Barriers and facilitators of acceptability and uptake of long-acting reversible contraceptives in Ethiopia: a systematic review using the COM-B model

Abstract

Background

Long-acting reversible contraceptives (LARCs), including implants and intrauterine contraceptive devices (IUCDs), are essential in preventing unintended pregnancies and empowering women by providing long-term, reliable contraception that supports informed decision-making about family planning and reproductive health. However, their uptake and acceptability remain low in Ethiopia due to various individual, social, and systemic barriers. This study systematically reviews the factors influencing LARC acceptability and utilization among Ethiopian women, adolescents, and healthcare providers, using the Capability, Opportunity, Motivation, and Behaviour (COM-B) framework.

Methods

A systematic search of PubMed, Embase, Scopus, African Journals OnLine, and EBSCOhost (CINAHL) was conducted, along with gray literature sources, to identify studies published between January 2021 and June 2024. Inclusion criteria encompassed studies conducted in Ethiopia that examined the acceptability and utilization of LARCs, focusing on implants and IUCDs. The types of studies considered included quantitative, qualitative, and mixed-method designs, focusing on postpartum, post-abortion, and nonpostpartum women, adolescents, and healthcare providers. Data on barriers, facilitators, and associated factors of acceptability and utilization were extracted, and the findings were mapped to the COM-B framework. Atlas.ti v.9 software was used in the analysis process.

Results

A total of 58 cross-sectional, qualitative, and mixed-method studies were included, encompassing diverse Ethiopian populations and geographies. Among immediate and extended postpartum women, barriers included limited awareness and fear of insertion pain for IUCDs, low awareness, and limited access to LARCs, while postpartum counselling emerged as a facilitator. For adolescents, social stigma, male partner disapproval, and misconceptions about LARC side effects were prominent barriers; school-based education and youth-friendly services supported acceptability. Healthcare providers noted inadequate training on family planning methods as a barrier, while targeted training improved their confidence in recommending LARCs. Nonpostpartum women frequently cited partner opposition and cultural beliefs as barriers, but family planning programs with partner engagement facilitated greater acceptance.

Conclusions

The findings highlight an urgent need to expand community-based education programs to dispel myths and misconceptions about LARCs, particularly in rural and pastoral regions. Prioritizing provider training to improve counselling and service delivery, alongside engaging male partners in family planning discussions, is essential for enhancing LARC utilization and meeting reproductive health needs in Ethiopia.

Systematic review registration

PROSPERO CRD42024594288

Background

Long-acting reversible contraceptives (LARCs), including implants and intrauterine contraceptive devices (IUCDs), are highly effective methods for preventing unintended pregnancies [1] and promoting reproductive autonomy [2]. LARCs provide prolonged prevention time, require minimal maintenance, and have proven effective across diverse populations, making them an essential component of family planning initiatives worldwide [3].

However, despite their benefits, LARC uptake remains low and inconsistent, particularly in low- and middle-income countries (LMICs) like Ethiopia, where sociocultural, religious, and systemic barriers often limit access and acceptance [4,5,6]. As a result, Ethiopia faces substantial challenges in meeting family planning needs, with an unmet contraceptive need of approximately 22% among married women of reproductive age [7]. Additional factors such as community’s misconception, fear of side effects, lack of women’s decision-making autonomy, conflict, and topography were reported to contribute to low uptake of family planning methods, in general [8]. Further, the supply-side barrier still remains to be a challenge whereby health facilities lack the capability to sustainably ensure availability of these products [9]. According to a systematic review conducted in 2018 by Gebeyehu and colleagues, supply-side barriers would encompass broader issues such as provider-, facility-, and policy-related dimensions as well [10]. However, since that review is now several years old, our updated review offers more recent insights into the changes that have occurred in healthcare systems, policy frameworks, and provider practices. By incorporating the COM-B model, we analyzed how factors such as capability, opportunity, and motivation shape these barriers in the Ethiopia’s broader social and cultural context. Studies also indicate that myths surrounding LARCs [4], concerns about side effects [11,12,13], and religious or cultural opposition [14] can significantly affect women’s attitudes toward these contraceptive methods, particularly in underserved rural and pastoral communities.

