Status of modern contraceptive use among married women in Debre Birhan District , Ethiopia

Unless evidence based decisions are made based on local contexts, the low prevalence level of contraceptive use and the corresponding higher total fertility rate will make Ethiopia to remain the most populous country in Africa. The purpose of this study was to assess the status of modern contraceptive use among married women in Debre Birhan district, Ethiopia. A community based crosssectional study was conducted among married women of reproductive age. Systematic random sampling technique was used to choose 851 study subjects. Before data collection, ethical clearance was obtained from the institution, and data was collected by trained diploma nurses using pretested structured questionnaire and analyzed by statistical package for social sciences (SPSS), version 20. Logistic regression analysis was employed to identify the predictors of modern contraceptive use. Modern contraceptive prevalence rate among married women was 46.9%. Injectables were the most frequently used type of modern contraceptive method (62.9%), followed by intrauterine device (16.8%), pills (14%), norplant (4.3%), male condom (1.2%) and female sterilization (0.8%). Multiple logistic regression model revealed that the need to have more children [AOR 95% CI: 9.27 (5.43 to 15.84)], husband approval [AOR 95% CI: 2.82 (1.67 to 4.80)] and husband-wife communication about contraceptives [AOR 7.32, 95% CI (3.60 to 14.86)] were found to be an independent predictors for the use of modern contraceptives. There were no statistical significant differences between modern contraceptive use and other socio-demographic and reproductive health related variables after an adjustment. Modern contraceptive use declined among married women in the district. The culture of publicly discussing the use of contraceptives and breaking the silence among the people demands substantial efforts. Considering users of contraceptives as deviant also requires paradigm shift in thinking.


INTRODUCTION
Despite the introduction of modern contraceptives in Ethiopia in 1966 (Korra, 1997;Assefa et al., 2006) contraceptive prevalence rate (29%) remained lowest (Central Statistical Authority, 2011).The country is the second most populous in Africa with a total fertility rate of 4.85 (Population Reference Bureau, 2009).The importance and benefits of slowing down population growth does not seem to get more attention by the government.Maternal and child health related problems are also rampant in the country.Unwanted pregnancy is among the prominent reproductive health related problems (USAID Health Policy Development, 2010) resulting i n unsafe abortion to be the most significant cause for maternal morbidity and mortality (World Health Organization (WHO), 2004).Imagine how appropriate use of modern contraceptives would save the life of millions of women, but with this current rate of utilization, the country may not be successful in achieving one of the indicators of Millennium Development Goal 4 and 5 unless all stakeholders are able to exert substantial and multidimensional efforts collaboratively.However, local government efforts complemented by strong support of NGOs working on reproductive health have not been able to bring the desired impact as demanded and expected.Much remains to be done in pinpointing the main local context contributing factors for the low utilization of modern contraceptives.Program implementers/stakeholders need to make evidencebased decisions based on reliable information for action if service provision needs to be improved.Reproductive health strategies need to be tailored taking the potential risk factors of the local situation into consideration, otherwise, the trend may continue as such and further damages may occur.Thus, the need to improve modern contraception use within the country in one way or the other is a must to do assignment for all potential stakeholders.
Currently, family planning service is offered as free of charge in both governmental and NGO health facilities in Ethiopia, including hospitals, clinics, health centers and health stations.But, Ethiopia is among countries with low contraceptive prevalence rate, with only 28% at national level among married women, respectively, (Central Statistical Authority, 2011).Factors that influence contraceptive use are multifaceted and challenging.Different studies evidenced that socio-demographic, socio-cultural and socio-economic factors (Beekle and Mccabe, 2006;Ibnouf et al., 2007;USAID Ethiopia, 2010) mostly affected women's knowledge and use of contraception.More specifically, a woman's age (Kebede, 2006;Ibnouf et al., 2007;Chourn, 2008), number of living children (Ali et al., 2004), parity (Stephenson and Hennink, 2010), desire to have children (Ibnouf et al., 2007;Chourn, 2008;Stephenson and Hennink, 2010) educational level (Beekle and Mccabe, 2006;Ibnouf et al., 2007;Chourn, 2008;Nega, 2008;Saleem and Pasha, 2009;Stephenson and Hennink, 2010), occupation (Ali et al., 2004;Kebede, 2006;Chourn, 2008;Stephenson and Hennink, 2010), and income (Ali et al., 2004;Haile and Enqueselassie, 2006;Ibnouf et al., 2007;Chourn, 2008) majorly impact woman's use of modern contraceptive methods.Yet, these determinant factors and others to the use modern contraceptives have not been studied in Debre Berhan district.Existing information in the district on this regard is very often limited and scarce (Beekle and Mccabe, 2006;Nega, 2008;Saleem and Pasha, 2009).Hence, the study aims to investigate potential risk factors that affect utilization of modern contraceptives so that program implementers would know where to act more to bring about the desired changes within a given period of time.

