Medical & Clinical Reviews

Keywords

demand for long acting and permanent contraceptive methods; married women

Introduction

Background: The health of women is closely related to their reproductive role and pregnancies which are either too early, too close, too many or too late, exposing mothers to high morbidity and mortality at the time of pregnancy and/ during parturition. Family planning one of the key elements of reproductive health that would prevent 67 million unintended pregnancies and reduce induced abortions from 48 million to 13 million, maternal deaths by 76,000 per year, newborn deaths from 2.9 million to 660,000 per year and HIV infections in newborns from 130,000 to 9,000. estimated 214 million women in the developing world want to delay or prevent pregnancy but are not using a modern method of contraception [1-3].

Through the use of Family planning, young women can delay or space the pregnancy. After a live birth, family planning helps a woman space her next pregnancy for at least two years or approximately three years between births. With such spacing, children are more than twice as likely to survive infancy and are healthier and allow the mother to provide the benefits of breast feeding longer and spend more time with each child which contributes to the child’s physical health and mental and emotional development. It has saved the lives of millions of mothers and their children through the prevention of high-risk pregnancy or unplanned pregnancy [1-4-6].

For these women who want to prevent unplanned pregnancy, long acting and permanent contraceptive methods (LAPM) are very safe, effective and affordable methods which do not require daily use or repeated visits to get the supply. These LAPM include contraceptive methods like Implants and intrauterine contraceptive device (IUCDs) and tubal ligation which are the most effective contraceptive (99% or more unplanned pregnancy protection rate). Their effectiveness vary based on their type (effective for 12 years (IUCDs), for three to five years based on the type (Implants) and for permanent prevention of pregnancy (tubal ligation)[4-6-9]

Worldwide, around 10 million adolescent girls marry each year. These young brides are not fully matured physically and their body is not prepared for pregnancy however they are pressured to begin to have children. Study show that the age at which a woman has her first pregnancy affects the health and life of a mother and her baby. The percentage of teenagers who have given birth or are pregnant with their first chilled be 13% in Ethiopia , 14% at study area and 3% at Addis Ababa which can leads to obstetric complication during, intra-partum and after pregnancy to both mother and new born [8,11,12]

High fertility directly or indirectly affects environment, socio-economic and the health of country which can be prevented by contraceptive use. The global fertility rate is 2.5 United States of America, 1.9 Sub-Saharan Africa, 4.7 Asia and Latin America and the Caribbean (2.2), Europe 1.6, while the total fertility rate (TFR) in Ethiopia is 4.6 children per woman[12,13].

The average contraceptive prevalence rate of sub-Saharan Africa was 22% and South Asia (53%) ] . Kenya has CPR 50%, Ethiopia has 36% CPR (8% implant, 2% IUCD and <1% tubal ligation). the percentage of currently married women aged between 15-49 who wants no more children (including women who are sterilized) were 37%[13,14]The total demand for family planning increase with time periods but Substantial gaps still persist the utilization and demand for modern methods among couples who want to prevent pregnancy and demand for contraception. In 2015, less than half of total demand for family planning was being met with modern methods in 54 countries (34 of which are in Africa). In an additional 76 countries, less than 75 % of total demand was met by use of modern methods. In Ethiopian 58% women age 15-49 have a demand for family planning; 35% want to space births, and 23% want to limit births [8,13,15]

EDHS 2016 report indicates the CPR of the region as (28% benishangule-gumuze, 50% Addis Ababa, 47%Amara ,40% SNN ,35% Tigray ,35% Gambella and 29% Harari [13] .