To better understand the factors that drive or hinder LARC acceptability and uptake, it is essential to explore these issues through a behavior change framework. The Capability, Opportunity, Motivation, and Behaviour (COM-B)) framework [15] offers a comprehensive lens to examine how individual, community, and systemic factors influence contraceptive decision-making. The framework has also been widely applied in other reviews [16, 17] and primary studies [18, 19] to identify and map barriers and facilitators of health services-related behavioral change. By categorizing determinants into capability (knowledge and skills), opportunity (access and social support), and motivation (attitudes and beliefs), the COM-B framework enables a nuanced understanding of the barriers and facilitators to LARC adoption.

This manuscript presents a systematic review of recent studies on LARC acceptability and utilization among various Ethiopian populations, including immediate postpartum or postabortion women, extended postpartum women, adolescents, nonpostpartum women, and healthcare providers. The review focuses on Ethiopia due to its unique healthcare challenges, socio-economic conditions, and policy environment that are distinct from other low-income settings. Ethiopia’s diverse population, healthcare infrastructure, and specific barriers to accessing sexual and reproductive health services make it a critical context for this study. By focusing on Ethiopia, we can provide targeted insights and recommendations that directly address the needs and opportunities within the country. Within this spectrum, we aim to identify the specific barriers and facilitators within the COM-B framework that influence LARC acceptability and uptake and to provide a summary of findings to inform future reproductive health interventions in Ethiopia.

Methods

Eligibility criteria

Population

The review included studies focusing on diverse groups within Ethiopia, including adolescents, women of reproductive age, healthcare providers, and broader community members. These groups provided insights into varied perspectives and experiences related to LARCs, which are essential for understanding barriers and facilitators across the population.

Condition

Only studies addressing the acceptability and utilization of LARCs were included. This encompassed research examining behavioral determinants affecting LARC use, specifically focusing on long-acting reversible contraceptive methods like implants and intrauterine contraceptive devices (IUCDs).

Outcomes of interest

The review focused on outcomes related to the acceptability and/or utilization of LARC, more specifically the factors influencing these behaviors. Key behavioral determinants considered were facilitators and barriers to LARC use, classified under the COM-B framework categories: capability (knowledge, skills), opportunity (social and physical access), and motivation (attitudes, beliefs).

Study types

All quantitative, qualitative, and mixed-methods studies that provided relevant data were included. This broad approach allowed for a comprehensive analysis of LARC acceptability and utilization, integrating both statistical evidence and in-depth perspectives to better understand the factors influencing these behaviors in Ethiopia.

Information sources

A comprehensive search strategy, aligned with the COM-B framework, was conducted to capture studies examining the capability, opportunity, and motivation factors influencing LARC acceptability and utilization in Ethiopia. Databases searched included PubMed, EM, Scopus, African Journals Online, and EBSCOhost (CINAHL) to ensure coverage of peer-reviewed studies. Additionally, gray literature sources, such as Google Scholar, were explored to gather further insights into social and contextual determinants of LARC use.

Search strategy

Key search terms targeted components of the COM-B framework, including “acceptability,” “utilization,” “intention to use,” “uptake,” “LARCs,” “contraception,” “barriers,” “facilitators,” “associated factors,” “determinants,” and “Ethiopia,” using Boolean operators (AND, OR) for precision. The search was limited to English-language studies published between January 2021 and June 30, 2024. This review period was selected to capture the most recent and relevant data, reflecting the latest developments in healthcare access, policy changes, and healthcare delivery models in Ethiopia. Earlier studies were excluded to ensure the focus remained on current trends and challenges, as older studies may not accurately represent the evolving landscape of healthcare access.

