Eligibility criteria

Original research studies of all designs including grey literature conducted in PICTs were considered.

To be included in the review, papers had to meet the following inclusion criteria (S2 Appendix):

1. Report on the FP service component of the SRH Care Services in PICTs or world regions that include countries in the Pacific;
2. Report on the successes/enablers and challenges/barriers to FP service provision;
3. Published in the English language; and
4. Published between 1994 and 2019 to capture the 1994 ICPD focus on the global commitment strategy for universal access to SRH including FP, and also encompass the period of the MDG and commencement of the SDGs. The PICTs also signed an agreement to ICPD in 1994 and this guides their progress towards achieving targets for the SDGs.

Papers discussing SRH and STIs that did not include aspects of FP were excluded, as were papers focused on surgical termination of pregnancy as a form of FP, antenatal care and pregnancy services.

Information sources and search

Informed by the research questions, we determined keywords (S3 Appendix), before constructing search strategies. University librarians assisted to review and confirm search strategy drafts for electronic databases and grey literature searches, which were then refined through author group discussion. Scopus, MEDLINE (Ovid), CINAHL and PsycINFO databases were searched using key words and database-specific subject headings to identify relevant studies. These databases were chosen as they provide most relevant peer reviewed articles about family planning in the Pacific. The search strategy was adapted for each database. The search was conducted between 2018 and 2019. The final search strategy for MEDLINE (Ovid) can be found in S4 Appendix. Searches were performed for published and unpublished work on Google Scholar, organisational websites (WHO, UNFPA, United Nations International Children’s Emergency Fund, UN), Pacific-based journals and reports (i.e. Pacific Journal for Reproductive Health, South Pacific Commission) including government reports such as Demographic and Health Surveys. Organisational websites and Pacific-based journals and reports were selected to augment papers identified by electronic sources, as these were known to report on reproductive health services including FP in PICTs.

Selection of sources of evidence

All papers were imported into Endnote bibliographic software and duplicates removed. Two authors (RH and MRM) performed the initial screening. Papers that did not clearly meet the inclusion criteria were reviewed by the other two authors (NH and SL) before a decision was made to either include or exclude the papers from the review. We extracted data using a MS Excel spreadsheet designed for this review to capture information about the study characteristics (publication year, country of study, study focus, design), and a data extraction sheet (Table 1) where key findings of FP services were recorded (S5 Appendix). The PRISMA flow chart in Fig 1 shows the procedure for selecting papers for inclusion.

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Fig 1. PRISMA flow chart for inclusion of articles [43].

https://doi.org/10.1371/journal.pone.0255080.g001

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Table 1. Data extraction sheet.

https://doi.org/10.1371/journal.pone.0255080.t001

Data charting process

Full-text papers that met the inclusion criteria were thoroughly read to capture relevant information required in the review [39, 40]. Findings were analysed using content analysis and synthesised using a thematic, narrative approach [42, 44]. During this stage, decisions about what information should be recorded from the primary studies were made using an iterative process [40]. Given that limited peer reviewed research was conducted on FP service provision in the Pacific region, studies were not excluded on quality grounds but included purposely to map available evidence as consistent with the scoping review methodology. However, the overall quality of the included studies was limited.

Family planning services in the Pacific

Family planning services in the Pacific region were available in most health facilities. Thirteen papers [5, 45, 50, 53, 58, 63, 66–69, 72, 76, 79] described government operated public health facilities as the main provider where contraceptives are usually free. A further five papers [5, 52, 53, 67, 72] described services provided in a variety of venues such as family planning associations, non government organisations (NGOs) and faith based organisations (FBOs). In addition, FP services could also be obtained from private pharmacies and doctors working in private practices [50]. One paper reported people sourcing contraceptives from relatives overseas [53]. Overall, the most available way to access FP services was reported to be via the government public health system.

Pacific health facilities traditionally operated a once a week session for FP within the context of MCH/FP [34, 54]. This context now included RMNCAH, which means FP was made available along with other SRH services in the RMNCAH platform. Some settings also provided outreach RMNCAH to extend services to community villages [73]. Most health facilities in PICTs offered three to five modern contraceptive methods: oral contraceptive pills, long acting reversible contraceptives (injectable and implant), intrauterine contraceptive device, condoms and permanent methods (vasectomy and tubal ligation). Emergency contraceptives are the least known and used method and not available in most health facilities. The use of traditional methods such as the ‘rhythm’ and ‘withdrawal’ methods were also reported but were not recommended because they were unreliable [36, 50]. The availability of these methods depend on the level of health facilities. Higher-level facilities like hospitals and urban centres often provide comprehensive options compared to community facilities like rural health clinics and aid posts where less options and expertise are available [57, 74].