Despite the complication/ death related to pregnancy, the utilization of contraceptive method especially LAPM were remain the least utilized method among reproductive age women. Study shows that 120 million women worldwide want to prevent unwanted pregnancy but they and their partner do not the contraception of their choice. Utilization of LAPM prevent 67 million unintended pregnancies and reduce induced abortions from 48 to 13 million, maternal deaths by 76,000 per year, newborn deaths from 2.9 to 0.66 million per year [3,8]

While current challenges to health throughout the world are many and serious, the need to control one’s own fertility probably touches more lives than any other health issue. Report show global fertility rate of 2.5, USA 1.9, Asia 2.8 and Africa 5.6,Ethiopia 4.6 and Benishangule-Gumuze 4.4 % [1,8,13]Short-term and reversible methods are more common in Africa and Europe whereas long-acting or permanent methods are more common in Asia and Northern America. Less than 10 per cent of married or in-union women of reproductive age were using contraception in Chad, Guinea and South Sudan and five countries in Eastern Africa (Kenya, Malawi, Rwanda, Zambia and Zimbabwe) had CPR of 50 % or more in 2015 [4,16]

Ethiopia Demographic Health Survey 2016 (EDHS) indicates CPR of 36 %( 8% implant, 2% IUD and <1% tubal ligation). The total demand for family planning in Ethiopia were 58 %( 35% want to space births, and 23% want to limit births). It is known that despite the increased demands of women for LAPM to long term spacing or even limiting the child bearing, the utilization of short term remain high in the country despite their lower effectiveness rate of unplanned pregnancy protection. In the study area,the fertility rate and teenage pregnancy were higher compared to the other region of Ethiopia. This has its own effect on rapid population growth, malnourishment and negative impact on the environment and reproductive organ related morbidity and mortality. However the reason for higher demand especially at the study area and lower utilization of contraception were remain unknown. There for this study aims to assess demand for long acting and permanent contraceptives methods and associated factors among married women visting Assosa governmental health institution for family planning. Mixed study

Methods

Study Setting and sample

The study was conducted in Assosa town governmental health institution which is located 561 km west from Addis Ababa. The town is bounded in the south by mao-komo special wereda, on the West by Sudan, on the north-east by kamashi. The town has one university, one poly Technique College, one health center and hospital. Based on the 2013 major town population estimation, Assosa town has 35,752 total populations (17,669 male and 18, 084 female).

Assosa Hospital provides service for client referred from Assosa zone and Oromya region like Mendi and Begi. It provides family planning service, ANC, delivery service, postnatal service and comprehensive abortion service and other medical and surgical care service. Cross sectional institutional based study was used to conduct the study in Assosa hospital and Assosa health center from April 12-May 10/2019 to asses demand for long acting and permanent methods and associated factors among reproductive age women visiting the two institution. Source population was all married women found in Assosa town aged 15-49 years and study population was Married woman’s aged 15-49 who visits Assosa governmental health institution for family planning service

Sampling procedure and sample size

The sample size was calculated by using single population proportion formula by considering 0.181 proportion for demand for LAPMs(5), 95% confidence level, 5% Margin of error and 10% non-response rate .i.e.

Where

n= sample size

Z =is the level of significance corresponding to 95% confidence interval (1.96)

P = proportion for demand for LAPMs=0.181

D= the absolute precision required =5%

So the total sample size was 251 with10% non-response rates. The samples were allocated to the health center and hospital proportionally based on their monthly plan of family planning under the coverage. All married women who visit the two health institution were selected randomly to get 251 total sample size (102 Hospital and 149 Health center).Sample size for qualitative method was based on the saturation of information.

Operational definition

Demand for LAPM

According to this study, it is defined as an expressed need of married women to utilize LAPM.

Reversible Long acting contraceptive

contraceptive methods which used temporarily

Permanent methods of contraceptive- contraceptives methods used to limit pregnancy

To delay pregnancy

contraceptive used to prevent the first pregnancy (implant and IUCD).

To space pregnancy

contraceptive methods used to make gap between the first pregnancy and the next pregnancy (implant and IUCD).

To limit pregnancy

contraceptive methods used to control pregnancy permanently(tubal ligation).

Dependent variable

Demand for LAPM

Independent variable

Socio demographic and economic characters (age, religion, occupational status).

Behavioral characteristics (method awareness, partner involvement, myths and misconception, intention to use LAPM).