METHODOLOGY Study design and area
A Community-based cross-sectional study was carried out among married women aged 15 to 49 year in Debre Birhan district, Ethiopia.The district had nine Kebeles (the smallest administrative divisions) with an estimated total population of 72,097 (Federal Democratic Republic of Ethiopia population and Census Commission, 2007) of whom 23% were estimated to be married.Based on information obtained from the District Health Office, family planning services were available in most of the health institutions (one hospital, one health center, and 18 clinics) including four health posts.

Sample size and sampling
EPI INFO was used to calculate the sample size using single population proportion formula based on an assumption that 29% of the modern contraceptive prevalence utilization in Ethiopia, and design effect of 2 (The main reason of using design effect of 2 is to reduce the variability as a result of two stages that we passed from the District level to village and then household level).A total of 851 study subjects were selected from all married women who lived at least for six month in the district using systematic random sampling technique.Simple random sampling technique was applied for the selection of representative Kebeles.In cases of selected households with more than one eligible study subjects, only one was chosen using a lottery method.If an eligible study subject was not found from a selected household, the next household with an eligible study subject in the clockwise direction was included in the sample.

Data collection
Pretested structured questionnaire which composed of closedended questions was used to collect the data on variables related to socio-demographic characteristics, reproductive history, modern contraceptive use and other related factors.Female diplomaholding nurses were recruited as data collectors and collected the data through face-to-face interview after being trained for two days on interview techniques, data collection methods and confidentiality and privacy issues.Oral consent was obtained from each participant once the purpose, confidentiality and anonymity of data for this study was explained to each individual.Study subjects who were not available in the household during the first visit were revisited two more times before the women in the next household made the substitution.Two immediate supervisors were assigned to help the data collectors during the process of data collection.The questionnaire was developed and administered in Amharic, the local language.

Data analysis
Data were entered and cleaned using EPI INFO software and then analyzed using SPSS 18. Univariate analysis was used to describe study variables accordingly whereas Bivariate regressions analysis with crude odds ratio (COR) along with the 95% confidence interval was used to verify the association between covariates and modern contraceptive use.Multivariate Logistic regression analysis on the other hand was carried out to determine the adjusted effect of each factor on modern contraceptive use.Variables with more than two categories were entered into the model in the form of two "indicator" contrasts comparing each category to the first group as reference.Variables that were statistically significant at the bivariate level were entered into a multivariate logistic regression analysis, and the strength was presented using odds ratios and 95% confidence intervals at the conventional P-value =0.05 level.The significance for variable removal and entry was set to 0.10 and 0.05 respectively.The Hosmer and Lemeshow test was used to check the goodness-of-fit of the model as well.

Ethical clearance
Ethical clearance was secured from the Institutional Ethical Committee of Amref Health Africa and Debre Berhan University.Official letter of cooperation was taken from Amref Health Africa and Zonal Health Department where the study was undertaken.Consent was obtained from each respondent.Anonymity and confidentiality were ensured for information obtained from the charts reviewing.

Socio-demographic characteristics
Of all 851 married women who responded to the questionnaire, the majority of the respondents were Amhara by ethnicity and Orthodox by religion.The mean age of the respondents was 29.5 ± 6.6 years.The proportion of illiterate respondents was as high as 22.3%, and more than three-fourth of the respondents were from urban areas Table 1.

Reproductive history
The number of married women who ever experienced birth was eight times higher than their counterparts.The average number of living children per woman was 2.37.In addition, 498 (58.5%) of respondents had a desire to have one or more children in the future, and the average number of desired children was 3.54.Among the pregnant women, 21.6% reported as unwanted and resulted 5.3% abortion rate Table 2.

Married women's awareness about modern contraceptives
Of all respondents, 98.5% heard about either of the contraceptive methods.Their main sources of information were health professionals of the health centers (66.83%), radio programs (57.4%), television program (55.08%) and health extension workers (20.17%).The most commonly reported types of modern contraceptives were injectable (98.9%) and pills (97.3%).In addition, child spacing (70.5%), prevention of unwanted pregnancy (63%), limiting the number of children (48.6%) and prevention of human immunedeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (12.3%) were mentioned as an advantage of modern contraceptive methods among study participants and 735 (86.4%) of respondents still had a desire to know more about contraceptives while the remaining 116 (13.6%) of respondents did not have any desire to know more about it Figure 1.