Overwhelmingly, 18 papers [2, 6, 30, 34, 46, 49, 54, 55, 60, 61, 63, 65–67, 72, 76, 78, 80] reported that FP services provided were not always accessible to everyone. Services that provide FP were perceived as inconvenient, unsatisfactory, and not culturally sensitive [51]. Services were usually female oriented; men were not involved and often not targeted in educational awareness of safe motherhood initiatives [54, 55, 78]. Married women aged 20 to 35 were the most common cohort accessing FP services [2, 46, 55, 63, 65, 66]. Unmarried women or unmarried adolescents (12–19 years) [2, 55, 61, 65, 67, 71, 78], older women (over 40 years) [30] and men aged 15–54 [47, 49, 54] years were relatively neglected in FP clinics. Pacific countries with dispersed island populations and remote locations also received poor services [63, 70, 72]. Although the emphasis on providing services for outer islands and rural communities has been articulated, the actual implementation has varied depending on available resources and support including staffing, political commitment and logistic systems. Evidence about the extent to which FP services are reaching those who use the service and how the service was provided at the health facility level was lacking in the literature [30, 47].

Most PICTs are committed to upholding human rights and have adopted policies based on the principle of free and ‘informed choice’ for all couples and individuals [50]. Reports on the existence and use of relevant SRHR policies in five Pacific countries (Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu [70–74], including ICPD progress reports [3, 18, 21], showed some PICTs have used some form of SRH policies. Other PICTs have SRH policies in either draft form or under development. The incorporation of these policies into national strategies in PICTs occurred in varying degrees. These policies aim to provide an enabling environment where reproductive rights of women and men can be fully recognised and exercised. However, for those PICTs who have polices, most are outdated. In some cases, policies are not visibly available and approaches to FP shown to be ineffective [34]. For example in Tonga [73], there are no mentoring programs to monitor skills retention. In Kiribati [70] SRH care is not standardised across all health facilities due to lack of FP guidelines. Where guidelines and tools are available, they can only be effective if supplies to meet increased demand are available [59]. The UNFPA progress report [14] also highlighted that achievement of reproductive health rights are yet to be fully established in the Pacific region.

The integration of SRH, including FP within PHC service is part of the comprehensive SRH package prioritised in PICTs. Integration in this review refers to integration of population policies into sector plans and strategies and integration of FP services within the SRH platform at the program and health facility levels. Hayes and Robertson [50] reported most Pacific countries have incorporated reproductive health including FP into national and subnational development plans. However, assessments of SRH programs in some Pacific countries showed integration was not fully implemented [70–74]. There is less progress in the integration of population policies into sector plans [21]. At the program level, although the MCH/FP focus has changed to RMNCAH to enhance inclusivity for everyone, there is little focus on STIs including HIV, abortion, infertility, and adolescent health by FP clinics [57, 72]. Evidence also suggests that clinics for STIs, including HIV, are delivered separately from routine reproductive health clinics in some PICTs [14, 28, 55, 62, 63, 65, 68, 69, 72].

The availability of quality and relevant SRH, including FP data was a common and ongoing challenge in PICTs. Robertson [36] and UNFPA [14, 70, 72, 74] documented poor reporting systems and processes that made it difficult to determine whether valid data existed for most countries. Prior to 2006, DHS were undertaken in only two countries in the region: PNG and Samoa. As such, the use of contraceptives could be under-reported. One example is the difference in CPRs reported in the DHS when compared to Ministry of Health (MOH) reports. This difference could be because women are accessing contraception from private pharmacies, private practitioner and other NGOs and this data is not routinely being captured in the national data [78]. Therefore, there is an urgent need to improve current reporting systems so that all parties communicate more effectively to produce an accurate reflection of CPRs in the Pacific context.