Screening and data extraction process

Following the location of studies from multiple sources, entries were populated into EndNote v.9 for further processing. The screening process involved manually reviewing each study by title, abstract, and full text to ensure relevance to the barriers, facilitators, and factors associated with the acceptability and utilization of LARCs within the COM-B framework. Data extraction was performed using a standardized template to capture key information, including study identification, publication year, design, setting, population, objectives, outcomes, and specific determinants—such as barriers, facilitators, and factors—mapped to the COM-B domains (Capability, Opportunity, Motivation, Behaviour). Extracted themes were further refined into subcategories within the COM-B framework, such as physical capability, social opportunity, and reflective motivation to provide a comprehensive categorization of the findings. Two reviewers (T. S. and Z. S.) conducted the screening and extraction process. If a consensus could not be reached, a third reviewer (G. T.) made the final decision to ensure the integrity and consistency of the coding process. EndNote v.9 was used to manage search results, with duplicates removed manually before proceeding to title and abstract screening.

Quality assessment and reporting

The quality of included studies was assessed based on their design. For observational studies, the Newcastle-Ottawa scale (NOS) was used. Qualitative studies were appraised using the Joanna Briggs Institute (JBI) checklist for qualitative studies [20], and mixed-methods studies were evaluated with the Mixed Methods Appraisal Tool (MMAT). The review was conducted based on a pre-developed and registered protocol, the international prospective register of systematic reviews (PROSPERO: CRD42024594288). Finally, the findings were reported following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA-2020) guidelines [21].

Outcome assessment

The outcomes assessed in this review centered on the acceptability, utilization, and influencing factors (barriers and facilitators) related to long-acting reversible contraceptives (LARC), specifically focusing on implants and intrauterine contraceptive devices (IUCDs) among diverse populations in Ethiopia. The outcomes aimed to identify the barriers and facilitators that impact LARC uptake, which were categorized using the COM-B framework into capacity, opportunity, and motivation domains as well as their respective subcategories.

Data synthesis

Qualitative data synthesis

In this review, thematic synthesis was applied specifically to qualitative data, with an emphasis on identifying barriers, facilitators, and influencing factors related to the acceptability and utilization of long-acting reversible contraceptives (LARC). While there was no formal coder reliability check performed, the coding process involved multiple reviewers to ensure consistency and reduce bias, and any discrepancies were resolved through discussions to enhance the reliability of the findings. Using Atlas.ti v.9, qualitative data were coded and organized according to the COM-B framework (Capability, Opportunity, Motivation, Behaviour), categorizing themes into relevant subdomains, such as physical and psychological capability, social and physical opportunity, and reflective and automatic motivation. As such, effect measures were reported narratively, focusing on key patterns and themes identified through qualitative analysis. Figures and tables were also employed to in depicting thematic and framework synthesis results.

Ethics considerations

This review was based solely on published data, with no primary data collection involving human participants, thereby not requiring ethical approval. Additionally, none of the included studies explicitly disclosed financial or nonfinancial conflicts of interest.

Results

Study screening and selection

The PRISMA flowchart for this review outlines the process of identifying, screening, and selecting studies across multiple databases. A total of 527 records were initially retrieved from databases, including PubMed (148), Embase (253), Scopus (69), and Google Scholar (57), while EBSCOhost (CINAHL) yielded no relevant records. These records were imported into EndNote v.9 for de-duplication and further management. After removing 177 duplicates, 350 records remained for preliminary manual screening. During the title and abstract screening phase, 267 records were excluded, leaving 83 for further evaluation. Among these, 2 records were excluded for not reporting the outcomes of interest, resulting in 81 records sought for retrieval. One record was not retrievable, leaving 80 records for full-text assessment.

After evaluating the full texts, 22 records were excluded for various reasons: being outside the review scope (8), publication in earlier years than specified (9), or misalignment with the study aim (5). Ultimately, 58 studies, represented by 107 reports, were included in the systematic review. This flowchart demonstrates a thorough and systematic process for selecting relevant studies (Figure 1).

