ORs (aORs) with their corresponding 95% CIs. The statistical significance level was set at p<0.05.

Patient and public involvement

No patient involved.


The percentage distribution of women who intend to use contraception based on sociodemographic and obstetric characteristics

We used 4504 women aged 15–49 who were not using a contraceptive in the study. The results showed that 37.33% (95% CI 34.44% to 40.32%) of non-users of contraceptives intend to use a method. We found significant differences in women who intend to use contraceptives among the following sociodemographic and obstetric characteristics, with the exception of place of residence: marital status, age group, education, region, religion, wealth index, marital status, having ever used anything or tried to delay or avoid getting pregnant, and age at first sex (table 1).

Table 1

The weighted prevalence of the intention to use contraceptives based on respondents’ sociodemographic and obstetric characteristics

Association between sociodemographic and obstetric characteristics of women and their intention to use contraception

A binary logistic regression model was used to determine the relationship between women’s sociodemographic and obstetric characteristics and their intention to use contraception. The analysis found that women in a union have significantly lower odds of intending to use contraception compared with those who have never been in a union (aOR 0.78; 95% CI 0.62, 0.98). Furthermore, with increasing age, the likelihood of intending to use contraception decreased substantially. Specifically, women aged 25–34 (aOR 0.35; 95% CI 0.27 to 0.45) and 35–49 (aOR 0.10; 95% CI 0.07 to 0.13) years had a lower intent to use contraception than those aged 15–24 years. Women with at least one child displayed a higher likelihood of intending to use contraception compared with those without children.

Regarding religious affiliation and wealth, the study found that Muslim women and those in higher wealth categories were less likely to intend to use contraception when compared with Christian women and the poorest women, respectively. Furthermore, the study revealed that women who had prior experience using any method to delay or avoid becoming pregnant were more likely to intend to use contraception in the future than those who had never used any of such methods. Similarly, women who had their first sexual experience at the age of 13 or older exhibited a higher intent to use contraception compared with those who had their first sexual encounter below the age of 13 (table 2).

Table 2

Association between sociodemographic and obstetric characteristics of women and their intention to use contraception


This study examined the prevalence and factors associated with contraceptive intent among women of reproductive age who were not currently using any contraceptive method. The analysis used nationally representative data from the 2019–2020 LDHS. Out of a total of 4504 women aged 15–49 who were not using contraception, it was found that only 39.42% expressed an intention to use it, which may be attributed to differences in knowledge and understanding of contraceptive methods.16 Such low intention not only affects their reproductive choices but also increases the risks of mortality and disease.12 The adoption of contraception plays a vital role in preventing unplanned pregnancies and unsafe abortions, significantly reducing maternal and child mortality. Additionally, the use of condoms also contributes to the prevention of HIV and other sexually transmitted diseases.36

According to the TPB, behavioural intentions precede the actual execution of a behaviour, provided that individuals possess the necessary skills and there are no significant obstacles hindering the execution of the intended behaviour.19 37 The study identified several factors influencing contraceptive intention among women, including age, age at first sexual intercourse, marital status, religion, number of children ever born, region and wealth group, reflecting the interplay of attitudes, subjective norms and perceived behavioural control within the TPB. The study’s findings indicate that women in a union are less likely to express an intention to use contraception compared with those who have never been in a union. This observation aligns with similar studies conducted in sub-Saharan Africa.38 39 However, a study conducted in Ghana revealed that unmarried women also showed a lack of intent to use contraception.40 The marital status of an individual has the potential to influence both subjective norms and attitudes towards behaviour. Married women may encounter distinct social pressures and expectations pertaining to family planning in contrast to their unmarried counterparts.41 Additionally, women’s attitudes towards contraception may be influenced by their marital status, as contraception may be considered within the context of their marriage.42 43 Women in a union might still desire to achieve their desired family size and, therefore, do not currently intend to use contraception. However, with adequate knowledge and understanding of contraceptive options, these women could recognise the importance of spacing births even if they have not attained their desired family size yet.

Additionally, an increase in a woman’s age is associated with a reduced likelihood of intending to use contraceptives. Women older than 25 were less likely to intend to use contraception compared with those within the age range of 15–24 years. Women aged 15–24 may be pursuing education, including secondary or tertiary studies, and their intention to use contraception may be driven by their aspirations to achieve their career goals.7 On the other hand, elderly women may perceive themselves as not being at risk of pregnancy or might assume they are no longer fertile, potentially explaining their lower inclination to use contraceptives.44 45 In other words, in the context of the TPB, the variable of age has the potential to exert an influence on contraceptive intention, primarily through the mediating construct of attitude towards behaviour. Younger women may have different attitudes towards contraception than older women due to variations in life experiences, societal norms and awareness about contraceptive methods.46 These results emphasise the importance of targeted family planning interventions for younger age groups and the need for educational campaigns to address misconceptions among older women, promote informed contraceptive decision-making, and improve reproductive health outcomes across all age ranges.

Furthermore, the study revealed significant differences in contraceptive intent based on religious affiliation. Compared with Christian women, Muslims exhibited a lower likelihood of intending to use contraception, while traditionalists were three times more likely to express an intention to use contraception. Religion exerts a predominant influence on subjective norms and attitudes towards behaviour. The religious convictions and doctrines that individuals adhere to have the potential to shape their perspectives on contraception, thereby exerting an influence on the prevailing social norms within their religious community.47 48 Certain religious beliefs can influence a woman’s intention regarding contraception, either by promoting or discouraging its use. In previous research conducted in Northwestern Nigeria, residents indicated that family planning was strictly forbidden in Islam.49 Similarly, in predominantly Muslim populations in Northern Nigeria,50 Northern Ghana,51 and outside of Africa, such as in Bangladesh,52 it has been reported that religious beliefs serve as a barrier to contraceptive usage. Additionally, other studies have indicated that Muslim women tend to be more hesitant about adopting contraception.53 54 Observations of American Muslim women and their contraceptive practices revealed multiple factors contributing to their reluctance, including preferences for gender-specific healthcare professionals, concerns about modesty and misconceptions regarding potential health risks associated with contraceptive use.55 These insights shed light on the complex interplay of religion in influencing subjective norms regarding contraceptive use among different populations.