Source of information about LAPM (health professionals, Media. health extension workers) printout materials

Method factors (ease of use, side effects, fear of the method used).

Inclusion criteria

All married women’s of reproductive age group who visit family planning unit and volunteer to participate.

Data collection procedures

Data was collected by face to face in-depth interview by using structured questionnaire adapted from the literature review. The questionnaire was prepared in English and translated in to Amharic and back to English. Four trained health care provider (two BSC midwife and two diploma midwives) were used for data collectors. Two BSC midwives, one from each health institution was used as supervisor during data collection period. Pre -test of the questionnaire was done on 5% of the sample on married women at Bambasi health center (nearby Assosa town health center) to identify any ambiguity, consistency and acceptability of questionnaire, and then necessary corrections was made before the actual data collection.

For the qualitative method, a total of seven in-depth interviews were conducted with purposively selected key informant to explore the barriers for non-use of LAPM. These key informants were selected based on the socio demographic variation. The interview was conducted by principal investigator (PI) and supervisor. Both audio record and note was taken.

Data quality control

Quality of the data was controlled through continuous checking questionnaires for the completeness. The questionnaire was transferred to Amharic language to maintain consistency and pre-test was given before actual data collection to check any difficulty and then after the possible correction, data collection was started. Data collectors and supervisors were trained intensively for one day on the title of the study, objective, data collection tool, procedure, informed consent and methods of sample selection.

The in-depth interview were conducted on the selected key informant in the private room selected for the interview purpose. The interview was started after the participants were informed about the aim of the study and the privacy was assured. The principal investigator and one supervisor conducted the interview. The recorded data were translated to the note after repeated listening and coding of the data to ensure a degree of standardization. Final transcripts were compared against note takers’ notes to ensure quality. Finally, the report was done to support the quantitative data based on the participant report after coding and checking the similarity and difference between the note taken from codded data and note takers note.

Data analysis

The collected data was cleaned, coded, and entered in to EPI info 7 and then exported to SPSS version 24 for further analysis. Bivariate analysis was done to determine factors influencing demand for LAPM and variables which was found to have significant association at p-values <0.2 in bivariate analysis was taken to multivariate regression to test effect of independent variables on dependent variable. Proportion, percentage, frequency distribution, logistic regression, odds ratio with 95% confidence interval at P<0.05% was used in describing the data. The results were displayed using text, tables and figures.

Qualitative data was transcribed verbatim, coded and analyzed using thematic analysis to support quantitative analysis and presented in the narrative. Finally the findings were triangulate with the quantitative result during write up.

Ethical consideration

Formal letter of cooperation was written from Addis Ababa University to Assosa town health institution administrator and informed consent was obtained from each study participant after the objectives of the study were fully explained by their local languages. The participant was informed the aims of data collection and informed as the sensitive issue was kept secret and after getting consent and insuring confidentiality, the data collectors start to collect the data. Also they informed as they have the right not to participate and failure to participation do not affect any care and service they get now and in the future and the collected data was stored in a file, without the name of study participant (anonymously), but code will be assigned for each and was not disclosed to others except to the principal investigator.

Dissemination of the study result

The result of the study will be presented to School of Nursing and Midwifery. Dissemination of result will be made through Addis Ababa University College of health science, CHs library, Assosa health bureau, MOH and Assosa health institution administration. Also effort will be done to publish in peer review journal

Result

Socio demographic characteristics of study participant

From the total of 251 participant, 96(38.2%) were at age group of 25-29 years. The result shows that, 104(41.4%) of the respondent completed secondary education. Table 1

Table1: Socio demographic characteristics of married women who visited Assosa governmental health institution.

Awareness, source of information and knowledge about LAPM

The finding of this study shows that, majority 197 (78.5%) of the participant had information related to LAPM and health care provider was the main source of information 78(31.1%). The result shows that, 182(72.5%) knows any of the LAPM and tubal ligation was least known at the study area 69(27.5%). Table 2

Table2: Awareness of LAPM among married women who visited Assosa governmental health institution.