Fig. 1

PRISMA flowchart diagram for search results across various databases

Characteristics of included studies

The studies analyzed in this review were conducted between 1 January 2021 and 30 November 2024, primarily utilizing cross-sectional, qualitative, and mixed-method designs to assess the acceptability and utilization of long-acting reversible contraceptives (LARC) in different contexts of Ethiopia. This range of methodologies was considered to capture both quantitative measurements of LARC use and qualitative insights into the barriers and facilitators within different geographies across the country. Most research locations span urban centers [5, 22,23,24,25], including Addis Ababa. The studies also addressed on unique subgroups such as individuals living with HIV/AIDS [26], women with disabilities [27], and residents in pastoral regions [28] or rural areas [12, 27, 29, 30]. The target populations are diverse, encompassing reproductive-aged women—particularly immediate postpartum or post-abortion groups, such as [5, 24, 25, 29, 31] women in the extended postpartum period [14, 32,33,34,35]—as well as adolescents [36, 37] and healthcare providers [38, 39].

Sample sizes in these studies vary widely, from small qualitative studies ranging from 13 to 50 [4, 13, 40] participants to large-scale surveys involving over 14,593 individuals [41], enabling both localized insights and broader national perspectives. Most studies focus on specific LARC methods, particularly implants and intrauterine contraceptive devices (IUCDs), assessing acceptability and utilization rates across different subpopulations. Reported outcomes reveal significant variability; for instance, postpartum IUCD acceptability ranged from 12.5% [5] to 30% [30], and implant utilization among reproductive-aged women averaged approximately 24.7% [37], with notable regional and population-specific differences [42, 43].

Synthesis of findings

Acceptability or intention to use LARCs

Capability

Under capability, both physical and psychological factors play a role. One significant barrier is the lack of awareness and understanding about postpartum intrauterine contraceptive devices (PPIUCDs). Many women are not fully informed about the benefits and safety of these methods, which reduces their psychological capability to make informed choices [5]. Furthermore, misconceptions about contraceptives, including fears of infertility or discomfort, hinder individuals’ ability to make informed decisions about using these methods. [30]. On the other hand, effective counselling and prior discussions with healthcare providers significantly enhance psychological capability by equipping women with the knowledge they need to accept and use LARCs [29].

Opportunity

Opportunity also plays a crucial role in contraceptive acceptability, particularly in terms of both physical and social opportunity. Physically, limited access to healthcare services and contraceptive counselling can hinder LARC adoption, especially during the immediate postpartum period[25]. Women with disabilities and who do not have easy access to health facilities adequate information during antenatal visits are less likely to use these methods [27]. In contrast, women who have consistent access to healthcare services, particularly through antenatal follow-ups or public healthcare facilities, are more likely to accept LARCs [29]. Social factors, such as partner influence, can either facilitate or act as a barrier. Requiring approval from others or disapproval from husbands or mothers-in-law can decrease a woman’s ability to use contraceptives [5, 30]. Additionally, cultural and religious beliefs that oppose contraceptive use further limit social opportunity[12]. However, when women engage in open discussions about family planning with their partners, the likelihood of contraceptive acceptance increases, as partner support becomes a facilitating factor [44].

Motivation

In terms of motivation, both automatic and reflective motivations are crucial in determining LARC utilization. A key automatic barrier, as conceived in terms of motivation or negative perception, is the fear of side effects, such as potential health risks or long-term impacts on fertility, which creates anxiety and reduces the willingness as well as intention to use these methods [5, 12, 30]. Reflective motivation, on the other hand, is influenced by women’s reproductive goals. For instance, women who plan to have more children are less likely to use LARC, viewing these methods as too long term. Additionally, many women express a preference for short-acting contraceptive methods, such as injectables, which leads to the rejection of options like IUDs[5]. However, facilitators of LARC acceptance include factors such as multiparity, where women with more children seek to space or limit future pregnancies [29]. Similarly, women who feel they have completed their family are more motivated to adopt long-term contraceptive methods like LARC [24].

Barriers and facilitators of LARC uptake

Capability

Both physical and psychological capabilities play significant roles in the utilization of LARC. A key barrier under physical capability is the lack of awareness about IUCDs. Many women are not fully informed about these contraceptive methods, leading to decreased utilization [45]. On the other hand, a strong facilitator of LARC utilization is good knowledge about LARC, which women typically gain through counselling sessions. Those with more knowledge are better equipped to make informed choices about using LARC [37]. Education also serves as an important facilitator; women with primary, secondary, or higher levels of education are more likely to utilize LARC because they are more informed about family planning methods [28], while higher income also increases their capability to access methods [42]. Educated women can understand the benefits of LARC more comprehensively, boosting their psychological capability to use them effectively.

