Based on current literature, the questionnaire consisted of three sections. The first section gathered sociodemographic details of the women, including gender, age, education level, marital status, employment status, income level, health status, and family structure. The second part of the questionnaire assessed women’s obstetric characteristics such as pregnancy history, miscarriages, number of planned and unplanned pregnancies, parity, number of children, knowledge, and use of family planning methods [2, 8, 10, 11].

The third part of the questionnaire assessed attitudes toward family planning using the Family Planning Attitude Scale (FPAS). The FPAS was developed by Örsal and Kubilay [12]. The scale is Likert-type and consists of 34 items. Each statement on the scale is scored from 1 to 5. The response “I strongly agree” is assigned 1 point, “I agree” is assigned 2 points, “I am undecided” is assigned 3 points, “I disagree” is assigned 4 points, and “I strongly disagree” is assigned 5 points. There are no reverse-coded statements on the scale. A minimum of 34 points and a maximum of 170 points can be obtained from the scale.

The scale has three sub-dimensions: “Social Attitudes Toward Family Planning”, “Attitudes Toward Family Planning Methods”, and “Attitudes Toward Childbirth”. The subscale “Social Attitudes Toward Family Planning” consists of 15 items, with possible scores ranging from 15 to 75. The subscale “Attitudes Toward Family Planning Methods” consists of 11 items, with a possible score range of 11 to 55. The subscale “Attitudes Toward Childbirth” consists of 8 items, with a possible score range of 8 to 40. The Cronbach’s alpha of the original scale was 0.90, which was found to be 0.88 in our study.

Data were analyzed using means, standard deviations, medians, frequencies, and percentages using the Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM Corp., Armonk, NY, USA). The reliability of the FPAS was evaluated using Cronbach’s alpha. Statistical significance was determined using a two-tailed test with a significance level of p 0.05.

Currently, approximately half of the women of reproductive age worldwide use some form of family planning. In sub-Saharan Africa, the prevalence of family planning use among women of reproductive age has increased to 29% over the past decade [16]. The overall contraceptive prevalence rate is 26% in Africa [17] and 20.42% in Ethiopia. However, this rate is significantly lower in Afar (12%) and Somalia (1%) [18].

In this study, 82.2% of the participants reported not using any family planning method (Table 2). In Somalia, only 7% of women of reproductive age use any form of contraception, while the percentage of women using modern methods remains below 1%. Additionally, 37% of Somali women reported that their family planning needs were unmet, a figure substantially higher than the sub-Saharan African regional average of 23.7% [7, 19].

Approximately 60% of the 88 women who reported being aware of family planning methods indicated that they had used them (Table 2). This finding shows that approximately two out of every three women with knowledge of family planning actually practiced a method. In this context, enhancing women’s awareness of family planning and fertility and promoting positive attitudes toward the use of family planning would be highly beneficial through collaboration with nongovernmental organizations, revision of national health policies, inclusion of family planning in international development goals, and preparation of a sustainable education plan for family planning methods, which could contribute to reducing high fertility rates and mitigating this issue as a significant public health concern.

Although the proportion of women using family planning methods in this study appears to be higher than that in the SHDS report, it is still not at a desirable level. Furthermore, the fact that most participants were unaware of family planning methods and did not use them suggests that a significant proportion of women’s family planning needs remained unmet (Table 2).

The relatively higher family planning utilization rate observed in this study compared to the SHDS 2020 [7] report data may be attributed to several factors. The study was conducted in a central fee-based hospital, where participants may have had better access to healthcare services. The participants were likely to have a higher economic status, enabling them to seek healthcare services. Most of the participants had some level of education, making them more informed than the general female population in Somalia.

Like all Somali women, the participants in this study exhibited lower rates of family planning method utilization than the global average. This discrepancy is thought to be influenced by several factors including limited access to healthcare services, low socioeconomic status, and religious and cultural barriers.

