Modern contraceptive use among married women: the case of Aleta Chuko district, Southern Ethiopia

INTRODUCTION

Family planning (FP) is defined as a voluntary and informed decision by an individual or couple on the number of children to have and when to have them. And FP is achieved mainly through use of various contraceptive methods and treatment of involuntary infertility.¹

Globally, use of modern contraceptives (MCs) has risen slightly, from 54% in 1990 to 57.4% in 2014. Regionally, the proportion of women aged 15-49 reporting use of a modern contraceptive method has raised minimally between 2008 and 2014. In Africa it went from 23.6% to 27.6%, in Asia it raised slightly from 60.9% to 61.6%, and in Latin America and the Caribbean it rose slightly from 66.7% to 67.0%.¹ The above reality shows that contraceptive use continued to be low in Sub-Saharan Africa.

According to Ethiopian Demographic and Health Survey (EDHS) 2016, overall, 36 percent of currently married women are using a method of family planning: 35 percent are using a modern method. Additionally 22 percent of currently married women have an unmet need for family planning services. The contraceptive prevalence rate (CPR) for MC methods among currently married women in SNNPR was 39.6%.²

Low MC utilization highly contributes to high maternal and child mortality by increasing unwanted pregnancies, maternal and child morbidity. Spacing children can reduce mortality among the under-fives by 10% and among pregnant mothers by 32%. Providing unrestricted access to contraceptives will help ensure a reduction in unwanted pregnancies and thereby contribute to increased female education, women’s empowerment, poverty reduction, and even environmental sustainability. It empowers women living in poverty through enabling them to have fewer children and reduces competition for available resources at the household.^3,4

As contraceptive is women’s choice and practice is a key element of quality care in FP service program, knowing utilization status and factors affecting utilization of MC methods is a crucial one.⁵ In the current study we examined the utilization of modern contraception among married women in Aleta Chuko district, Southern Ethiopia.

METHODS

Study setting

The study was conducted in Aleta Chuko district, Southern Ethiopia. The district is located at 338 km South of Addis Ababa, capital city of Ethiopia and 63kms South of Hawassa city which is the capital of SNNPR.

Study design and sampling approach

A community based cross- sectional study was conducted from February 15 to March 15, 2016. A qualitative study was conducted after the completion of the quantitative data collection.

According to 2014 EDHS,⁶ the prevalence of utilization of MCs among currently married women in SNNPR was 38.6%. Where; Z=1.96 (Z score corresponding to 95% CI), p=0.386 (prevalence of use of MCs), 1-p=0.614 and d= 0.05 (margin of error (5%). So the sample size for the study was 364 married women living in Aleta Chuko district.

The participants recruited into the study were married women who are 18 - 49 years, willing to participate and who gave consent. Due to hetroginiosity between the urban and rural kebeles (smallest administrative unit), multistage cluster sampling procedure was employed for the quantitative study and purposive sampling technique was utilized for qualitative approach. The district was primarily staged according to the 5 urban kebele administarations and 26 rural kebele administrations in the woreda. Out of the five urban kebeles, two kebeles and out of 26 rural kebeles, four kebeles were randomly selected the sample was allocated proportionally. Simple random sampling method was employed to select the households from each kebele using the list of number of households.

Data collection procedures and study variables

Structured questionnaire was used to collect data. The questionnaire was first prepared in English and then it was translated in to Amharic. The questioner was developed based on the standard, demographic and health survey (DHS) survey questioners. To maintain the quality of data to be collected, interviewers and supervisors were trained for two days. Pre test was carried out on 5% of the sample who were included in the study in a kebele which was not selected for the study.

Discussions focused on the factors influencing MC utilization were carried out among groups. A total of 4 focus group discussions (FGDs) were carried out. Two FGDs contain 8-12 currently married women and the other two FGDs contain 8-12 married men. A key informant interview was employed, to gather in depth data related to MC use. Health workers, health extension workers (HEWs) and women health development army (WHDA) leaders were included as a key informant. A total of 10 key informant participants were interviewed.