Opportunity

When considering opportunity, both physical and social factors contribute to the utilization of LARCs. One significant barrier under physical opportunity is poor access to healthcare services, particularly in regions with long distances to health facilities and a shortage of trained personnel or supplies, such as in Afar and Ethiopian Somali regions [37]. This makes it difficult for women to access or sustain LARC use. However, regular antenatal care (ANC) visits and delivery at health facilities, where counselling services are available, serve as facilitators by increasing access to LARCs [46].

The reviewed studies also indicated that social opportunity plays a crucial role. Partner disapproval and religious prohibitions are major barriers that prevent many women from using LARCs. Social dynamics, particularly the influence of husbands or religious leaders, can discourage women from considering these contraceptive options [14, 45]. Conversely, partner support and discussions about family planning significantly improve the likelihood of LARC utilization. When women engage in open communication with their partners and receive their support, they are more likely to adopt and continue using LARCs [42].

Motivation

Automatic motivation was predominantly shaped by emotions such as fear. Many women expressed concerns about the potential side effects of LARCs, which included fears of infertility, physical discomfort, and long-term health consequences. These fears were exacerbated by misinformation and cultural stigma, leading to reluctance to use LARCs [12, 45]. Additionally, some women were hesitant to use LARCs due to their desire for more children, further reducing adoption rates [47].

Reflective motivation was driven by women’s attitudes and beliefs toward LARCs. Positive attitudes toward LARC, particularly among educated women or those with higher-income levels, contributed to increased usage [28, 42]. However, negative beliefs, often stemming from religious prohibitions or cultural misconceptions, limited the use of LARC, especially in rural communities [14, 48]. Another key factor identified in the current review was women’s desire for pregnancy spacing. Those who wished to space their pregnancies due to history of termination[41] or those who want to avoid future pregnancies were more inclined to use LARCs [46]. This motivation was particularly strong among women who had completed their desired family size and were looking for long-term contraceptive solutions.

Mapping barriers and facilitators on the COM-B framework

As shown in Figure 1, the commonly enumerated barriers and facilitators of LARC acceptability and uptake have been summarized and presented onto the COM-B framework. Accordingly, physical capability barriers include a lack of awareness and misconceptions about methods like IUCDs, along with discomfort during the insertion process. These barriers are countered by facilitators such as counselling sessions during antenatal care, which improve knowledge and reduce fears. Psychological capability barriers involve fears of side effects and infertility, compounded by cultural myths and negative rumors about LARCs. However, facilitators like increased awareness through counselling and media campaigns help reduce these psychological barriers, improving women’s understanding and attitudes toward LARCs. In terms of physical opportunity, barriers such as limited access to healthcare services, lack of provider training, and insufficient information on LARCs hinder uptake. Facilitators in this domain include early service seeking, especially during the first trimester, and availability of midlevel healthcare providers at public sector facilities, which increases access. Further, urban residence has been reported as a facilitator for LARC uptake as compared to living in rural or remote areas. Social opportunity barriers include partner disapproval, religious restrictions, and cultural opposition, while facilitators include discussions with supportive partners and the influence of multiparity, where women with more children are more likely to adopt LARCs. Automatic motivation is influenced by fears of side effects or emotional hesitancy, but positive prior contraceptive experiences may help mitigate these barriers. Finally, reflective motivation barriers such as the desire for more children and preference for short-term contraceptive methods limit LARC uptake, while facilitators like a lower desired number of children and longer-term family planning goals can encourage greater use (Fig. 2).