Long-term and permanent methods such as female and male sterilization, intrauterine devices (IUDs), and implants are most effective in preventing unintended pregnancies [20]. However, in sub-Saharan Africa, family planning method preferences tend to favor short-term contraceptive methods. The widespread use of injectables, pills, male condoms, the calendar method, and withdrawal is considered a major contributing factor to the region’s high fertility rates [16]. Among modern contraceptive methods, injectables are the most commonly used in the region, with a prevalence of 39.5%, followed by implants/Norplant methods at 26.5% [21].

Similarly, in this study, although oral contraceptive pills (14.3%) were the most well-known family planning method, implants (4.5%) were the most commonly used. This finding suggests that the ease of use and follow-up associated with implants may contribute to their higher utilization compared with other methods.

When the attitudes of the participating women toward family planning methods were assessed using the FPAS, more than half held similar views. Most women believe that having many children demonstrates a man’s strength, provides social power within the community, and helps families distribute their workload more effectively. Additionally, they expressed that having many children is not problematic, as siblings can take care of each other, and having a large number of children ensures mutual support among siblings in the future (Fig. 1 and Table 3).

In Somali society, attitudes toward family planning are shaped by a combination of traditional values, Islamic teachings, and modern influences. Islam emphasizes child welfare and responsible parenting. Although the acceptance of family planning has increased in recent years, some communities remain distant from modern contraceptive methods, preserving traditional practices [22].

Factors such as a lack of education, limited access to healthcare services, and deeply rooted cultural beliefs, including viewing children as a form of social and financial security, are believed to contribute to the reluctance of individuals in Somalia and other Sub-Saharan African countries to use family planning methods [10, 23, 24].

In Somali society, large families are widely perceived as beneficial in multiple ways. There is a strong societal belief that children will support their parents in old age and assist younger siblings [25]. In particular, community and religious leaders view modern family planning methods as barriers that limit the number of children an individual can have, leading to negative attitudes toward birth control methods [26].

Children are considered socially and economically significant for various reasons, including sustaining population growth, protecting communities and land, and providing labor for livestock care. Due to these reasons, Somali women often aspire to have large families [25, 26]. The findings of this study align with the existing literature, further suggesting that this societal perspective constitutes a major barrier to the adoption of modern family planning methods.

Half of the women included in this study stated that a woman should have at least four children, God provides sustenance for every child born, and the use of family planning methods is a Western imposition (Fig. 1 and Table 3).

In several sub-Saharan African countries with majority-Muslim populations, [27] modern family planning methods (such as condoms, IUDs) are not used because of the belief that they contradict Islamic teaching. Birth control is perceived as an intervention in God’s plan, and there is a strong belief that each child is a gift from God, who also provides for them. Additionally, many people in the region hold the religious conviction that Islam encourages individuals to reproduce and populate the earth. In line with these religious and cultural perspectives, there is a widespread perception that having more children enhances social status and respectability [25, 28, 29, 30, 31, 32, 33].

Similarly, in a qualitative study conducted by Gele et al. [10] in Mogadishu, Somalia, women perceived family planning methods as Western practices that contradicted their norms and traditions, which in turn hindered the adoption of these methods. The study also highlighted that the participants believed Westerners had introduced a family planning culture to Somalia [10].

A study examining the influence of religious beliefs on family planning in Western Ethiopia revealed that Ethiopian Muslim women believed that if a woman had an implant or any contraceptive device in her body at the time of death, her soul would be unable to enter heaven [34]. Similarly, Abdi et al. [34] reported that women perceived the use of birth control pills as equivalent to killing an unborn child [35].

The findings of this study are consistent with the existing literature demonstrating that traditional and religious values exert a strong influence on women’s perceptions of fertility and family planning. These findings reflect the prevailing societal belief that fertility is a natural process dictated by religious faith, and highlight the widespread conviction that encourages high fertility rates within the community.

In this study, half the women stated that they believed giving birth is a woman’s primary duty (Fig. 1 and Table 3) and that having male children was superior.