Note : BTL- bilateral tubal ligation IUCD- intrauterine device

Reproductive history of study participant

The finding shows that, 172(68.5%) of the study participant had desire for more child in their future and 147(58.6%) of the participant want to have children after 2-5 years. Table 3

Table3: Reproductive history of married women who visited Assosa governmental health institution.

Utilization of LAPM

The result of this finding shows that, more than half 147(58.6%) of the study participant ever used at least one of the LAPM and 116(46.2%) of participant utilized contraceptive implant. Fig.3

Demand for LAPM, reason for use, reason for nonuse and couple discussion about any LAPM

From this study result, 157(62.5%) of married women had demand for LAPM. 135(53.7%) of the participants want to space inter-pregnancy. Fear of side effect 34(13.5%) and preferred short term methods were main reason for non-utilization of LAPM. Majority of the respondent 188(74.9%) were ever discussed about any of LAPM with their husband. Table 4

The result of in-depth interview also revealed that, client had an expressed need to utilize LAPM but they failed to utilize it as contraceptive methods of their choice due to some reasons like fear of side effect, prefer short term method, religious prohibition and fearofhusband.“I do not want to use LAPM due to its side effect. Currently I am using contraceptive implant,itcause menses irregular, I faced headache after I started it, it weaken my hand andinfluencemydailyworksowhyIcometoremoveittoday.”/I4,client/“Theyreportedthat,usingimplantcausemensesirregularity,causeheadache/dizziness,brings about weight gain/loss and brings about behavioral change.”/I2. health care provider / “Most of the time client takes contraception without the permission of their husband, duetothisthey want to use the invisible type of contraceptive methods like Depo-Provera.” /I1. Health care provider /

Table4: Demand for LAPM, reason for use and non-use and participant discussion about LAPM, among married women visiting Assosa governmental health institution.

Myth/misconception reported by study participant

The result of this study shows that, 65(25.9%) of the respondent belief as using implant cause weakness of hand/arm and 42(16.7%) belief as using implant brings about behavioral change. These the finding revealed that, 27(10.8%) of the respondent belief that, using IUCD interfere with sexual activity and 14(5.6%) belief that IUCD cause reproductive organ infection. also this study shows that, 53(21.1%) of the participant belief as tubal ligation need major operation and 49(19.5%) belief as tubal ligation procedure cause severe pain. Table 5

The study finding was supported by the result of in-depth interview. The key informant pointed out that, client has an expressed demand to utilize LAPM but did not want to utilize due to some perceived misconception/rumors related to LAPM they heard from the community. . “IUCD is not preferred by client due to different misconception related to the contraceptive methods. They belief as IUCD cause infertility, the procedure need major operation, cause severe pain during and after insertion, do not give comfort during sexual activity , cause reproductive organ infection and may disappear after insertion.” /I1, health care provider / “Some client said that implant needs major operation and the operation site takes long healing duration. It also move to the other body part like to brain and heart. Implant cause numbness/weakness of hand which can interfere with daily work.”/M2. Health care provider/ “There where client who want to limit the pregnancy permanently but utilize short term methods due misconception/rumors heard from the community. They belief that tubal ligation need major operation, its wound healing take long time, it decrease sexual desire and its procedure cause severe pain.”/I3, health care provider/

Table5: Myth/misconception related to LAPM among married women who visit Assosa governmental health institution

Associated factor’s bivariate and multivariate result

The result of this finding show that, Respondent who had secondary school education were 71.1% lower odds of demand for LAPM (AOR=.289, 95%CI= (0.137-.608)). Women’s who had information about any of the LAPM from different source of information were significantly associated with demand for LAPM (AOR=2.503, 95%CI=1.188-5.2274). Women’s who knows any LAPM were significantly associated with demand for LAPM (AOR=2.62, 95%CI=1.295-5.299). From this study finding, women’s who had ever used any LAPM were significantly associated with demand for LAPM (AOR=3.369, 95%CI=1.805-5.291). Respondents who ever discussed about any LAPM with their husband were significantly associated with LAPM (AOR=2.067, 95%CI=1.027-4.163).Table 6

