Contraceptive Method Mix Utilization and its Associated Factors among Married Women in Gedeo Zone, Southern Nations, Nationality and People Region-Ethiopia: A Community based Cross Sectional Study

The family planning method is unique in its range of potential benefits, encompassing economic development, maternal and child health, educational advances, and women’s empowerment. It is crucial for couples, as they allow them to exercise their reproductive right to control their fertility and to make decisions about whether, when and how often to become pregnant [1].

Worldwide, 170 million women have no access to safe and effective methods of contraceptive in developing countries. As a result, one third of population growth is due to unplanned pregnancies. Of 210 million pregnancies occurring each year, nearly 80 million are unintended and about 39% found in Africa. For every 100,000 births, 640 women die due to related complications of pregnancy and childbirth in Africa [2,3]. In Ethiopia, the levels of maternal mortality and morbidity are among the highest in the world and account for 30% of all deaths. Maternal mortality ratio (MMR) is 676 per 100,000 women aged 15-49. Unsafe abortion was estimated to account for 32% of all maternal deaths [4-6].

The history of family planning in Ethiopia started in the 1960s. In different times Ethiopia faced challenges in terms of providing better access to family planning [7]. Now a day Ethiopia is one of the most notable family planning success stories in sub Sahara Africa. In the last fifteen years from 2000 to 2014, there is a fivefold increase in the use of contraceptive methods by married women, from 8 percent in 2000 to 42 percent in 2014. Contraceptive prevalence among married women increased by 46% in the last three years, from 29 percent in 2011 to 42 percent in 2014. Though there has been an increase in contraceptive use in the country, it greatly varies regionally and urban-rural. Southern nations and nationality people region (SNNPR), is one of the regions with a high fertility rate in the country, with a TFR of 5.6. Contraceptive prevalence rate and unmet need in the region were relatively high with 34% and 37.4%, respectively [4,8-10].

The prevalence of modern contraceptive use among married women has increased from 13.9% in 2005 to 40.4% in 2014 while from 11.4% to 38.6% in SNNPR respectively [10]. The contraceptive method mix, utilization is dominated by short term methods like pills and injectable [4,11-15]. The share of injectable was rising over the last decade from 37.5% in 2000 to 67.2% in 2005 and in 2011 to 72.6%. But the share of the implant to the total contraceptive use was very low at 0.5% in 2000, 1.2% in 2005 and 3.4% in 2011. Although the overall use of implants continues to be low, its use has increased in the last 10 years from less than one percent (0.2 percent) in 2005 to 5 percent in 2014. In the 2011, utilization of IUCD was still low which accounts 2.1%. In the same manner the prevalence of long acting methods (LAPMs) in the SNNPRS was very low which accounts for 2.9% of implant, 1.4% for intrauterine contraceptive device (IUCD) and 0.5% for female sterilization [4,10]. Similar data observed in the selected countries in sub-Saharan Africa, short-acting methods, particularly injectables, are the most commonly used methods, and LAPMs generally constitute a small fraction of the method mix [11-15].

Even though family planning has been the central issue in reproductive health programs, fertility has been decline slow in Ethiopia. Accordingly 2014 EDHS report TFR decreased only slightly from 5.5 children in 2000 to 5.4 children in 2005, with a more pronounced decline to 4.8 children in 2011. This trend continues between 2011 and 2014 with fertility declining by 0.7 children per women. There are substantial differentials in the TFR among the regions, ranging from 1.7 children per woman in Addis Ababa to 7.3 children per woman in Somali-Ethiopia. Fertility levels are higher than the national average in Somali, Affar, Benishangul-Gumuz, Gambela, Tigray and SNNPRS [4,9,10,16].

The Ethiopian Ministry of health has planned to increase the contraceptive utilization to 66% by 2015 from baseline of 32% of women in the union and is working on the provision of all FP methods [17]. Concerning family planning policy at national level, six priority areas were identified as Ethiopia´s Reproductive Health Strategy (2006-2015), among them fertility and family planning [18]. Besides, this demand for various contraceptive uses is also an important question in dealing with the accessibility to contraceptive methods mix [19]. Since many countries rely on “short-term” contraceptive methods that can be discontinued at any time, this has an implication for rural people who are far from access to family planning, to the respect of their choice and to the way they can be reached [20,21].

Moreover, available data in Ethiopia indicate that the discontinuation rate of short term contraceptive was higher than long acting and permanent contraceptive methods (LAPMs). Thus, such discontinuation rate of short term contraceptive methods was inefficient and expensive to the family planning program and resulted unintended pregnancies [4,22]. Contraceptives vary widely in their effectiveness; short-acting methods having lower rates of effectiveness during typical use than long-acting or permanent methods. Yet family planning users who would prefer to stop childbearing were more likely to use short-acting or traditional methods than the more effective LAPMs [15].

