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Health system barriers and facilitators influencing contraceptive service utilisation among women in South Africa: a scoping review with implications for rural settings

Year: 2026
Type: article
Abstract: South Africa records approximately 93,000 births to mothers aged 10–19 years annually (12.4% of all live births), one of the highest adolescent fertility rates in sub-Saharan Africa. Despite constitutional guarantees and a national programme providing free contraceptive services, modern contraceptive prevalence among adolescents is critically low, with unmet need estimated at 31–38% - more than double the national average. This burden falls disproportionately on rural and peri-urban communities, where health system fragilities, geographic isolation, and structural inequalities intersect. This review maps barriers and facilitators influencing contraceptive service utilisation among women in South Africa, with emphasis on adolescents and rural settings. We followed the Arksey and O’Malley scoping review framework and reported in accordance with PRISMA-ScR guidelines. The Population-Concept-Context framework guided eligibility: women of reproductive age in South Africa; barriers and facilitators of contraceptive access and use; and the South African public-sector health and education systems. Searches across PubMed, CINAHL Complete, PsycINFO, and MEDLINE were conducted in two phases (2010–2024; update 2025–2026), identifying 939 database records; 71 grey literature sources were additionally reviewed. Following screening and full-text assessment, 64 sources met inclusion criteria. Three intersecting domains of constraint emerged. Health system barriers - stock-outs of long-acting reversible contraceptives, provider bias, confidentiality failures, inconvenient operating hours, and inadequate counselling were particularly acute in rural facilities. Interpersonal barriers included partner opposition, reproductive coercion, and parental disapproval. Structural barriers, poverty, gender-based violence, and social norms normalising early childbearing were most severe in underserved communities. Facilitators included youth-friendly services, community-based and digitally augmented delivery, and integration with education and economic empowerment programmes. A six-pillar Multilevel Access Reform Framework grounded in constitutional accountability is proposed. Contraceptive service utilisation in South Africa is shaped by complex, interacting determinants in which health system and structural factors play a central role, particularly in rural settings. First-principles analysis reveals that dominant programmatic investments are misaligned with the actual binding constraints. Integrated, multi-sectoral reform anchored in community-based service delivery, digital health infrastructure, gender-based violence programming, and outcome-oriented monitoring is essential to achieving reproductive equity.
DOI: 10.1186/s12913-026-15928-7
Language: English
Field: Medicine
Open Access status: gold
Estimated APC paid: $3,290
OpenAlex ID: W7223474892
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