Table6: factor associated with demand for LAPM among married women visiting Assosa governmental health institution

Note *=significant at p<0.05 **=significant at p=0.00, reference =no

Discussion

The finding of this study shows that, Demand for long acting and permanent method was 62.5%. The result was higher when compared to the result reported by EDHS 2016(58%), study done in north-west Ethiopia (17%), Debremarkose (52.4%) and Bale Goba (18.1%). These discrepancies might be due to increased client access to information regarding to the contraception especially LAPM and their use through time or might be due to different study periods (5, 13, 20, 25).

The finding of this study show that, the main reason that client want to utilize LAPM were to space inter-pregnancy (54.2%). The finding Was higher than the result of study done in north-western Ethiopia(16.4%)(20) and report of EDHS 2016(35%). These the possible justification for the discrepancy between the findings might be due to increased service delivery setting with respect to trained service providers. Also, the variation may be due to the different study period.

Fear of side effect(13.5%), preferred short term method(8.8%),religious prohibition(4.4%), want to become pregnant(0.8%) and lack of adequate knowledge about LAPM(5.6%) were some of the reason for non-utilization of LAPM as contraceptive methods of their choice. On the other hand perceived misconception related to LAPM developed from the community or from past self-experience were other challenging factors to utilize LAPM despite the expressed demand for those contraceptive methods. The result of this study shows that the prevalence of misconception related to utilizing contraceptive implant( cause infertility(11.2%), cause numbness of hand/arm (25.9%), cause behavioral change(16.7%)) and IUCD related misconception as (cause infertility(4%),decompose in the uterus(5.2%), interfere with sexual activity(10.2%) and misconception related with BTL as (cause severe pain during the procedure(19.5%),need major operation(21.1%) and decrease desire for sexual activity(17.5%)) . These, the fore mentioned above misconception/rumors related to the utilize LAPM were supported by the result of qualitative in-depth interview.

But there where discrepancies between this study result and the result of the study done in Bale-Goba (religious opposition (55.9%), husband opposition (17.5 and fear of side effect (25.5%)(5), Debremarkose(Fear of side effect (58.4%), preferring short term (36.3%) and religious prohibition (24.2%)(20) and western Ethiopia(Side effect (38.9%), rumors related with LAPM (49%))(25) . These, LAPM related misconception/ rumors were also mentioned by the study result conducted in Iran (16) . The possible reason for such discrepancies between the studies may be due to the fact that, there might be increased provision of information related to misconceptions about LAPM in the study area. Also the variation may be due to different study period.

The finding of this study shows that, majority of the study participant had ever given birth (79.7%) and more than half of those who gave birth (41.5%) didn’t want to have child within three years. This may indicates as there is need for assessing client contraceptive need inline with their reproductive plan. Also this may indicates as there be need for disseminating the adequate information related with the types LAPM and their duration of services.

The result of this study shows that, the majority (78.5%) of the participant had ever heard about any of the LAPM which is significantly associated with demand for LAPM (AOR=2.505, 95%CI=1.192-5.265). The result of this study were higher than the result reported by Malawi DHS (74.6%) (24) And Amuru district, Northern Uganda (76.3%)(21) . The possible reason for the variation might be due to different study area and periods. But result of this finding was lower than the result of the study done in west Ethiopia (82.5%)(25).The discrepancies might be the fact that client in the study area has limited accessibility to the information related to contraception especially LAPM or might be there were limited source of information at the study area.

Different study shows that, Client can get information from different source that help them to choose the contraceptive methods of their choice easily(26, 28). The finding of this study result indicates that, health care provider (31.1%) and health extension workers (25.1%) were the main source of information related to LAPM. There where discrepancy between the result of this study finding and the result of study finding conducted in the West Ethiopian which shows that (health care provider(78.2%), Radio/TV (72.5%)(25) and study result of Debre-markose(Health care provider (63.8%) and television/radio (61.5%))(20). These the possible reason for such variation might be, there were limited client access to the source of information in the study area. Also it might be an indication that, there were limited source of information related to LAPM in the study area.

