Intention to use long acting and permanent contraceptive methods and factors affecting it among married women in Adigrat town, Tigray, Northern Ethiopia

Background

Long acting and permanent contraception methods (LAPMs) are convenient for users and effectively prevent pregnancy and also cost effective for programs overtime. They can result in substantial cost savings for couples, governments, and contribute directly to reaching national and international health goals by providing long lasting contraceptive protection [1]. Contraceptive use has increased worldwide over the last decade [2]. Yet, Africa has high unmet need of family planning (FP). Approximately 25% of women and couples in sub-Saharan Africa (SSA) who want to space or limit their births are not using any type of contraception [3]. Many potential clients in SSA lack information or have misconceptions about LAPMs [4,5].

In a country like Ethiopia with high fertility rate and unmet need of contraceptives, shifting towards LAPMs is an important strategy to ensure continuity of services. But the issue is controversial; the contraceptive method mix is dominated by short term methods like pills and injectables [6-9]. The Ethiopian ministry of health has planned and is working on the provision of all FP methods, especially LAPMs in the lowest service delivery level [10]. Despite the fact that modern contraceptive services are made accessible nearly at all major urban areas in Ethiopia (including the study area, Adigrat town) and in most instances at lower or no cost [11], the utilization and intention to use LAPMs is low [8]. The modern contraceptive prevalence rate among currently married women in Tigray, Northern Ethiopia was 21.2%. It account implants 5.6%, female sterilization 0.3%, and none of them were using IUCD [8].

A given behavior is more likely to occur if the intention to practice is strong, no environmental barriers to perform it, and individual has skills and ability to perform the behavior [12]. Intention to use a method of contraception is an important indicator of the potential demand for FP services [13,14]. Therefore, understanding the characteristics of women with intention to use may provide further insight to demand and future use of LAPMs. In Ethiopia in general and in Tigray regional state in particular, very few studies have ever been conducted on intention to use LAPMs. It is, therefore, essential to examine the magnitude of intention to use and identify the associated factors affecting intention to use LAPMs.

Methods

A community based cross sectional study complemented by qualitative method was conducted from December 20, 2011 to January15, 2012 in Adigrat town, Tigray, Northern Ethiopia. The total population of the town according to the 2007 census report was 57,572, of which 31,573 (54.8%) were females in all age group [15]. According to the information obtained from the town Health Office, in the town there are six Kebeles with a total of 14,000 households (HH). There were 2 public health centers, 1 public hospital, 7 private clinics, 5 drug shops and 4 rural drug venders in the town during the survey.

A sample of 594 currently married women aged 15–49 years were included in the quantitative method. The sample size was determined using single population proportion formula. It is computed by considering the prevalence of intention to use LAPMs (65.8%) in Butajira town, Gurage zone, Southern Ethiopia, unpublished observations from MPH thesis conducted by Abdi Temesgen; marginal error of 4%, and 95% confidence level. This was found 540 and adding a 10% allowance for a non-response rate, the total sample size was 594.

Out of the total 6 administrative Kebeles in Adigrat town, 3 Kebeles were selected by lottery method. The total sample size was allocated by using proportional allocation to size (PAS) to the total number of HH in the selected Kebeles. The study subjects were selected by systematic random sampling. The sampling interval was 11 obtained by dividing the total HH in each of the selected Kebeles to the allocated sample to each of the selected Kebeles. Every 11th HH with currently married women aged 15–49 years were included. The first HH was chosen at the center of each Kebele by lottery method as a starting point, and then the data collectors were going in the right direction from the first chosen HH until the required sample size for the Kebele was achieved.

Eligibility criterion was currently married women of aged 15–49 years who were resident in the selected Kebeles of the town at least for 6 months. In case of absence of eligible woman in the selected HH, the next HH was taken. If there were more than one eligible woman in the selected HH, one was considered by lottery method for the interview.

For the qualitative method, purposively selected currently married women and currently married men were included in the focus group discussion (FGD). Participants interviewed in the quantitative survey were excluded from the FGD. Age and sex of the participants were considered for grouping of the participants in the FGD. Three sessions of currently married women and 2 currently married men FGD were conducted based on information saturation. Each FGD consisted of seven up to twelve discussants. Additionally, a total of six in-depth interviews were conducted with purposively selected FP service providers to see the perceptions and choice of clients towards the LAPMs. The inclusion criterion was health professionals in the health facilities who offer any of the LAPMs, and available during the data collection period.