Data management and analysis

Data entry, cleaning and analysis was done using SPSS version 20. The associations between the dependent variable and independent variables were tested using odds ratio, and 95% CI. The relative contribution of each of the selected variables to the outcome of interest was assessed using binary multiple logistic regression. The qualitative data was translated and transcribed to English and categorized accordingly to main thematic areas manually. The findings were presented in narratives in triangulation with the quantitative results using the well said verbatim as illustrations.

RESULTS

Socio-demographic characteristics

A total of 364 married women aged 18-49 years were interviewed. Most of the study participants (33.5%) were between the age of 25-29 and 23.4% were youths (less than 24 years of age) and additionally 6% of the participants are adults above the age of 40, with the mean age of 28.68. Almost all (98.4%) of the participants were followers of Protestant religion and again majority of them (96.4%) are Sidama by ethnicity.

Most of the respondents (84.6%) have ever attended school. Regarding occupation, majority of the study subjects were house wives (84.7%). Additionally majority of the husbands (64%) were farmers.

Regarding income generation by the respondents, 69.2% of the respondents do not generate their own income. The most used source of information is Radio. But 33.8% of the respondents do not have any source of information at household level.

Among the study participants 68.4% of the respondents have attended primary education and 16.2% of them attended secondary and above and 15.4% of the respondents do not have formal education. Regarding the educational level of the husbands most of them (53.3%) have attended primary education followed by secondary education and above (38.4%).

Reproductive characteristics

Regarding their age at first marriage 75.8% of the study subjects responded age greater than 18 years and the remaining 24.2 % are married before the age of 18 with mean age of 18.83 and with minimum and maximum age at first marriage of 14 and 30 respectively. Most of the respondents (97.3%) were ever pregnant. And in the most of the respondents (58.8%) their first pregnancy took place between the age of 18 and 20. Sixteen percent of the respondents had their first pregnancy before the age of 18. The mean age at first pregnancy was 19.39 years with a standard deviation of 2.331 years. The minimum age at the first pregnancy was 15 years.

Regarding pregnancy history of the respondents 38.7% of the study subjects were 1-2 times pregnant, 33.1% were 3-4 times pregnant and 28.2% of the respondents were pregnant more than 5 times. Among those who have history of pregnancy 10.2% of them had history of unwanted pregnancy and 16.1% of them had history of abortion.

Above 39% of the study participants have given birth to 1-2 children and 35.6% of them have given birth for 3-4 children and the remaining 25.7% have given birth to more than four children. Forty of the participants have 1-2 live children and the majority of them (69.2%) and 64.4% of them have 1-2 male and female children respectively.

Majority of the study participants (58.8%) had their first pregnancy between the ages of 18 and 20. Similarly majority of them (56.5%) gave birth for their first child between the ages of 18 and 20. About 16.4% and 9.1% of the study participants got pregnant and had their first birth respectively before the age of 18 years.

Knowledge of modern contraceptives

Looking at the knowledge of the exact period to get pregnant 47.5% responded that pregnancy happens right after the menstrual period has ended and 30.2% believe pregnancy happens during the menstrual period.

All of the study subjects have ever heard of contraceptives. Most of the study subjects (91.2%) got information about MCs from health facility. Most of the study participants (99.4%) and (90.6%) know the injectable contraceptives and pills respectively. Additionally 78.2% of the study participants know the implants. Regarding the sources of MCs known by the study participants 99.4% and 95% of the study participants responded health posts and health centers respectively. The composite score of knowledge of MCs is that most of the study participants (97%) have good knowledge and the remaining 3% have poor knowledge.

Attitude about MCs

Attitude towards MCs were assessed using a five scale Likert type scale by reading positive and negative standard statements about MCs. Ninety percent of the study subjects disagreed with the statement 'contraceptive use may cause infertility in a women'. When two tailed one sample t test was computed, study participants were significantly against this statement. The second statement was 'children will have better opportunities for education if their parents practice modern contraception' and the study participants significantly agreed with this statement.