In a country with rapidly increasing acceptance of contraception [10] and local area assessments of contraception may be useful in improving policies, programs and services. Assessing the magnitude of contraceptive method mix, utilization and factors affecting contraceptive use is essential to evaluate the success and identify barriers to further promoting contraceptive use. It is, therefore, essential to examine the contraceptive method mix, the magnitude of contraceptive use and identify the factors affecting contraceptive use in the study area, Gedeo Zone, which will have greater input for evaluating their progress and further promote contraceptive use.

A community based cross sectional study was conducted in Gedeo Zone, which is located about 365 Kms to the south of Addis Ababa, the capital city of Ethiopia, and 85 Kms to Awassa the regional capital city of SNNPRS. The total population of the zone according to the 2007 census report was 1,694,868, of which 845,384 were females in all age groups.

Samples of 1056 currently married women aged 15-49 years were included in the study. The sample size was calculated by using tow population proportion formula. The sampling procedure was multistage stratified cluster sampling technique with probability proportional allocation (PPA). Initially, the zone was stratified into two strata: urban and rural weredas. Five sample woredas were selected using simple random sampling methods from urban and rural weredas. Two kebeles from each woreda were selected randomly and again two sub kebele were selected randomly from each kebele and all households in sub kebele were interviewed. If there are more than one eligible married woman in one household, one was selected randomly by using a lottery method during data collection time; however, if we couldn’t find any eligible married women in a household, we shift to the next immediate household to the right of the index household.

The questionnaire was adopted and developed with modification from related studies [4,11-13]. A questionnaire was pre-tested on similar setting by using 5% of sample size and appropriate modification was made to have the final version. Ten diploma nurses who had the experience of data collection were collected the data through face-to-face interview. Four master holder health professionals were supervised the data collection process in each day. The interview was conducted in a place where the woman feels free to express her feelings and ideas. Filled questionnaires were checked daily for completeness, legibility and consistency.

Cleaned data were analyzed by Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics were computed and presented in the form of texts and tables. A binary outcome variable indicating no use of contraceptive as “0” and use of contraceptive coded as “1” was used as the dependent variable. Bivariate analysis was used to determine the association between different factors and the outcome variable. Multivariable logistic regression was used to identify the relative importance of each predictor to the dependent variable by controlling for the effects of other variables. Those variables which were significant on bivariate analysis (P-value <0.05) were entered to multivariable logistic regression analysis. The association between dependent and independent variables was determined using odds ratio (OR) with 95% confidence interval (CI). The level of significance was taken at α=0.05.

Ethical clearance was obtained from Research and Ethics Committee of College of Health Sciences and Medicine of Dilla University. Written permission letter was also obtained from Gedeo Zone Health department and from the respective woreda health office. Oral informed consent was obtained from the study participants. Confidentiality of the participants was kept throughout the study.

Socio-demographic characteristics of the respondents

A total of 1056 married women in the reproductive age were interviewed. The mean age of the respondent was 28.44 (±6.1 SD) years. Most of the respondents, 368 (34.8%) were in the age group 25-29 years. The majority of the participants were Gedeo 460 (43.8%) by ethnicity and protestant 518 (49.1%) by religion. The majority respondents 430 (40.7) were attended primary school. More than half of the participants, 587 (55.6%) were housewives by occupation. The median monthly income of the respondent was 700 ETB with the range of 150 to 8000 ETB (Table 1).

Table 1: Socio-demographic variables of married women in reproductive age in Gedeo Zone, South Ethiopia, 2015 (N=1056).

Reproductive history of the participants

The mean age of first marriage was 19 (±3.3 SD) years, respectively. Most of the respondents 534 (50.6%) were less than nine years after getting their marriage. Of the total respondents, 517 (49.0%) of the women had less than two children, whereas 270 (25.6%) of women had above five children. Around 531 (50.3%) women were desire one up to four children in their whole life. Among the total participants, 265 (25.1%) of a woman’s husband were desire above seven children. Of the total respondents, 206 (19.5%) encountered at least one child death (Table 2).

Table 2: Reproductive health characteristics of married women in reproductive in Gedeo Zone, South Ethiopia, 2015 (n=1056).