Information on unmet needs for contraceptives was not initially included [36]. The sociocultural and demographic diversity of PICTs made it difficult to interpret certain indicators and targets such as maternal mortality rates, within the context of very small populations. The disparities that existed across socio-economic groups contributed to the challenge of monitoring progress to achieve target goals [21]. While most countries are now able to conduct population census, the capacity to process, analyse and interpret survey results from policy perspectives remains limited [18]. Routine health information systems will need to be validated, and capture contextual issues, that can inform relevant policies and FP service outcomes.

Education, knowledge and attitudes

The education, knowledge and attitudes of FP service users was a common theme among the reviewed literature [2, 5, 6, 46, 48, 49, 53, 54, 56, 58, 61–63, 65–69, 76, 77]. The service user’s knowledge about the different contraceptive methods varied across countries by education levels, gender, marital status, parity, age group, wealth quintiles and where they live. While it is expected that women with higher education levels (more than secondary education) are more likely to use contraceptives to delay pregnancy because they may have greater exposure to contraceptive knowledge and options, some exceptions and inconsistencies were reported [46, 48]. For example, some women were unaware of important information about contraceptives, such as the availability and use of emergency contraceptives and the use of condoms to prevent pregnancy [61]. Nine reports of DHS conducted in PICTs between 2007 and 2018 [53, 58, 62, 63, 66–69, 76] showed a consistent result of almost universal contraceptive knowledge among married women and men above 40 years of age but lower knowledge levels in the unmarried and adolescent cohorts. Increased contraceptive knowledge was also seen in women with higher parity (>3) compared to women with lower parity (<2). Contraceptive knowledge according to wealth quintiles and rural or urban dwelling also showed inconsistent findings throughout PICTs. This knowledge is defined as having heard about a method, however, for adolescents, they lack knowledge about services and important information on pregnancy prevention, condom use, puberty, sexuality and relationships [2, 48].

Contraceptive use was relatively low in PICTs. Davis [49] and Naidu et al., [61] reported that having high contraceptive knowledge did not always translate to use of contraceptives and having heard about a method did not always influence individual decisions. For example, in Kiribati and Marshall Islands, contraceptive use was high among those with low or no education and lower among the highly educated populations, compared to Solomon Islands and PNG [53, 58, 63]. In Samoa, there was no difference by use in rural and urban settings [66], whereas in Tonga, women in urban settings are less likely to use contraceptives than their rural counterparts [68]. In PNG, men’s educational background increases the likelihood of women’s use of contraceptives, and male literacy contributed to men’s participation in FP [54]. The DHS reports included in this review [53, 58, 62, 63, 66–69, 76] further detailed that more than half of the men interviewed say they knew that their wives or partners used contraceptives, but only a few countries reported it was a joint decision. In addition, many women in PICTs (>70%) did not intend to use contraception in the future regardless of their knowledge of contraceptives. Contraceptive knowledge, use and attitudes will need to be understood within the respective PICT contexts before relevant strategies can be implemented.

A health worker’s education, knowledge and positive attitude is essential to the success of FP services in PICTs. Health workers need education to increase knowledge, confidence and skills to empower couples and individuals to make informed contraceptive choices [57]. Marshall [57] and the UNFPA report on the Pacific’s RMNCAH workforce [81] reported that not all health workers had adequate knowledge about the risks, uses and options for contraceptives available to women. There was also a lack of knowledge and skills to dispense contraceptives and how best to deliver FP services. This includes the ability to give appropriate contraceptive counselling advice; practical skills to insert uterine devices or implants; and communicating with and managing adolescents [6, 48, 77]. This means planners in PICTs will need to explore if skill mix and task shifting will be beneficial in their context.

Some health workers also lack the training required and slowly abandon their moralistic attitudes to deliver effective adolescent SRH services [78]. In some PICTs contexts, even if training in FP was provided, negative attitudes and beliefs of health workers about contraceptives influenced whether the health workers promoted or discouraged adolescents from accessing the service and using contraceptives [5, 34, 60]. A recent report on the status of the RMNCAH workforce in the Pacific region [81] stated that most countries in the region have sufficient nurses who are competent to provide the RMNCAH care, including FP. However, there is also an overall shortage of nurse-midwives, and these healthcare workers will have multiple responsibilities additional to RMNCAH, meaning FP may not be prioritised or provided when needed. Adding to this challenge is the high staff turnover and the education and recruitment of RMNCAH workers, as many smaller countries did not have their own education institutions to provide this specialised training. For health workers working in remote areas, further training opportunities are often limited, therefore, the lack of training incentives also influenced the way health workers deliver FP services in PICTs.

