From 1994 to 2013, family planning decisions among married couples in China followed the firm “one-child” family planning policy [14]. However, with the introduction of safer and smarter contraceptives, there has been a relaxed one child family planning policy since 2013 [9]. Key socio-economic and environmental factors intricately influence couples’ contraceptive choices [16]. The study explored factors associated with modern contraceptive usage among currently married non-pregnant women by residence in Hubei Province, China. The study revealed that, age (< 35 years), number of children (0 or 1), and knowledge of condoms as contraceptive methods were positively associated with contraceptive usage among married women resident rural areas. Again, ethnic minorities other than Han negatively correlated with contraceptive use among the respondents in rural areas. Alternatively, age (< 25 years), having no living child, usage of contraceptives by spouse and involvement of male partner in FP were key determinants of contraceptive usage among urban dwellers.
Short-term methods of contraception were preferred by young married women, which is probably attributable to the relaxation of national family planning policies in recent years [26]. Also, empirical literature demonstrates that contraceptive preferences and the decision to adopt contraceptive increases in concert with family planning policies implemented by governments [13, 27]. Our study revealed that, young married women less 34 years and less than 25 years were positively associated with contraceptive use compared to aged married women (45–49 years) irrespective of place of residence. This trend may be ascribed to young couples’ aspirations to have more children in the future or delay childbearing to pursue their careers [28]. Sociocultural changes in China, including increasing educational attainment and changing family structures, may influence reproductive decision-making [28]. However, our study did not directly assess societal attitudes or behavior change over time. As such, broad generalizations should be avoided, and interpretations should remain focused on the observed associations. Furthermore, several decades ago, a Chinese woman would not see her husband before her wedding day, nowadays, some young people in both rural and urban areas are choosing to live with their partners before they decide to wed but the society still frowns on having a baby out of marriage [10, 29].
Pursuing higher education and career development is very high among Chinese women. The general aspiration is to provide a better future for their children [29]. Therefore, if they are not economically sound to provide their children with the best future, they resort to contraceptives to delay pregnancy until they are well equipped financially, psychologically, and materially [9, 10]. The topic of sex is becoming more open, and sex before marriage is not a taboo as it used to be. Therefore, the tendency to use contraceptives to prevent unplanned pregnancy was very high [9, 10]. Moreover, the Chinese Government has recognized the importance of promoting the use of condoms in the fight against human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted diseases [30].
Interestingly, our findings indicate that married Han women in rural areas were significantly less likely to use modern contraceptives compared to women from ethnic minority groups, with an adjusted odds ratio (AOR) of 0.29. While this result may seem counterintuitive given the Han group’s majority status and generally higher access to resources, it may reflect broader sociopolitical and demographic shifts following the relaxation of China’s one-child policy in 2013 [31]. The changing policy landscape may have led to a reduced perceived need for contraceptive use among Han women, who were previously the primary targets of stringent fertility regulations. As restrictions eased, especially for rural Han families, fertility intentions and contraceptive behaviors may have shifted toward larger family preferences, contributing to lower uptake of contraceptives. Conversely, ethnic minority women may have experienced stronger engagement with community-level family planning programs, particularly in autonomous or rural regions where targeted outreach initiatives were historically implemented to address reproductive health disparities. Cultural differences, smaller family norms, and stronger influence of localized reproductive health education in minority-dense areas could have contributed to the relatively higher contraceptive use observed among these women. However, it is important to interpret this finding with caution as other ethnic minorities represented only a small portion of the study population, and their distribution across the sampled districts was uneven. As such, while the association is statistically significant, the potential for sampling variability limits the generalizability of this result. Future studies with larger, more proportionately distributed samples of ethnic minority populations are recommended to further explore the role of ethnicity in contraceptive behavior in China.
Traditionally, it has been argued that high parity is positively correlated with contraceptive usage irrespective of residence [32]. Remarkably, our results showed otherwise as the number of living children among both rural and urban married Chinese women who reported to have no child were 12.55 and 10.68 times more likely to use contraceptives than those who had two or more children. Also, rural married Chinese women who had at least one child been 1.75 more likely to use contraceptive than their counterparts who reported to have two or more living children. This result may be due to the one-child and other related birth control policies implemented over three decades ago, which might have a negative impact on procreative intentions among Chinese couples [10, 30]. Other prominent factors that contribute to the departure from procreative aspirations and actual fertility behaviors are the postponement of age at first marriage and childbirth, infecundity, competing factors and opportunity cost, and the costs involved in childcare [33, 34]. Among the disincentives, the overly high costs of having and nurturing children have been cited as the top two most important factors militating against reproductive decision-making among couples [33, 34].