The study found that the wealthiest women exhibited a lower likelihood of intending to use contraceptives in comparison to the poorest women. The wealth group is related to perceived behavioural control. Women in different wealth groups may have varying access to resources, including healthcare facilities and contraception methods. Previous research has indicated that household wealth may grant women access to health information and the financial resources needed for contraception.32 56 57 Consequently, economic barriers hinder the ease of accessing contraceptive services and education for economically disadvantaged women in Africa.56 57 However, women in wealthier households may perceive a lower immediate need for contraception due to a higher level of financial security and access to resources. They might feel more confident in their ability to handle the potential consequences of unplanned pregnancies, such as access to prenatal care and childcare support. As a result, they may exhibit a lower intention to use contraception compared with women in lower-income households, who may be more concerned about the financial impact of unplanned pregnancies. Women from the south-central, south-eastern and north-central regions of Liberia showed a decreased intention to use contraception, aligning with findings from previous studies in the same area.15 16 This disparity may arise from sociocultural variations across these regions, which can significantly influence contraceptive intentions. This observation is supported by the higher percentage of non-users of contraception in these regions who did not engage in family planning discussions either at a health facility or with fieldworkers within the 12 months preceding the 2019–2020 LDHS: south-central (74.2%), south-eastern A (52.7%) and north-central (54.7%).7

This study found that women with at least one child exhibited a higher likelihood of intending to use modern contraceptives, corroborating findings from previous studies.56 58 59 Women with more children may have different attitudes towards contraception, as they may consider factors such as family size and spacing between children.60 Additionally, the number of children may affect their perceived control over contraception, especially if they desire to limit their family size. As the number of children increases, women may become more inclined to use contraception as it aligns with their goal of achieving a specific family size.61 62 The study also found that women who had prior experience using contraceptive methods were more likely to intend to use contraceptives, which is consistent with a study conducted in Morocco.63 Prior experience with contraception relates to all three dimensions of the TPB. Positive experiences with contraception may shape a woman’s perception that using contraceptives is effective, safe and aligned with her reproductive goals.64 Regarding social norms and their influence, women who have used contraceptives may have peers, friends or family members who support and encourage their contraceptive use.64 65 This positive social influence contributes to their intention to continue using contraceptives. Furthermore, prior experience with contraceptives can enhance a woman’s perceived control over their use. Having successfully used contraceptives in the past may boost her confidence in her ability to access and manage contraception effectively, reinforcing her intention to continue using them.

Notably, women who had their first sexual encounter at the age of 13 or older were approximately three times more likely to express an intent to use contraceptives. Age at first sexual debut can be related to both attitude towards behaviour and perceived behavioural control. Women who had early sexual experiences may have different attitudes towards contraception compared with those who had later experiences. Additionally, the age at which they initiated sexual activity might impact their perceived control over contraception use. Indeed, early sexual encounters characterised by coercion may result in diminished control over subsequent sexual interactions, potentially influencing the motivation to use contraception.66 67 Additionally, these women may possess a heightened awareness of the beneficial health effects of contraception in preventing fertility-related issues, unintended pregnancies and other challenges affecting maternal and child health.68

Strengths and limitations of the current study

The use of nationally representative population-based data, which enables the results to be applied to women aged 15–49 in the study context, is the study’s main strength. It is, however, impossible to establish causal relationships because the findings of this study are based on a cross-sectional survey. Additionally, the study’s variable selection was constrained by the analysis’s use of secondary data.


Our study sheds light on the intention to use contraception among women in Liberia who are currently not using any contraceptive methods. We found that approximately one-third of non-contraceptive users expressed an intention to use contraception, highlighting the potential for increased uptake of family planning services in the country. However, factors such as being in a union, getting older, having a higher income and adhering to the Muslim faith significantly reduce the intention to use contraception. An integrated approach is required to enhance women’s agency in making decisions regarding family planning and to address the disparity between their intentions and actual behaviours. This entails the implementation of focused educational initiatives and counselling interventions tailored specifically for older women, while also recognising and addressing the distinct requirements of nulliparous women. The cultivation of positive attitudes and norms regarding contraception can be facilitated through the involvement of religious leaders and communities, who can address the intersection of religious and socioeconomic factors. Furthermore, it is imperative to prioritise the enhancement of perceived behavioural control through measures that promote improved access to and affordability of contraceptive methods.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statements

Patient consent for publication

Ethics approval

This study analysed secondary data from the 2019–2020 Liberia Demographic Health Survey (LDHS). The 2019–2020 LDHS strictly follows a protocol that protects the privacy of participants in the study. The authors were permitted to use the data by MEASURE DHS/ICF International. Before the survey, the 2019–2020 LDHS project sought and received the required ethical approval. This study, therefore, did not require any additional approvals. More information on data and ethical principles can be found at


We acknowledge the effort of the MEASURE DHS for granting us free access to the original data.



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  • Contributors DY, A-NI, MRK, CA and MB conceived and designed the study. DY and MB performed the data analysis. A-NI, MRK and CA interpreted the results for intellectual content and wrote the draft manuscript. DY and MB revised the draft manuscript. All authors read and approved the final manuscript for submission. MB is responsible for the overall content as guarantor

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.