Communication about modern contraceptives
Only one-fifth of married women discussed contraceptive related issues with the nearby health extension workers whereas the proportion of married women who discussed with their husbands was more than 3 / 4 th of the total respondents.However, 1 / 4 th of the respondents did not get approval to u s e contraceptives of their choice by their husbands Table 3.

Modern contraceptive use
More than half of the respondents, 448 (52.6%) had ever used contraception.Three hundred a n d ninety nine (46.9%) of them had been using it during the time of the interview.Injectable 251 (62.9%) were among the most frequently used type of contraceptives followed by IUD 67 (16.8%), pills 56 (14%), norplant, 17 (4.3%)and male condom 5 (1.2%), and the remaining 3 (0.8%) used permanent type of modern contraceptive method namely female sterilization.Of the total current modern contraceptive users, 335 (80.3%) were from the urban areas and the remaining 82 (19.7%) were from rural areas.Of currently married women who had ever used contraceptives, 49 (10.9%) of them discontinued taking contraceptives.The total number of married women who never used contraceptives was 403 (47.4%), and reasons for discontinuing and/or never using modern contraceptives were, need of more children (160), natural method (82), religion probation (56), husband disapproval (56) and health concern were the frequently mentioned.

Relationship between socio-demographic characteristic of married women and use of modern contraceptives
Results of Bivarate analysis showed that education status of the women, average family income, educational status of the husband and having access to television and radio were statistically significant to the use of modern contraceptives unlike the place of residence, age and educational status of the husband (P-value <0.05) Table 4.

Relationship between children, communication and Knowledge related variables and use of modern contraceptives
As shown in Table 5, all tested variables showed statistically significant associations with the use of modern contraceptives at a P-value < 0.01.For example, women who did not wish to have more children in the future were 6.42 times more likely to use modern contraceptive than women who wished to have children within two years (OR 6.42, 95% CI 4.21 to 9.78).
Women who had three or four children were 2.45 times more likely to use modern contraceptive than women who had no children (OR 2.45, 95% CI 1.5 t o 3.99).Likewise, those women who discussed about contraceptives more than three times with their husbands were 14.89 times more likely to use modern contraceptive than women who did not discuss family planning with their husband (OR 14.89, 95% CI 9.08 to 24.43).

Determinant factors
As presented in Table 6, results of the multiple logistic regression model revealed that women's desire for more children, husband-wife discussion and approval of husband to use modern contraceptive were among the predictors of modern contraceptive use by married women.Married women who did not desire more children at all were 7.75 times more likely to use modern contraceptive methods than those women who desire children within two year.Similarly, women who had discussion with their husband on contraceptives were more likely to use modern contraceptives than their counterparts.But variables like educational status of the women and husband, residence, women and husband occupation and discussion with health extension workers including average monthly family income were not statistically significant to the use of modern contraceptives in the multiple logistic model.