Geographical isolation and access

Accessibility of SRH services in PICTs is a particular challenge due to geography and climate. These countries are predominantly sparsely populated, small island nations dispersed across the Pacific. Some remote geographical locations make access to family planning services difficult [2, 73]. The majority of the population in most PICTs live in rural, often isolated areas or atolls with limited infrastructure such as roads, electricity and running water [14, 21, 55, 70, 73]. Access to health services is often threatened by bad weather, rough seas for those who live in coastal islands and flooded rivers for those who live on large islands [60]. People survive on subsistence farming and fishing, and the health centre is often too far away to reach. Irregular supplies of medical equipment and drugs to the clinic can result in unavailability of contraceptives for women and men at point of need. The cost of travelling is expensive, and additionally prohibitive if people have to make return visits to the health centre or if contraceptives are out of stock [3, 9, 13, 21]. Access to FP services depends upon the adequate geographical spread of health facilities and a health workforce supported by reliable transport and communication networks [81]. Therefore, reliable and updated information about the country’s health systems and effective planning are important to address resource allocations to prepare for expected and unexpected adverse situations.

Socio-cultural beliefs, practices and influences

Most of the reviewed papers acknowledged the strong negative influence of socio-cultural and religious beliefs and practices relating to SRH issues in the Pacific [3, 5, 6, 14, 30, 34, 36, 46–49, 52, 54, 56, 58, 60, 62, 63, 65, 66, 68, 69, 73, 74, 76, 77]. Socio-cultural and religious beliefs and practices are very important to people in the Pacific. These beliefs and practices play a major role in community life, and the ubiquitous Christianisation of the Pacific by missionaries that enabled colonisation is associated with the idea of refusing contraception. [5, 60]. The common reasons reported in the literature as barriers to contraceptive use mainly rose from misconceptions, health concerns and a mixture of cultural and religious beliefs. Understanding and acknowledging these sociocultural influences is important to identify acceptable ways to reach people with FP services.

Although socio-cultural practices are seen to constrain progress in SRH including FP [3], in some PICTs, culture is viewed both as a way to promote, as well as constrain, SRH [21]. This reflects the hyper-diverse culture in the three main ethnic groups: Melanesia, Polynesia and Micronesia [14]. For example, in Samoa, women hold important traditional roles in society and can promote FP. In Kiribati, men have the traditional role in taking care of their wives during pregnancy and childbirth; therefore, they will have already fulfilled the role of men as partners in reproductive health [21, 70]. In Solomon Islands, an ‘O clinic’ (Ovulation clinic) was provided for those who wish to use the natural methods for cultural, religious or health reasons. Such opportunities to promote FP will need to be further explored when dealing with constraining issues in the socio-cultural context in PICTs [34].

The physical layout of health facilities and how services are delivered present barriers to service access in some PICTs. Burslem et al., [46] and Kennedy et al., [5] reported that some health facilities in Solomon Islands and Vanuatu, including those providing FP services, were considered not culturally suitable or accessible according to acceptable norms surrounding modern contraceptive use. These norms include gender-access issues, husband/partner opposition and beliefs that using contraceptives will encourage promiscuity, and use is therefore morally wrong for unmarried women and young people [34, 49]. One barrier that stands out in the reviewed literature is the culturally insensitive FP services that are not conducive for men or young people to access [36, 47, 49]. The gender of the service provider often affected men or women’s access, and the lack of privacy and confidentiality was a common hindrance for young people and the marginalised groups [52]. While adolescents may have adequate knowledge about the importance of using contraception, they may be denied access because the service did not offer culturally appropriate options to ensure inclusivity [6, 46, 52, 55, 60].

The desire for many children is consistently described in the DHS reports, with men expressing wanting more children than women [53, 58, 62, 63, 66–69, 76]. Having larger families is an accepted cultural norm in the Pacific region. Children are valued as future social and economic gains and security [34, 50]. Although the number of children per woman in PICTs has been declining since the 1970s, one paper recently reported having three to five children was seen as ideal [56]. It is important to note that remnants of traditional practices and ideologies to limit fertility still exist in some Pacific countries. However, Hayes and Robertson [50] considered using traditional ‘modes of reproduction’ to encourage Pacific Island people to adopt family planning has not been an effective strategy. The reasons are many and complex, and can be traced back to the initial contacts with missionaries and later colonial authorities, which resulted in the criminalisation of some traditional population control methods such as abortion and infanticide; postpartum abstinence and abstinence from sexual activity during ceremonial events. However, Lincoln et al., [56] suggested, if future family planning programs could also address the number of children in an ideal family unit, this could potentially be a way forward to ensure contraceptives are acceptable in PICTs.