The increased knowledge about contraceptive method help client to easily choose the contraceptive methods of their choice according to their reproductive plan to prevent unplanned pregnancy. The result of this study shows that, majority (72.5%) of the study participant knew any of long acting and permanent methods which also positively associated with demand for LAPM (AOR=2.809, 95%CI=1.41-5.595). This result was higher than study conducted in Uganda (25.8%)(21). The possible reason for the variation of the result might be due to different geographical location, increased globalization and may also due to different study period. But the result of this finding was lower than the result of the study conducted in the western Ethiopia(82.5% )(25). This discrepancies might indication that, there were limited access of client to the education related to LAPM given by different concerned body like health extension worker in the community, at the health post or it might be indication that, there were limited provision education related to LAPM by any concerned body in the study area.

Knowing the types contraceptive help client who want to use family panning to easily choose the contraceptive methods which correspond with their reproductive plan. This finding revealed that, 72.5%, 61.4% and 27.55% knows contraceptive implant, IUCD and tubal ligation respectively. This result was higher than the result of study done in Angola (39.6% IUD and 38.6% implants)(30), India (48.3%IUCD)(22) and Bale-Goba (47.7% implant, 15.8% IUCD and 3.85% tubal ligation)(5). The discrepancy might be due to different study period.

In this study finding, the utilization rate of LAPM were 58.6% which is positively associated with demand for LAPM use (AOR= 3.201, 95%CI=1.731-5.917). The result of this finding was higher than the result of study conducted in Iran(21.4%)(16), Kenya(9.9%)(14), Bangladesh(6.9%)(18), Pakistan(35%)(26), EDHS 2016(36%)(13) and Northwest Ethiopia (9.2%)(31). The possible reason for the variation might be, there were increase client access to the reproductive health related information and the role of LAPM to maintain reproductive organ health or might be an indication that, increased client decision making related to family planning utilization especially LAPM .

The result of this study finding indicates that, 46.2% and 12.4% of the study participant utilized contraceptive implant and IUCD respectively. There were variation between the result of this finding and other study result such as study conducted in Iran(14.1% used IUCD)(16), Kenya(7.9 implant and 0.8 IUCD)(14), Bangladesh(4.6% implant and 0.6% IUCD)(18) , 2016 EDHS(8% implant, 2% IUD and <1% female sterilization)(13) and Northwest Ethiopia shows (8.2% Implanol and 1% IUCD)(31) and Bale-Goba town( IUCD 1.5%, implant 6.5%)(5). The reason for this variation might be due to, increased service provision setting, increased supply and increased trained health care providers. Also those variation may be happened due to different study period.

Partner discussion and approval play role in the selecting and utilizing the contraceptive method of choice. The result of this finding shows that, majority (74.9%) of the participant ever discussed about any LAPM which is positively associated with demand for LAPM (AOR= 2.071, 95%CI=1.031-4.16). The result of this study was lower than the result of study done in the West Ethiopia(81.5%) and study conducted in northern district of Kenya(79%) (25, 32). The possible justification for such discrepancies may be, there were limited involvement of husband in the reproductive health related matters in the study area. Also it might be due that, couple in the study setting has limited knowledge on the importance of joint decision making related to family planning utilization.

Limitation of the study

The limitation of this study was cross-sectional nature of the data that temporal relationship between exposure and outcome variable could not be established and also this study do not include health care provider role to meet the demand for LAPM during the service provision session.

Conclusion and recommendation

Conclusion

The finding shows that 62.9% of the participant had demand for LAPM. Factor which are associated with demand for LAPM were ever use of LAPM, couple discussion about LAPM, awareness about LAM and know LAPM. The client who comes for family planning services had expressed demand for LAPM but due to certain reason they like Fear of the contraceptive side effect and misconception related with LAPM hindered married women from utilizing LAPM as contraceptive methods as choice .

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