Modelling strategic interventions in a population with a total fertility rate of 8.3: a cross-sectional study of Idjwi Island, DRC

BACKGROUND Idjwi, an island of approximately 220,000 people, is located in eastern DRC and functions semi-autonomously under the governance of two kings (mwamis). At more than 8 live births per woman, Idjwi has one of the highest total fertility rates (TFRs) in the world. Rapid population growth has led to widespread environmental degradation and food insecurity. Meanwhile family planning services are largely unavailable. METHODS At the invitation of local leaders, we conducted a representative survey of 2,078 households in accordance with MEASURE DHS protocols, and performed ethnographic interviews and focus groups with key informants and vulnerable subpopulations. Modelling proximate determinates of fertility, we evaluated how the introduction of contraceptives and/or extended periods of breastfeeding could reduce the TFR. RESULTS Over half of all women reported an unmet need for spacing or limiting births, and nearly 70% named a specific modern method of contraception they would prefer to use; pills (25.4%) and injectables (26.5%) were most desired. We predicted that an increased length of breastfeeding (from 10 to 21 months) or an increase in contraceptive prevalence (from 1% to 30%), or a combination of both could reduce TFR on Idjwi to 6, the average desired number of children. Increasing contraceptive prevalence to 15% could reduce unmet need for contraception by 8%. CONCLUSIONS To meet women's need and desire for fertility control, we recommend adding family planning services at health centers with NGO support, pursuing a community health worker program, promoting extended breastfeeding, and implementing programs to end sexual- and gender-based violence toward women.