Comprehensive knowledge of contraceptive methods and method mix

Among 1056 respondents, 1022 (96.8%) ever heard about any contraceptive methods. The most heard contraceptive methods is injectable 993 (26.2%) followed by pill 899 (23.7%). Regarding contraceptives importance 980 (92.8%) heard about contraceptive importance; to avoid pregnancy, to limit number of birth, to space child were 45.8%, 35.8% and 18.4% respectively. Among 1056 respondents, 461 (43.7%) ever heard about the side effect of FP. The most frequently mention the side effect were irregular ministration 193 (39.5%) and gaining of weight 103 (21.1%) (Table 3). Generally, 692 (66.8%) of women were knowledgeable about contraceptive methods, whereas 344 (33.2%) of women were less knowledgeable about contraceptive methods.

Table 3: Knowledge of married women on contraceptive method in Gedeo Zone, South Ethiopia, 2015 (N=1128).*Each of the percentages does not add up to 100.0 because respondents could choose several responses which could be spontaneous or prompted.

Contraceptive method mix, utilization

The current contraceptive prevalence was 734 (69.5%). The most preferred method among short term contraceptive method was injectable 433 (57.0%) followed by pills 62 (8.2%), whereas among long acting and permanent contraceptive methods (LAPMs), implanon 201 (26.1%) was a highly used method followed by IUCD which accounts 50 (6.6%). None of the participants had reported vasectomy and tubal ligatio or permanent methods. One hundred sixty two (15.3%) of the participants has ever been used at least one of the methods of contraception.

Among the current users, the majority of the respondents, 495 (67.4%) were deciding to use a contraceptive method with jointly. Yet about 206 (28.1%) women were reported that they decided to use a contraceptive method independently. Involving men and obtaining their support and commitment to family planning is of crucial for family planning service utilization. From the total current users, 562 (76.6%) of women get support from her husband to use or not use family planning methods. Among the total ever and non-user respondents, 119 (37.0%) of the study participants were no intention to practice family planning method in the future (Table 4).

Table 4: Contraceptive method mix, utilization among married women in the reproductive age group in Gedeo Zone, South Ethiopia, 2015 (n=1056).*Each of the percentages does not add up to 100.0 because respondents could choose several responses which could be spontaneous or prompted.

Factors associated with contraceptive method utilization

Those variables which were significant in bivariate analysis (P-value ≤0.05) were entered in multiple logistic regression analysis to examine the effect of an independent variable to contraceptive use, while controlling other independent variables. The result of multiple logistic regressions revealed that participant’s residence, participants’ education, number of a live children women’s desire to have a child, knowledge on contraceptive methods and women attitude toward contraceptive method were found significantly associated with contraceptive use (Table 3).

Urban women were more likely to use a contraceptive method than the rural women (AOR 2.23, 95% C. I=1.55, 3.21). Women who had attended secondary education had higher odds of contraceptive use (AOR 1.51, 95% C. I=1.02, 2.31) compared to those who had no attended school. Married women who have more than five children were two times more likely to use a contraceptive method as compared to those who have fewer children (AOR 2.29, 95% C. I=1.33, 3.93). In the same manner women who have two up to four children were more likely to use a contraceptive method as compared to those who have fewer children (AOR 1.57, 95% C. I=1.04, 2.37). Women who desire to have four up to six children had higher odds of contraceptive use (AOR 1.69, 95% C. I=1.04, 2.76) as compared to those who desire to have greater than seven child’s.

Women who were knowledgeable about the overall aspects of contraceptive methods were more likely to use contraceptive to their counterparts (AOR 1.36, 95% C. I=1.02, 1.89). In the same manner, women who had positive attitudes towards contraceptive methods were more likely to use contraceptive methods (AOR 5.74, 95% C. I=4.10, 8.07) (Table 5).

Table 5: Multivariate analyses of selected factors affecting contraceptive use among married women, in Gedeo Zone, South Ethiopia, 2015 (n=1056).

This study assessed the utilization of a contraceptive method mix, the magnitude of contraceptive use and identifies the factors associated with contraceptive use in Gedeo Zone. Current contraceptive use among the study subjects was 395 (74.8%) among urban and 339 (64.2%) among rural women. Urban women were two times more likely to use contraceptive methods [OR 2.23, 95% CI (1.55, 3.21)] compared with rural women. The overall current prevalence of contraception was 734 (69.5%). This current contraceptive practice was comparably higher than the national average for Ethiopia and SNNPR in 2014 report (42% Vs 38.6% respectively) (3). This finding was also comparable to the study conducted in Butajira District (25.4%), Debre Birhan District (46.9%), Gonder zones (48%) and abroad in Khartoum (51.4%) [11,23]. This may be attributed to the health extension program in the area. And also could be attributed to the expanding health service coverage in the area

In this current study the method mix was dominated by short term contraceptives. Most of the study participants were using injectable 433 (57.0%) and pills 62 (8.2%). These findings were consistent with the national and SNNPR in 2011 and 2014 EDHS report and study conducted in different studies in Ethiopia [4,11-14]. This might be due to the availability or acceptability of this method by the community. Thus, this finding suggests that women’s contraception needs change during the course of their life [24,25]. It is therefore healthcare professionals need to inform their patients or users about the benefits and risks of all available contraceptives. This may prompt women to reconsider their original choice, potentially selecting a method which best suits their medical and lifestyle needs. In addition to this community-based strategies should be used to expand male involvement in family planning as the societal factors play a great role in men´s fertility behavior too [26].