Fig. 2

COM-B framework-mapped barriers and facilitators of LARC acceptability and uptake in Ethiopia

Summary of barriers and facilitators by method and population

The combined result in Table 1 highlights key barriers and facilitators influencing the acceptability and uptake of long-acting reversible contraceptives (LARCs) across different population groups in Ethiopia. Accordingly, the common barriers include a lack of awareness reported in three studies (n = 3) [45, 49, 50], misconceptions (n = 3) [11, 13, 51], fear of side effects (n = 6) [11, 25, 33, 45, 51, 52], cultural and religious restrictions (n = 6) [4, 14, 47, 48, 50, 53, 54], and limited access to trained providers (n = 3) [40, 55, 56], particularly in rural areas. Specific challenges, such as parental disapproval for adolescents and partner/family opposition for women (n = 6) [11, 33, 45, 50, 52, 57], further hinder LARC utilization. Facilitators focus on provision of counselling (n = 7) [35, 46, 57,58,59,60,61], community-based or peer education (n = 1) [62], and healthcare provider training (n = 1) [63], which improve knowledge and dispel myths. Additional enablers, such as youth-friendly services (n = 1) [64], facility-based LARC availability (n = 1) [65], and discussion with and support from partners or communities (n = 5) [39, 44, 57, 59, 66], enhance both the acceptability and uptake of LARCs. Addressing these barriers through targeted interventions and leveraging facilitators can significantly improve LARC utilization across diverse Ethiopian populations (Table 1).

Table 1 Summary of barriers and facilitators for acceptability and uptake of long-acting reversible contraceptives (LARC) in Ethiopia across population groups

Discussion

This systematic review aimed to examine the multifaceted factors influencing the acceptability and uptake of long-acting reversible contraceptives (LARCs) in Ethiopia, utilizing the COM-B framework. The framework effectively analyzes LARC acceptability and utilization in Ethiopia and is widely applicable to other public health interventions [16, 19]. Although a previous systematic review in 2018 focused on barriers to LARC uptake [10], changes in acceptability and uptake since then remain unclear, along with the evolving changes driving this behavior, necessitating this review. More specifically, the current review provides a more detailed analysis using the COM-B framework, revealing how capability, opportunity, and motivation influence LARC acceptability and utilization. By focusing on population-specific barriers and facilitators among postpartum, post-abortion, nonpostpartum women, adolescents, and healthcare providers, this review offers targeted insights that were not captured in the previous review. Additionally, by incorporating recent evidence (2021–2024) and examining both barriers and enablers, this study highlights tailored strategies to enhance LARC uptake, particularly by leveraging community-based education, youth-friendly services, and partner involvement.

Key findings indicate that individual capability factors, such as knowledge and misconceptions, significantly shape attitudes toward LARCs. Knowledge gaps are pervasive across various population groups, including immediate and extended postpartum women, adolescents, and healthcare providers, often exacerbated by limited access to comprehensive family planning information and counselling. This is in line with other reports which mention misconception and access issues limited uptake of LARCs, especially among young women [67, 68]. While limited knowledge and awareness are frequently cited as key gaps to LARC uptake from the user’s perspective [69], providers also face challenges, particularly due to insufficient skills for inserting methods like IUCDs, an issue even in high-income settings [70]. Myths and fears about potential side effects, such as infertility or physical health changes, are widespread and negatively impact the acceptance of both IUCDs and implants. Misconceptions surrounding LARCs have persisted as a global issue [71], with studies in South Africa showing that myths and misunderstandings similarly hinder the use of modern contraceptives among adolescent girls and young women (AGYW) [72].

