This is the first study in Sierra Leone to quantify the rural-urban disparity in modern contraceptive use among sexually active women of reproductive age and to identify the factors that explain this disparity. The usage of modern contraceptives among sexually active women of reproductive age showed a rural-urban discrepancy of 18 percentage points, favoring urban women. According to the findings of this study, more women in urban areas used modern contraception than women in rural areas. Similarly, studies conducted in Uganda (23, 24), Sub-Saharan Africa (13), and Ethiopia (25) found that women in urban areas used modern contraception more than rural women. In contrast to our findings, a study conducted in Myanmar found that rural women used more contraception than urban women (26).

Material, behavior/cultural, psychosocial, and demographic explanatory factors jointly explained 68% of the difference in modern contraceptive utilisation between rural and urban dwellers. Education, marital status, hearing about family planning on the radio, respondent age, distance to healthcare facility, and obtaining permission to seek treatment accounted for most of the explanation of this gap. If urban and rural women had the same material, behavioral, psychosocial, and demographic variables, the “explained” portion would close the rural-urban disparity in modern contraceptive use. Based on our findings, we can conclude that the rural-urban disparity in modern contraceptive use is an inequity, reflecting the inability of low educated, and disadvantaged rural women to achieve their desired fertility by using modern contraceptives, in place of an inequality in which rural women merely desire big families.

Among all the variables, education, a material variable, made the most statistically significant contribution (76%) to explaining the modern contraceptive use gap between urban and rural women of reproductive age. This is supported by descriptive statistics in table 1, which show that rural women are less educated than urban women and an increasing level of education had a strong positive association with modern contraceptive utilization in the intermediary results. When comparing urban and rural communities, rural women tend to have lower levels of education due to unfavorable cultural attitudes toward girls’ education, traditional attitudes toward women that position women as subservient, homemakers, and inadequate school provision (27). Women in rural Sierra Leone struggle to complete primary school due to cultural beliefs, poverty, gender discrimination, long distances to schools, perceived low value placed on education, early marriages and teenage pregnancies that often hinder their participation(28) (10). Due to the conservative nature of rural societies, women in rural areas are less empowered than their urban counterparts. Education has been identified as a path to empowerment over a woman’s reproductive health, holistic well-being, and it raises awareness of the benefits and drawbacks of contraceptives (24). Rural women in a Tanzanian study claimed that their low levels of education made it difficult for them to understand family planning information from various sources (29). Evidence suggests that education improves women’s knowledge and attitudes toward modern contraceptive use (30). Improving rural women’s education about the importance of using modern contraceptives is essential for increasing contraceptive use (23) in rural areas in Sierra Leone.

Correspondingly distance to healthcare facility significantly contributed to explaining the gap in modern contraceptive use between rural and urban women. More women living in the rural areas perceived distance to healthcare facilities as a big problem compared to urban women. Women who perceived that distance to healthcare facilities was a big problem were less likely to use modern contraceptives in the intermediary analysis results, and this favoured the urban dwellers. The urban setting provides logistical advantages for contraceptive supply, more clinical facilities for methods, and a more active private sector (1) compared to rural environment. Evidence indicates that distance plays a significant role in determining physical access to family planning services (31). According to a study conducted in Uganda, rural women faced difficulties in accessing family planning services due to long distances from their homes (32). A study conducted in Malawi discovered that rural women who lived more than 4 kilometers away from health facilities were significantly less likely to use modern contraception than those who lived within 2 kilometers of health facilities (33). Bringing modern contraceptive services closer to women in rural areas, for example, through outreaches, would increase modern contraception uptake and close the rural-urban disparity. According to an Ethiopian study, rural women who live near facilities that provide a wider range of contraceptive methods are significantly more likely to use modern contraceptives (33). This is supported by findings from a Nigerian (34) and an Ethiopian (33) study which showed that rural women are significantly more likely to use modern contraceptives if they live close to facilities that offer a wider variety of contraceptive methods.

Similarly, getting permission to seek treatment contributed significantly to explaining the gap in modern contraceptive use between rural and urban women. From the descriptive statistics more women living in the rural areas perceived getting permission to seek treatment was a big challenge compared to urban women. Women who got a big problem in getting permission to seek treatment were less likely to use modern contraceptives, and this disfavoured the rural dwellers. In patriarchal African societies (35), men regard themselves as the head of the household, support their wives and children financially, as well as being responsible for making reproductive health decisions and their decisions take precedence over any other family member or friend’s approval or disapproval (18). According to a study conducted in the Democratic Republic of the Congo, rural women reported that their male partner’s resistance to modern contraceptive use was a major barrier to modern contraceptive use (18). Educating men about modern contraceptives and involving them in family planning programs can boost modern contraceptive uptake and retention among rural women. Rural women’s empowerment would also help to close the rural-urban disparity in modern contraceptive use. Due to the conventional nature of rural societies, women in rural areas are less empowered than their urban counterparts. When rural women are no longer bound by their reliance on male leadership, they are better able to pursue their own goals and take charge of their own lives like urban women (36).

Correspondingly, hearing about family planning on radio also made a significant contribution to the explanation of rural-urban disparity in modern contraceptive utilisation among sexually active women of reproductive age in Sierra Leone. In our study, women from urban areas were twice as likely as those from rural areas to have heard about family planning on the radio compared to rural women. Whereas hearing about family planning on radio was associated with modern contraceptive utilisation in the intermediary results. Individuals benefit from social learning through mass media such as radio (37). Previous research has shown that increased media exposure increases contraceptive use among women (38) (39) (31). Inadequate family planning literacy has been linked to low acceptance, incorrect use, and uptake of various recommended family planning methods (40). Women in rural areas are more likely to blame poor health literacy for their failure to use recommended family planning methods (41). Sierra Leone’s government and program managers can increase demand for modern contraceptives among rural women by broadcasting family planning messages on radio. This message should be delivered at the most convenient time for rural women. In a Tanzanian study, rural women admitted that sometimes such information was disseminated through various mass media sources such as radio, but at a time when they were too busy with household responsibilities to get the information (29).

Among the psychosocial variables, only marital status contributed significantly to explaining the disparity in modern contraceptive use between rural and urban sexually active women of Sierra Leone. According to the descriptive statistics, more rural women were married than urban women (table 1) and being married was associated with a lower likelihood of using modern contraception in the intermediary analysis results (table 2). This may be due to difficulties in negotiating contraceptive use with their partners (42). In support of our findings, a study conducted in Ethiopia found that married women who resided in urban areas were more likely to decide on the use of modern contraceptive method than rural women (25). This emphasizes the importance of empowering rural women, as doing so will allow them to have autonomy over their own bodies and lives, as well as make informed contraception decisions. A study conducted in rural Zambia (37) was consistent with our findings.

The age of the respondent contributed significantly to explaining the disparity in modern contraceptive use between rural and urban residents. Women aged 35 and older were more likely to live in rural areas than in urban areas, and this age group was associated with a lower likelihood of using modern contraceptives in the intermediary analysis. These findings could be explained by the fact that older rural women face barriers to accessing modern contraceptive services, either because they lack knowledge about modern contraceptives, don’t know where to get them, or can’t afford them (42). Previous research conducted in Ghana (43) and Sub-Saharan Africa (44) discovered that older women were less likely to use modern contraception, but this finding contradicts the findings of other studies conducted in sub-Saharan Africa (13), and Ethiopia (45, 46) which revealed that women aged 35 and above used modern contraception more frequently. Similarly to our findings, a study conducted in Nigeria discovered that age contributed positively to the disparity in contraceptive use between rural and urban women (34).