Disentangling rural-urban modern contraceptive utilization disparity among sexually active women of reproductive age in Sierra Leone: A Blinder-Oaxaca decomposition analysis

Background: Sierra Leone has one of the world's highest rates of maternal mortality. Preventing unintended pregnancies reduces the burden of maternal mortality. Unfortunately, 25% of reproductive-age women do not have access to modern contraceptives, and the proportion of demand met for modern contraception remains low at 46% in Sierra Leone. Rural Sierra Leonean women use modern contraception less frequently than urban women. This study aimed to quantify the rural-urban disparity in modern contraceptive use among Sierra Leonean women of reproductive age and to identify factors that explain it. Method Data from the 2019 Sierra Leone demographic health survey was used. Participants were sexually active women aged 15 to 49 (n = 13,975). Modern contraceptive use was the outcome variable while the selected explanatory variables were grouped into materialistic, behavioral/cultural, and psychosocial theoretical perspectives. Descriptive statistics, intermediary analysis, and Oaxaca decomposition analysis were used to summarize and identify the factors that explain inequalities in modern contraceptive use between rural and urban women. Data were analyzed using Stata version 14.0. Results There was a rural-urban disparity in modern contraceptive use of 18 percentage points favoring urban women and the exposure variables explained 68% of this disparity. Education made the biggest (76%) contribution to the explanation of the modern contraceptive use disparity between urban and rural women. Other important contributors were marital status (39%), hearing about family planning on the radio (16%), age of respondent (13%), problems with distance to a healthcare facility (12%), and problems getting permission to seek treatment (9%). Conclusions There was a large rural-urban disparity in modern contraceptive use that favored urban dwellers. Material, behavior/cultural, psychosocial, and demographic explanatory factors jointly explained 68% of the difference in modern contraceptive utilization between rural and urban dwellers. To close the rural-urban disparity in modern contraceptive use, policymakers must address inequities in education, mass media (radio) access, and healthcare access. Rural women should be empowered so that they can have the autonomy to access healthcare. Involving men in modern contraceptive programs can increase rural women's ability to get permission to seek services hence increasing modern contraceptive utilization and consequently bridging the rural-urban gap.