Spatial distribution, integration and determinants of family planning service provision in Lubumbashi, DRC: a cross-sectional analysis from a health facility census

Background
Universal access to family planning (FP) services is essential for safeguarding sexual and reproductive health and rights. Integration of FP and routine maternal and child health (MCH) services has been associated with increased uptake of long-acting reversible contraceptives and contributes to reduced unintended pregnancies, unsafe abortions and complications associated with short interpregnancy intervals. In the DRC, FP use remains limited despite national efforts to expand services, and rapidly growing cities such as Lubumbashi face additional challenges due to health system fragmentation and reliance on private-sector care. This study examined spatial distribution, MCH-integration and determinants of FP service provision in Lubumbashi.

Methods
We analysed data from a 2023 census of 1,267 health facilities in Lubumbashi. Descriptive analyses summarized the availability of FP services in facilities by health zone, sector, type, routine-data integration, MCH services, -integration, monthly birth volume, medicine stock and mean cost of vaginal birth. Multilevel logistic regression models with random intercepts at the health zone level identified facility-level determinants of FP service provision. Geospatial analyses mapped service availability with 1 km coverage buffers, population-adjusted facility density, and FP-MCH integration levels by health zone.

Results
Overall, 731 facilities reported offering FP services (57.7% of total), with significant variation across health zones (31.0–70.5%). FP provision was strongly associated with high monthly birth volumes (aOR = 8.14, 95% CI 2.81–23.58), public ownership (aOR 4.09, 95% CI 1.62–9.99), and integration with all types of MCH services. Geospatial mapping showed that 94.3% of women live within a 1 km radius of a facility offering FP, but FP services and FP-MCH integration were less dense in peripheral health zones.

Conclusion
Despite near universal geographic access to FP in Lubumbashi, service integration with MCH-services remains suboptimal, and coverage gaps persist in peripheral areas. The city should prioritise under-served health zones for both health facility based and outreach FP interventions to guarantee universal FP access, and efforts should be made to expand subsidized or free services in areas dominated by private for-profit facilities. Additional barriers such as stockouts, costs, fear of side effects, misinformation or partner-related constraints warrant further investigation.

Plain English summary
Family planning (FP) services are an essential part of reproductive health, helping women and couples decide if and when to have children. Yet despite their importance, little is known about where these services are offered and how they are integrated with other maternal and child health care (MCH) services in Lubumbashi, the second largest city of the DRC.

We collected information from all 1,267 health facilities in the city in 2023. We wanted to know three things: where FP services are located, whether they are offered together with maternal and child health services, and what factors make a facility more or less likely to provide FP.

We found that just over half of all facilities offered FP services, and most provided this alongside MCH care, meaning women could access multiple services at the same place. Mapping the facilities showed that FP services are clustered in the centre of the city, but nearly all women still live within one kilometre of a FP-providing facility. But access is not equal. Larger, public and private non-profit facilities, and those charging higher fees were more likely to provide FP. Smaller and less well-resources facilities were less likely to do so. This means that even if FP services are close, some women may still face barriers.

While FP services in Lubumbashi are broadly available, health system and financial factors still limit equitable access. Policies to strengthen facilities and reduce cost barriers could help ensure that every woman can access FP services when she needs them.