Also, married Chinese women who revealed that, their partners have never used contraceptives before were positively associated with contraceptive usage in urban dwellers when compared to those whose spouses ever used contraceptives. Conversely, there was no significant association between contraceptive use and partners/spouse who ever used contraceptive among married Chinese women living in rural areas. This may be ascribed to the fact that, most Chinese married women in urban areas are empowered economically to take their personal reproductive health decisions with or without involvement and agreement of their partners/spouse than their counterparts in rural areas [35, 36]. Their relatively stable economic status enables them to afford and purchase modern contraceptives without necessarily relying on their partners [35, 36]. Again, most married Chinese women in urban areas are highly educated which empowers them to make informed decisions on their reproductive health and contraceptive use [37]. It is also evidenced that, education usually improves the knowledge and attitude of women towards modern contraceptive use [37, 38]. However, the data were collected between 2014 and 2016, nearly a decade ago. Since then, China’s family planning policies and contraceptive landscape have continued to evolve. These changes may affect the current applicability of our findings, and updated research is needed to assess contemporary patterns and determinants of contraceptive use.
Additionally, we found that married Chinese women who indicated no knowledge of condom as contraceptives were 3.19 more likely to use contraceptives among rural settlers when compared to respondents with knowledge of condom as contraceptives. Necessary logistics and sexual reproductive health education to these unreached communities in rural China may contribute to such findings [39]. While this finding appears counterintuitive, it may reflect reporting biases or misunderstanding of contraceptive terminology, especially in populations with limited health literacy, as other studies have shown that those from rural areas have low health literacy [40]. Alternatively, it is possible that women relied on provider-driven methods like IUDs or sterilization without being aware of other methods such as condoms. However, this interpretation should be treated cautiously, as the association may also result from unmeasured confounders or misclassification. There is therefore the need to increase dissemination of relevant information and education on contraceptives to women in rural China to equip them to make informed decisions on their sexual reproductive health [10]. Although, these results differ from previous studies, which found a positive correlation between knowledge of contraceptives and usage, they are consistent with previous studies in Nigeria [40].
Our study did not find a significant association between knowledge of condom as contraceptives and contraceptive usage among married Chinese women who live in urban areas. Moreover, the present study showed that partners involvement in FP positively correlated with contraceptive usage among urban dwellers. However, there was no significant association of contraceptive use among married Chinese women living in rural areas. This may be ascribed to the fact that, in the urban areas couples are more enlightened and more open to discuss their sexual and reproductive health concerns as compared to Chinese couples in rural areas who may be more reserved and conservative on the issue of sexuality [39]. Additionally, married couples in the urban areas are more informed and have easier access to FP services as compared to their counterparts in rural areas where access to family planning services is usually limited [40]. Hence there should be a deliberate intensification of family planning education in rural China and inclusive-family decision making on family planning by couples.
Strengths and limitations
The study employed a large sample size. The study also provides relevant context on China’s family planning history and contraceptive trends as well as covering the one-child policy and rapid development. Furthermore, the study adds to the body of knowledge on rural–urban differences in the factors associated with contraceptive usage among married women in China. However, some limitations were encountered in this study. This study used data from only non-pregnant married women; thus, future studies should explore unmarried women of reproductive age to better understand their knowledge and attitudes towards contraceptive usage in Hubei province. The cross-sectional nature of the study may prevent making any causal inference about the associations. Also, information on contraceptive use was self-reported hence the chances of reporting bias should not be discounted while interpreting the findings. The sample population was limited to only females, therefore male perspectives on contraceptive use should be explored in future studies. Again, there are chances of social desirability bias, sampling/selection bias (due to the literacy rates and/or use of WeChat), and reporting or response bias. Further, sampling weights were not generated, and cluster design was not adjusted for in the analysis, thus results of this study should be interpreted with caution and generalizations should not be exaggerated or overly emphasized. Although rural and urban samples differed significantly in age distribution, we did not apply post-stratification weighting or design weights in the analysis. This may introduce bias in comparisons of contraceptive usage across residence types, particularly for age-dependent patterns. The contraceptive usage rates reported reflect unweighted sample proportions and may not represent the broader population. While separate logistic regressions were conducted for rural and urban groups, we did not test for interaction effects between place of residence and key predictors. Thus, comparisons between groups should be interpreted cautiously. It is important to note that the findings presented are based on unweighted data and single-level analysis; applying population weights or conducting multilevel modeling to account for clustering at the community or district level could potentially alter the observed associations, for instance, diminishing rural–urban differences or affecting the significance of certain predictors. Future analyses using hierarchical or multilevel models could provide more nuanced insights by adjusting for community-level variation, particularly in regions with heterogeneous access to family planning services. Even though the study shows contraceptive use disparities across rural and urban areas, the data is not recent and a delay in reporting study findings and a close to 10 years evolution in time may affect the comprehensiveness of results, since modified techniques may have been employed by the Chinese government overtime to limit negative implications of contraceptive non-use and to improve uptake across all levels. Additional studies across both residencies are needed to corroborate the study findings. However, literature points towards a steady improvement in contraceptive uptake among urban settlers but still alarmingly low reproductive health services uptake among rural settlers in China. Nevertheless, this study indicated a significant improvement in contraceptive usage across both rural and urban residencies, highlighting an improvement in policy implementation and attitudes of reproductive-aged women and households towards contraceptive usage. Reproductive-aged women need constant education on health promotion measures, particularly contraception and support to advance their health and limit the burden of adverse health outcomes. However, this study is important in understanding the determinants and barriers of contraceptive uptake among the women in-union for resolute interventions to achieve global targets and to contribute to relevant knowledge on rural and urban variations in contraceptive uptake and its influences.