Research conducted in sub-Saharan Africa, particularly Somalia, Kenya, and Uganda, has shown that women prefer to have many children to increase their social status and as a sign of respect toward their husbands [36]. Similarly, men perceive having many children as a status symbol in society [37]. For instance, in Kenya, it has been reported that men expect women to continue giving birth until menopause, considering it a means of ensuring the continuation of their lineage [35].

According to Msoka et al. [37], in Tanzania, men do not support birth control until they reach a certain age and have fathered a sufficient number of children from multiple wives. Similarly, in a study conducted in Ethiopia by Davidson et al. [24] women perceived the ten-year duration of IUDs as too long, preferred to give birth before the ten-year period ended, and believed that IUDs could cause infertility, leading to their reluctance to use this method [25].

However, some studies conducted in sub-Saharan African countries report that women who wish to prevent pregnancy or regulate birth intervals often secretly use contraceptive pills and injectable methods without informing their husbands [38, 39]. Some women who use oral contraceptives reportedly remove the pills from their packaging and store them in an envelope to hide them from their husbands, fearing that their husbands will become angry if they discover their contraceptive use [38].

Additionally, some women avoid obtaining contraceptives from healthcare facilities because they fear that healthcare workers may violate their confidentiality. Instead, they secretly purchase contraceptive pills from street vendors [39]. The primary reason behind this secrecy is the fear that if husbands discover their limited reproductive capacity, they may seek additional wives, and women aim to prevent this from happening [40, 41].

A similar study conducted in Uganda found that women who use modern birth control methods often use them in secret because of fear of stigma. Consequently, some women chose to visit health centers at night to receive Depo-Provera injections [42].

The findings of this study support the existing literature by demonstrating how patriarchal family structures and traditional gender roles exert significant pressure on women’s fertility choices.

When examining the attitudes of the women in this study toward childbirth, more than 40% stated that they did not believe that pregnancies occurring at less than two-year intervals posed any risk to maternal health. Additionally, they believed that giving birth is better for a woman’s health than using contraceptive methods (Fig. 1 and Table 3).

In sub-Saharan African countries, when providing expert advice on birth control to Muslim women, the term “birth spacing” is preferred over “family planning”. In Islam, certain birth control practices (such as the calendar method and breastfeeding) are believed to be permissible because they support maternal and child health by allowing birth spacing [29]. Therefore, women who wish to increase the interval between births tend to choose these methods [10, 28, 29, 31, 32].

The fact that nearly half the women in this study were unaware of the importance of birth spacing in maternal health was a significant finding. Although Islam supports birth spacing for maternal and infant health, the belief that frequent childbirth is correct and healthy is attributed to cultural influences. These findings indicate that women may not be fully aware of the potential health burdens and risks associated with pregnancy and childbirth, and may not fully understand the benefits of family planning methods.

Women’s decision-making power in family planning is defined as their ability to make independent choices regarding their needs and preferences or to discuss these issues with their partners [43]. Decision-making power specifically refers to a woman’s ability to independently decide on her family planning needs and preferences or discuss them with her partner [43]. Active participation in household decision-making processes plays a crucial role in increasing the use of family planning methods for birth control [43, 44].

In this study, the participation rate of Somali women in the household decision-making processes was 61.5%. In many African societies, women tend to become more independent as they age, and their participation in healthcare decision-making processes increases accordingly [45]. When women’s participation in decision-making processes is evaluated in relation to their mean age (28.7 $\pm$ 5.57), the findings align with those seen in the existing literature [45, 46, 47].

However, according to the SHDS report, men generally dominate household decision-making processes in Somalia. The report indicated that 45% of the women stated that their husbands made major household financial decisions, and more than half reported that their husbands decided on family visits [7].

The higher rate of women’s participation in decision-making processes (61.5%) observed in this study compared to the SHDS report is likely due to the higher education levels of the study participants and the fact that this research was conducted among women who attended a private fee-based hospital in an urban center.

Although most women in South Africa participate in joint decision-making, a 2024 study conducted in Ethiopia reported that the rate of making family planning decisions jointly with a spouse or partner was 37% [48]. In Somalia, 45% of women reported that their husbands predominantly make healthcare-related decisions, whereas 34% stated that they made these decisions with their husbands [7].