In this study the most preferred method among long acting and permanent contraceptive methods (LAPMs), was implant, 201 (26.1%) and IUCD 50 (6.6%). Similar study findings demonstrated in a study conducted in the Debre Birhan District [11], in Mekelle town [12], and in the 2011 EDHS report, utilization of LAPM was very low [4]. This indicates that the FP providers need to assess the reproductive intention of the women and inform them. Meeting women’s reproductive intentions in the context of informed choice enables them to achieve their desire of choice and address misconceptions and fears that exist about LAPMs [15]. Facilitating the ability of women and couples to make informed choices about the number, timing, and spacing of their births supports a fundamental human right that must always be at the core of family planning programs [27]. Whether women use a family planning method often depends on the fit between their fertility preferences and the choices available. So making more contraceptive options available in a program’s method mix helps to ensure informed choice.

In this current study, women who were knowledgeable on contraceptive methods were more likely to use contraceptive to their counterparts. Similarly, women who had a favorable attitude towards contraceptive methods were more likely to use contraceptive methods. This may be knowledge about contraceptive method is found to be high in the study settings with 1022 (96.8%) respondents have heard and can mention at least one method. Overall, (66.8%) of women were knowledgeable about contraceptive methods, whereas 344 (33.2%) of women were less knowledgeable about contraceptive methods.

In the current study, those women who had attended secondary education had higher odds of contraceptive use as compared to those who had no attended school. This finding was also obtained in the study conducted Ethiopia [12,13] and a broad study in the Nkwanta District of Ghana [28]. Increasing education might help the discussion on contraceptive and would increase knowledge and utilization of FP methods. Literature also states that intervention needs to be implemented through educational and motivational strategy [29]. Married women who have more than five children were two times more likely to use a contraceptive method as compared to those who had fewer children. Women who have two up to four children were more likely to use a contraceptive method as compared to those who have fewer children. In this study, women who desire to have four up to six children had higher odds of contraceptive use as compared to those who desire to have greater than seven children. Women’s internal motivations to achieve their goal could be the possible reason for higher level of contraceptive use.

The impact of gender norms and socio-cultural factors were not assessed in detail in this study. More research should be done to identify how gender myths and misconceptions and specific roles and power inequalities can function as a barrier to family planning as well as on how individuals and couples deal with strong cultural norms to adopt family planning strategies. In addition, further investigation of intention and the discontinuation rate of the methods, providers experience and skills of providing all choices especially long acting reversible contraceptives need to be conducted.

Based on the findings of the research; the magnitude of contraceptive utilization in the study area is comparable with the other studies. But the contraceptive method mix is highly dominated by short term contraceptives. The poor contraceptive method mix in the study area as well as country is an area of concern, as this affects contraceptive effectiveness; and requires proper programmatic considerations. The main reasons for the poor method mix in the country are not well understood, but several factors can play their parts. Resistance to adopting some of the long acting and permanent methods by women due to misconceptions and fear of side effects, health workers biases to certain methods and absence of a range of methods in health facilities were implicated among the obstacles to achieving a balanced method mix in the family planning literature. Create acceptance and demand for family planning methods, especially long-term and permanent methods, without compromising safety or quality of care. The program should continue to devise ways to encourage women to adopt the most effective method that meets their personal requirements based on their fertility desires and health situation. Considering that, promoting better and more spousal communication on family planning should constitute an important pillar in any family planning program ultimately leading to fully share of decision-making process on the use of method mix. Hence, empowering women to speak about family planning with their husband helps to enhance their decision-making power regarding contraceptive use within the couple. We therefore believe that a good family planning, intervention should include both men and women, as it helps to develop a positive attitude towards family planning and spousal communication. Family planning interventions will aim at investigating behavioural change.

We acknowledge Dilla University that covered all the financial and material support for the research. We also acknowledge Gedeo zone Administrator, Gedeo zone health department and Dilla referral hospital Administrative for providing us important materials. Lastly, we thank all participants for devoting their time to take part in this study.