Almost all of the study participants (98.6%) agree with the statement which says 'family planning helps couples to become responsible parents' and the two tailed t test also showed that study participants significantly agreed with this statement. While a statement which says 'contraceptive use will improve one's standard of living' was read for them 98.3% of the study participants agree with the statement and this harmony was statistically significant. The other statement says 'having a large family strengthens couple's relationship' and 93% of the study subjects rejected this statement. Two tailed one sample t test was computed for this statement and study participants significantly disagreed with this statement.

Attitude toward MCs were also reflected during most of the FGDs. One of participants expressed her idea by saying: ‘Sometimes husbands oppose wife's use of contraceptive because they think she does not want to give birth and instead she has an intention to go for another man’’ (Female, 31 years). Another female focus group discussant from Rufo waeno said: “We don’t have to use contraceptives because we are very young, once we have 5 to 6 children then only we will think of it.” On the other hand one of the male focus group discussant said:‘‘Couples should limit their number of kids for the seek of child’s health and for the household economy’’ (Male, 25years). Computing the attitude of study participants towards MCs 10.7 % of the study participants have negative attitude towards MCs and the remaining 89.3 % have positive attitude (Table 1).

Practice of MCs

The CPR among currently married women in Aleta Chuko district was 45.5% (95% CI: 39.9-50%). When asked about their reason for the use, majority of the study participants (82.5%) use it for birth spacing and the remaining use for limiting of birth. Those who do not use were asked for their reason for non use and 46.7% of them do not use modern contraceptive because their partner disapproves it while 22.6% do not use because they need additional children.

These findings matched with the results of FGDs. A 35 years old male from Loko Hytala kebele said, “People do not use family planning mainly because they do not know how, when and what to use,” whereas a female from the same kebele said that “People don’t use contraceptive methods because of fear of side effects; a woman I know got herself injected, and for a whole month she bled and became weak as a result.” Another female FGD participant also said that “People talk that, to those girls who haven’t yet given their first birth, if they use contraceptives, they are exposing themselves to the risk of being infertile”. Regarding the types of contraceptives used among the study subjects, most of the contraceptive users (66%) use the injectable hormonal contraceptives, 15.8% use Implants, 9.7% use Pills and 7.3% use IUCDs (Figure 1).

*Recoded responses. SD=Strongly Disagree; D= Disagree; N= Neutral; A= Agree; SA= Strongly Agree.

Spousal factors

The study participants were asked about who they feel comfortable talking about contraceptives and 39.9% of them responded health care providers, 35.8% responded friends. Among all study participants 203 (55.8%) discuss about contraceptives with their husband.

In half of the study participants (52.2%) their husband approves the use of contraceptives. Non users were asked about who would make the decision whenever they want to use contraceptives in the future and the majority of the participants (79.9%) responded that the decision would be made by their husbands and only 13.1 of the respondents said the decision would be made jointly. Regarding decision at household level about the number of children, in the majority of the households (73.9%) the decisions are made by husbands, in 82 (22.5%) of the households the decisions are made jointly (Figure 2).

The finding from the quantitative study is also supported by the findings of the FGDs. One of male participant said: “Men should be the ultimate deciders on contraceptive use. If the neighbours hear that the women is using contraception without the approval of her husband, he will be seen as week in the community, therefore she must follow his decision” (Male FGD participant).

However, when the study participants were asked about who should decide on the number of children the family should have, most of them (85.2%) believe the decision should be a joint decision.

Majority of women FGD participants reported partner disapproval and verbal or physical abuse if the man discovered that the woman used contraceptives. The women also said that discussions about contraception were considered unacceptable, and often rejected by the partner. Young married women reported severe conflict with the husband in relation to contraceptive use.