A qualitative study conducted in Mogadishu, Somalia revealed that health professionals require spousal approval for modern contraceptive methods, except for oral contraceptive pills, to prevent women from making independent decisions regarding contraceptive use [10].

In this study, despite women participating in household decision-making processes, 69.2% were unaware of family planning methods, suggesting that this lack of knowledge did not influence their decision to use family planning methods. This finding highlights the significant barrier to the adoption of contraceptive methods among women.

The results of this study emphasize the importance of women having agency over their reproductive health and family planning decisions. It is crucial to enhance women’s knowledge and awareness, encourage their participation in decision-making processes along with their spouses, and create opportunities for them to express their needs and preferences while making autonomous healthcare decisions.

This study indicated that women’s awareness of family planning methods is positively associated with their use of these methods. Previous studies have shown that increasing women’s knowledge of family planning is one of the most effective ways to enhance their utilization rates and reduce unmet family planning needs [19, 48]. The findings of this study are consistent with the existing research and emphasize that organizing educational programs to address knowledge gaps is a crucial step in increasing the use of family planning methods among Somali women.

This study examines the attitudes and behaviors of married women of reproductive age in Somalia regarding family planning. However, this study had several limitations.

This study was conducted in a specific geographical region and included women who sought care at a central healthcare facility. This may limit the generalizability of our findings to all Somali women. The sample size was relatively small compared to the overall population, indicating that broader and more diverse samples could provide more comprehensive results.

Although the target sample size was calculated to be 312 women, the study was completed with 286 participants because only women who visited the hospital and consented to participate were included.

Additionally, because of religious and cultural beliefs, some participants may have been reluctant to openly discuss certain topics, potentially affecting the accuracy and completeness of the data. The study relied on self-reported data, which may have been influenced by social desirability bias, leading some participants to withhold or alter their opinions.

Because this was a cross-sectional study, we did not establish a cause-and-effect relationship. Furthermore, language differences and translation processes during the participant interviews may have resulted in misinterpretation or loss of information.

In addition, the study’s limitations include the inclusion of only women who were able to visit a private hospital because the Somali region is a conflict area and the decision not to collect quantitative data through home visits for the safety of the researchers. Therefore, only women who visited the hospital were included in this study. This is a limitation of our study.

In Somalia, societal views on childbearing are rooted in religious values, which may lead women to perceive family planning methods as negative from a cultural perspective. Consequently, they may be hesitant to openly state that they are knowledgeable about or use these methods; this should be taken into account, as it may affect the accuracy of their responses to the study questions. This situation created a limitation in obtaining information about family planning from participants.

This study provides important insights into Somali women’s attitudes and behaviors toward family planning and serves as a basis for future quantitative and qualitative research. However, further research is needed to gain a deeper understanding of the factors that influence the use of contraceptive methods and decision-making processes in this population. Future research should focus on the following areas:

⚫ Longitudinal studies should be conducted to track how Somali women’s attitudes toward family planning evolve over time and evaluate the effectiveness of interventions aimed at increasing contraceptive use.

⚫ Given the strong influence of cultural and religious beliefs on contraceptive use, qualitative research should explore the perspectives of religious leaders and community elders on family planning, and how their views shape women’s choices.

⚫ Studies evaluating the effectiveness of educational programs designed to raise awareness of family planning and empower women in the decision-making processes are crucial for identifying effective strategies for increasing contraceptive use.

⚫ Research should investigate structural and systemic barriers to accessing family planning services, particularly in relation to healthcare infrastructure, economic accessibility, and the attitudes of healthcare providers.

⚫ Future studies should examine the role of male partners in contraceptive decision-making and develop strategies to encourage greater male involvement in family planning.

⚫ Comparative studies should explore differences in family planning attitudes and access to services between women living in rural and urban areas of Somalia.

Addressing these research gaps will contribute to the development of more comprehensive policies and programs aimed at increasing family planning use among Somali women. This, in turn, is a critical step toward improving maternal and child health outcomes.