In the current review, opportunity challenges—such as limited access to LARC services in rural and pastoral areas—significantly restrict LARC use. Studies from rural Ethiopia highlight disparities in healthcare availability and provider training, with fewer skilled professionals available to counsel on and administer LARCs in these regions [40]. While limited product access is a primary factor, this could often be compounded by reduced media exposure and income limitations in remote communities for covering nonmedical and indirect costs, such as transportation. Furthermore, people in rural areas may lack adequate awareness and positive attitudes toward LARCs, affecting both their acceptance and continuation [13]. Likely, a review that covered the sub-Saharan African countries has reported that mass media exposure and higher income were associated with increased uptake of LARCs and permanent methods [73]. In Nigeria, disparities in LARC utilization were observed between urban and rural areas, with implants being more popular in rural settings and IUCDs more commonly used in urban areas [74]. Social factors, including partner disapproval and cultural or religious beliefs, further shape LARC acceptability; qualitative findings from western Ethiopia reveal that religious and cultural norms strongly deter the use of modern contraceptives [75]. Misconceptions, particularly about IUCDs, are prevalent throughout Ethiopia [4, 40, 76]. On the other hand, opportunity-related facilitators, such as community-based education and supportive healthcare settings, have a positive influence on attitudes and LARC uptake. According to earlier interventions implemented in Ethiopia [77] and Malawi [78], women with involvement and support of men were more likely to use family planning methods. A study in Kenya has also reported on the presence of strong misconceptions linked to both social and biological myths surrounding contraceptives highlighting that awareness and knowledge gaps in SRH literacy, especially among the young population [79].

Motivational factors such as personal beliefs, fertility intentions, and partner support significantly influence women’s decisions to adopt LARCs. Women who intend to limit or space their births are more likely to use LARCs, especially when supported by family or partners. A study in Malawi found that women with more children and partner approval were more likely to use LARCs [80]. Another report indicated that women’s motivations for choosing LARCs vary depending on whether they wish to postpone, delay decision-making about, or permanently stop childbirth [81].

The complex range of factors that drive women’s contraceptive choices is captured in theoretical models [16, 82], including the COM-B framework. A major strength of this review is its comprehensive scope, incorporating studies from various Ethiopian regions and population groups, including adolescents, nonpostpartum women, immediate and extended postpartum and post-abortion women, and healthcare providers. By applying the COM-B framework, the study provides an in-depth analysis of how different factors interact to influence LARC acceptability and utilization, offering a structured approach to inform future interventions. However, this review has limitations inherent, mainly, to the included studies and the methodology considered. Certain population subgroups, such as rural residents and women with specific health conditions, may be underrepresented due to the limited availability of relevant studies. While bringing in many useful aspects, the COM-B model is characterized by broader focuses on individual behavior change and may not fully capture the extended structural and systemic factors influencing contraceptive decisions, such as healthcare infrastructure, policy environments, and socio-economic inequalities. In addition, the framework’s categories—capability, opportunity, and motivation—may overlap in complex cultural contexts, making it challenging to distinguish between certain aspects, especially of capability and opportunity. Even though discussions and consensuses have been sought during the synthesis of qualitative studies, no formal coder-reliability checks were performed that might affect the reliability of findings. Additionally, the review process may have been influenced by language, selection, and publication biases, as it only included studies published in English and those accessible through selected databases. However, there is no non-English language publication in Ethiopia known to the reviewers. These factors could affect the comprehensiveness and generalizability of the findings.

Conclusion

This systematic review has contributed to an updated understanding of the barriers and facilitators of LARCs uptake in a resource-limited and diverse sociocultural context. The results reveal that the acceptability and uptake of LARCs in Ethiopia are shaped by complex and intersecting factors across the COM-B domains of capability, opportunity, and motivation. Knowledge gaps, accessibility issues, and sociocultural beliefs are prominent barriers, particularly in rural and pastoral areas. Conversely, community education, comprehensive counselling, and supportive family and partner involvement facilitate LARC adoption. To improve LARC acceptability and uptake across the country, all concerned health authorities, including the ministry of health and its agencies, would reconsider expanding community-based education and culturally sensitive counselling to dispel myths and increase knowledge. Enhanced training for healthcare providers, especially in rural areas, will improve IUCD and implant delivery and counselling. Greater LARC access in developing regions of the country, through mobile clinics or community health initiatives, can reduce logistical barriers. Encouraging partner and family involvement in family planning programs will support LARC acceptance, while policy support should ensure sustainable access and integration of LARCs into Ethiopia’s reproductive health strategy. In a nutshell, these findings reveal the need for comprehensive interventions that address educational, logistical, and sociocultural barriers to enhance LARC uptake in Ethiopia.