DISCUSSION
The need to have a well organized and coordinated birth control program for Ethiopia where its population increases alarmingly from time to time is an evident.Otherwise, its population is projected to reach 174 million by 2050 and become the 9th largest country in the world (Population Reference Bureau, 2009).A 6% reduction in contraceptive use among married women in the district also indirectly indicates that women's wish to have more children is still proactive in the area.
The need for more children was the main reason for the discontinuation of modern contraceptive use that is also supported by findings from Dembia district, West Belessa, Khartoum, Cambodia and Pakistan (Beekle and Mccabe, 2006;Kebede, 2006;Ibnouf et al., 2007;Chourn, 2008;USAID Ethiopia, 2010).Thus, the culture of having more children as indicators of wealth needs relentless efforts from all potential stakeholders.Women and other family members need to shift their mind in how to raise children as healthy as possible rather than bearing many children which is beyond the control of the family.The proportion of women who use modern contraceptives in Debre Birhan district was found to be consistent w it h a previous study conducted in Ethiopia in the town of Nazareth/Adama (Biruk et al., 2008) but found to be better than other similar studies conducted in Dembia District (Kebede, 2006), West Belessa Woreda (Nega, 2008) a n d the National average contraceptive use (Central Statistical Authority, 2011).A difference in time of study may be the main reason for the discrepancies in study findings of similar studies beside that of residence, availability, accessibility and knowledge and attitude level of the respondents.
Findings of this study also revealed that the study participants used five different types of modern contraceptives and this mix of modern contraceptive use was better than the previous study conducted in Dembia (Nega, 2008).A greater choice of methods increases contraceptive continuation and overall use of modern contraceptive methods including quality of services (Population Reference Bureau, 2009).In addition, the preference of long acting contraceptives particularly Inter uterine device (IUD) was higher unlike pills preference in contrast to a study done at Dembia district (Nega, 2008).This suggests that the possibility of using long acting contraceptives in the district is promising.Use of pills where many of the users complain about its side effect and claimed to cause unintended pregnancies may get substituted in the near future, and long acting contraceptives on the other hand may become first choices of women in the district.Such an improvement in the use of long term acting contraceptives is of course consistent with a study conducted in Khartoum, Sudan, where the use of long-term modern contraceptives showed an improvement as compared to short acting contraceptives (Ibnouf et al., 2007).
Child spacing was found to be the main reason for the women to use modern contraceptive, consistent finding with the study in Khartoum (Ibnouf et al, 2007).This can also tell that the thought of women to have more children was as it is.If it were limiting the number of children, it would show to what extent they were interested to raise a limited number of children in appropriate manner.Spacing children does not exclusively reveal women's initiation of limiting their birth.Taking the current living standards of the country and the corresponding life challenges, birth limit would not be their primary reason.Therefore, both govern-mental and non-governmental organizations working in the area of reproductive health need to work intensively to bring the agenda of 'limiting birth' on the table.Family members also need to determine the size of their family through open discussion and agree on which type of contraceptive shall be used.The proverb 'children grow by chance' shall be dodged from the minds of people through continuous education and promotion including reliable evidences and models from the developed world.
Factors that determine the use of modern contraceptives of course vary on the basis of the local situation (WHO, 2004).Results of this study also indicated that recent lack of interest to have children was a strong predictor of modern contraceptive use like the study findings of Cambodia and Pakistan (Chourn, 2008;Stephenson and Hennink, 2010).Discussion with the husband and their approval were another determinant factor for modern contraceptive use among married women in the district.Therefore, it is advisable for organizations working in the area of reproductive health to take such issues into consideration if their primary objective is to bring about significant changes within short period of time.
There are also other factors whose effect was diluted Dessalegn et al. 325 when adjusted for other variables; women's number of living children was among them.Despite the findings of this study different studies in Cambodia and Pakistan (Chourn, 2008;Stephenson and Hennink, 2010) suggested that the number of living children was an independent factor for the use of modern contraceptives.Religion, culture and perception/attitude may be the possible explanation for such variations.Similarly, those women who had more children in Debre Birhan may be at older age of reproduction and may perceive that they would have little risk of pregnancy.Documented evidences within the country (Beekle and Mccabe, 2006;Mon, 2009) and abroad (Ali et al., 2004;Mekonnen et al., 2008;Abraham et al., 2010; Stephenson and Hennink, 2010) also showed that husband-wife communication had significantly improved contraceptive use.Women discussing modern contraceptive use with their husbands were more likely to use modern contraceptives, indicating that men's involvement plays an important role in the use of modern contraceptives.Therefore, actors in the area of reproductive health had been advised to involve male partners equally, as they are culturally empowered decision-makers of the family, particularly in Ethiopia where men are the main decision makers of all issues.The high chance of women to use modern contraceptives hiding from their partners could not be a means, as the effect would be seen in the short run.
Monthly income of a family was not found to be an independent predictor for modern contraceptive use despite available evidences in the literature, indicating that modern contraceptive use is associated with income level both in developed (Chourn, 2008) and developing countries (Ibnouf et al., 2007).Women with high socioeconomic status are more likely to use modern contraceptive than those women with low socioeconomic status.However, in this study, sufficient evidence depicting the relationship between income level and modern contraceptive use was not found when adjusted for other variables.The concept that having children is a gift from God may be the reason for the absence of statistical differences between women with higher and lower income level.Stakeholders have to work to change such attitudes and opinions across the district so that people start to appreciate the joy of having sensible family size.
Generally, with all the efforts of governmental and non-governmental organizations including the provision of family planning services free of charge, the proportion of modern contraceptive users in the district remained low.This indicates the absence of breakthrough efforts and actions in the area of empowering women and modifying cultural beliefs.Women have to know that using modern contraceptives is their right like other basic human rights and needs.All family members have to discuss reproductive health issues openly, and considering it, as a taboo in the 21st century needs to be stopped through diversified efforts and actions.

Table 1 .
Socio-demographic characteristics of married women in Debre Birhan District, Ethiopia.

Table 2 .
Reproductive history of married women in Debre Berhan District, Ethiopia

Table 4 .
Relationship between socio-demographic characteristic of married women and use of modern contraceptives in Debre Birhan District, Ethiopia.

Table 5 .
Relationship between children, communication and Knowledge related variables and use of modern contraceptives in Debre Birhan District, Ethiopia.

Table 6 .
Multivariate analysis on of factors associated with the use of modern contraceptives in Debre Birhan District.