“One of my friends was using injectable contraception without approval of her husband but started bleeding severely and had to tell him to get help to go to the health center. This caused serious problems for her since her husband wanted more children” (FGD Married woman, 20-24 years). On the contrary one of the male focus group discussion participants explained his idea as 'Women also oppose contraceptive use and react negatively when men raise contraceptive issues, contending that women fear the risk of not having children following use of contraceptives' (A 30 years old male).

Health care system related factors

One hundred seven (65.2%) of modern contraceptive users got the method they are currently using from Health Center and 33.5% used from Health Posts. On the other hand those who have ever used contraceptives have been asked for the availability of the services and methods they want whenever they go to the facility, and the majority of them (84.1%) responded yes. The distance of the service units were assessed by asking the time it takes to reach the health facility. In the majority (63.9%) of the respondents it takes 15-30 minutes and in 14.7% of the respondents it takes greater 30 minutes.

It is obvious that distance of the services affects contraceptive use. The following quote from one of the FGD participants can be an evidence; “Sometimes a woman may want to use the modern contraceptives secretly especially for those whom their husbands or partners do not approve their use, but we fail to obtain the service as it can only be accessed in a distance of 7km from here which is far” (FGD participant from Loko Hytala kebele).

Two hundred twelve (64.8%) of the contraceptive ever users got the services with a weighting time less than 15 minutes, 106 (32.4%) got services within 15-30 minutes and 9 (2.8%) said it takes more than 30 minutes to get the services. Regarding the sex of the service provider they prefer, 157 (48%) of the study participants prefer female service providers, 158 (48.3%) have no sex preference. Finally current contraceptive users were asked if they were ever being informed about the benefits and risks of the contraceptive they are using and 227 (69.4%) responded yes, but the remaining 30% of contraceptive users were never told about the risk associated with the method they are using.

This finding was supported by a finding from an FGD as a young women from Rufo waeno, kebele said "There is nothing explained to us, it's just go through, they look at the appointment card and if it's an injection they will inject you. The nurses always look busy and we are afraid to ask questions."

Finally when we come to the findings of key informant interviews, health professionals and health extension workers were interviewed in order to provide an insight of contraceptive utilization, availability of methods and what should be done to improve utilization. Majority of service providers said that, availability of contraceptive methods is not a problem although enough stocks and some specific methods like injectable should be made. Majority of service providers were of the opinion that delivery of FP education should be strengthened, including in rural areas in order to increase utilization of contraceptive methods.

Most of service providers mentioned that, partner disapproval and sometimes unavailability of contraceptive methods as challenges that hinders utilization. This information from the key informant interviews complements the results from other study participants on factors that influence utilization of contraceptive methods.

*p<0.05.

Results of multiple logistic regression analysis

Those independent variables that had p-value less than 0.25 during bivariate analysis were further taken to multiple variable analyses. Accordingly, five variables were found to be significantly associated with MC use.

Participants who live in the urban areas are 24 time more likely to use modern contraceptives as compared to those who live in the rural kebeles, adjusted odds ratio (AOR), 95%, confidence interval (CI)=24.51, 3.25, 184.54. While looking at the educational level of the participants, those who had primary education are 3 times more likely to use modern contraceptives as compared to those who had no formal education (AOR, 95% CI= 3.1,1.07, 9.03) and those who had secondary and above education had 9 times increased chance (AOR, 95% CI= 9.1, 1.68, 49.25). Those who discuss about contaceptives with their husbands had 42 times increased chance of usage (AOR, 95% CI=42.1, 17.2, 102.9). Participants whose partners approve MC use were 3.7 times more likely to use modern contraceptives as compared to those whose partners disapprove (AOR, 95% CI=3.7, 1.74, 7.83) and finally participants who jointly decide on the number of their children with their husbands had 2 times increased chance of using MCs as compared to those participants of whom husbands alone decide on number of children (AOR, 95% CI=2.51,1.1,5.82) (Table 2).