With the introduction of pronatalist policies by missionaries and colonial authorities, some earlier control practices were considered immoral. Formal laws regarding marriage, births and deaths were formulated, and most derived from the Christian ‘laws’. One belief the church has instilled, that has become a common religious barrier to contraceptive use, was that children are a “gift from God” and having more children is a good thing [50]. However, despite this barrier, some PICTs have found ways to deal with this belief. For example in Kiribati, although faced with religious opposition, the injectable contraceptive Depo Provera was acceptable and commonly used by Catholics, as opposed to longer-term methods which are considered unacceptable [53]. In Vanuatu, traditional leaders and religious groups were becoming more accepting of reproductive health and rights [21]. Hence, opportunities can be sought in the diverse cultures of PICTs to promote acceptable strategies to deal with religious beliefs.

Potential enabling factors for improved family planning

Strategies to improve FP service provision and access in PICTs are outlined in nine of the reviewed papers [2, 36, 55, 59, 70–74].The importance of effective collaboration between government sectors, NGOs and private sectors was shown to increase access and avoid duplication of services. For example, adolescents in Vanuatu [5] prefer services provided by NGOs, as they were perceived to be more accessible, friendly and competent in helping people in this age group compared to government services. Integration of population policies such as SRH into other government sector plans were found to be beneficial in these small island states, where a lack of resources such as funding and staffing is prevalent [81]. Where contextual challenges such as cultural norms, religious obligations and geographic limitations occur, friendly service providers and context specific strategies are needed to implement relevant services [5, 47, 72].

Family planning education and health programs have been shown to positively influence contraceptive use. However, this review also identified that FP education in schools is underutilised in PICTs [2, 52, 57, 77] and there is a need to utilise peer educators, parents and schools to promote FP education in PICTs. Health education programs need to invest in a broad range of informational resources and utilise a multi-faceted approach to reach young people who are attending or not attending school and to reach other adolescents in both geographically isolated areas and urban settings [2, 52, 77]. In Tonga, a ‘settings approach’ to SRH program including awareness talks in schools, villages, workplaces, churches and radio talkback shows, was shown to improve young people’s knowledge about SRH services [73]. Reproductive health and FP education have been implemented in PICTs, but education materials need to be translated into local languages and presented in culturally sensitive ways [28, 59]. Different strategies are required for male, female, adolescent or mixed audiences. Attaining higher education levels and obtaining education on SRH and FP are not enough [49]. Evidence-based motivational interviewing and behavioural change action are required to meet individual contraceptive needs and deal with contextual barriers.

Educating and involving men in reproductive health has been a missed opportunity to improve services [49]. It is important to engage boys and men early in the reproductive life cycle [49]. Most RMNCAH care services in PICTs do not actively engage expectant fathers and fathers of young children. An evaluation of male involvement in reproductive health (MIRH) in Fiji and Solomon Islands [64] and a study of MIRH in PNG [54] showed an acceptance of MIRH in Pacific contexts, with MIRH seen as a key opportunity to break down cultural barriers and norms to accessing FP services and the use of modern contraceptives by women and men. A qualitative study [49] on perspectives of policy makers and practitioners in Cook Islands, Fiji, PNG, Solomon Islands and Vanuatu also noted that the inception of MIRH prompted men to appreciate their role in FP and to better support their wives. However, context-appropriate strategies are needed for health service providers to engage men and deal with sensitivities relating to culture when discussing sexual health issues with them [36].

The increasing youth population and their early sexual debut in PICTs compared to other world regions suggest that this group warrants more attention [52]. Adolescent-focused services have been recently implemented but these lack culturally sensitive approaches, confidentiality and privacy [81]. In rural communities, engaging community gate-keepers in education awareness is vital [57, 73]. This will enable community involvement in distributing SRH information and extending FP awareness. Overall, FP needs further research to understand the changing behaviours of Pacific peoples so that SRH care including contraception service approaches are based on current evidence for PICTs [21, 45].