DISCUSSION

This study revealed that the CPR among married women in Aleta Chuko district was 45.5%. The result of this study was almost similar with findings of a studies conducted in Debrebirhan district and Jimma zone, Ethiopia.^{7, 8} On the other hand it is higher than the findings of EDHS, which found the CPR among currently married women of 39.9% for SNNPR.² Contrarily this finding was much lower than studies conducted in Nekemte town, Farta district and Shire Endesillasie district, with CPR of 71.1%, 66.2% and 80.1% respectively.^9-11

The five factors which are found to be significantly influencing MC use were; residence, educational level of the participants, partner's approval of MC use and discussion about contraceptives with the husband and joint decision of husband and wife on issues related to fertility.

The multiple variable analyses revealed that participants who are from urban areas are 24 times more likely to use modern contraceptives as compared to those who live in the rural kebeles. The justification behind this association could be that women from urban areas are more knowledgeable about MCs and they might have increased access. The findings of this study were supported by different studies.^6,12

Educational level of the participants was the other factor which was significantly associated with MC use. This finding is in accordance with results from several previous studies.^9,11-14

Another factor which showed significant association with MC use was discussion of husband and wife on contraceptive issues. Women who discuss about MCs with their husbands had 42 times increased chance of utilization of modern contraception. Studies conducted in Farta and Butajira districts, Ethiopia supports the finding of this study.^10,12

The fourth factor identified to be significantly associated with MC was husband approval. Participants whose partners approve MC use were 3.7 times more likely to use modern contraceptives. This kind of relation is also established by other studies. Studies conducted in Tanzania, Butajira district, Debre Birhan district and Farta district supports the finding of this study.^{7,10,12,13,15}

The final factor which showed significant association was decision on the number of children at house hold level and those couples who jointly decide on the number of children they should have ware 2 times more likely to use modern contraception. Consistent with the result of this study studies conducted in Tanzania, Mozambique and Adwa town [Ethiopia] revealed that women reported joint decisions with their husbands on issues related to fertility were more likely to be current user of MCs compared to those reported final decision to be done by husband alone.^13,14,16

Other factors which showed significance in the bivariate analysis; educational level of the husband, maternal occupation, husband occupation and having own income did not show significance in the multivariate analysis. This is not in line with other literatures which state them as predictors of modern contraceptive.^7,17,18

CONCLUSION

The knowledge of MC is universal among the study participants. Majority of the study participants have favourable attitude towards MCs. The CPR in this district among currently married women is 45.5%. Only 55.8% of the study participants discuss about contraceptives with their husband. In the majority of the households (73.9%), decisions regarding the number of children are made by husbands only. Place of residence, educational status, husband and wife discussion on contraception, husband approval of contraceptive use and joint decision on contraceptive use were factors affecting MC use.

Therefore; health service programs and strategies of the district at each level of health care delivery system still need to consider the involvement of males for MC utilization because the study showed that husbands are one of the primary factors determining contraceptive use.

Encourage husband -wife communication on MC practice by HEWs and HDA leaders and encourage couples to exercise joint decision on fertility issues. District health office and concerned stakeholders should focus at household level to encourage girl’s education, communication between couples and male involvement for FP. District gender offices should work towards empowerment of women at household level to decide on contraceptive use alone or jointly with their husbands.

The study showed that contraceptive use is lower in rural than urban areas. Hence, governmental and nongovernmental organizations, health facilities and other stakeholders need to ensure availability, accessibility and sustained advocacy for use of MC methods for married couples in rural areas. Since this study did not involve men and sexually active unmarried women, further studies are needed to determine the extent and associated factors of use contraceptive methods among men and sexually active unmarried women.

ACKNOWLEDGEMENTS

We are grateful to Aleta Chuko district health office for all of their supports. We deeply acknowledge all respondents and participants of the FGD and Key Informant Interview who are crucial to this study. Finally, we would like to express our special appreciation to all data collectors and supervisors.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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