The questionnaire was adopted and developed with modification from related studies [8,16]. Both quantitative and qualitative instruments were prepared first in English then translated to the local language (Tigrigna) (see Additional file 1). To check consistency of the translation; retranslation to English was done by other translator. Questionnaire was pre-tested on 5% of the same source population other than the sampled population of the town. Based on the pretest, questions were revised, edited, and those found to be unclear or confusing were modified. Finally, structured closed ended Tigrigna version questionnaire was used for data collection.

Five Tigrigna speaker females who had a minimum 12th grade completed were collected the data. Two diploma nurses supervised the data collectors. They have been trained for two days on the study instrument and data collection procedures. Data were collected through face-to-face interview with the study subjects. Filled questionnaires were checked daily for completeness, legibility and consistency.

Prior to data entry, each questionnaire was given a unique code by the principal investigator. The principal investigator prepared template and entered data using Epi Info version 3.5.1. Ten percent of the entered data were double checked by comparing the entered data with the actual questionnaire. Data were cleaned for missing values by running frequencies and outliers by computing standard scores for the quantitative variables.

Cleaned data were exported from Epi Info version 3.5.1 to Statistical Package for Social Sciences (SPSS) version 16.0 for analysis. Descriptive statistics were computed and presented in the form of texts and tables. A binary outcome variable indicating no intention coded as “0” and intention to use any of the LAPMs coded as “1” was used as the dependent variable. Intention to use LAPMs refers to all currently married women who are not currently using LAPMs but reporting intent to use any of the LAPMs at some time in the future. No intention to use LAPMs refers currently married women who are not currently using LAPMs and stating no intention to use LAPMs or unsure of their intention. Knowledge of LAPMs refers to the participants’ ability to name or recognize at least one of the LAPMs (implants, IUCD, female and male sterilization).

Bi-variate 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 bi-variate analysis (P-value < 0.05) were entered to multivariable logistic regression analysis [7,9,17,18]. 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.

For the qualitative method, after selecting the participants, appropriate time and comfortable place of discussion was selected and organized. All the FGDs were moderated by the principal investigator with the assistance of one trained note taker. The in-depth interviews were also undertaken by the principal investigator. The FGDs and in-depth interviews were taped and note was taken.

The collected data were transcribed to Tigrigna on daily basis and translated to English for further processing. The principal investigator and note taker reviewed key terms in Tigrigna and their respective translations to ensure a degree of standardization. Final transcripts were compared against note takers’ notes to ensure quality. Open code software version 3.6.2.0 [19] was used to facilitate coding. The various codes were compared based on differences and similarities and sorted in categories. Finally, based on content analysis, the underlying meaning; that is the latent content of the categories were formulated in to a theme [20]. Finally the findings were triangulated with the quantitative result during write up.

Ethical clearance was obtained from Research and Ethics Committee of the School of Public Health, College of Health Sciences of Addis Ababa University (AAU). Written permission letter was also obtained from Tigray Regional Health Bureau, and then Adigrat Woreda Health Office. Oral informed consent was obtained from the study participants. Confidentiality of the participants was kept throughout the study.

Results

Discussion

In this study the magnitude of intention to use LAPMs was 48.4%. This result was higher than the finding in Goba town (27.3%), which is found in South East Ethiopia [6]. This discrepancy could be explained by the difference in the study areas, and access to information and the services. More than sixty percent of the respondents did not want to have child within the next two years but their intention was low. This indicates that the FP providers need to assess the reproductive intention of the women and inform them about all the FP methods available during FP counseling. Fifty nine percent of the participants have intention to use at least one of the LAPMs in the coming one year. The most preferred LAPMs was implants (71.3%). This is relevant for program planning and provides some background for the provision of the different contraceptive method choices.

Almost all of the participants (94.7%) were able to recognize at least one of the LAPMs. This finding was higher than the findings in Mekelle (63.9%) [9] and Goba town (66.9%) [6]. This could be due to the recent continuous advertisement of LAPMs through mass media. The least known method was permanent contraceptives. This was similar with the finding in Mekelle [9]. More than one quarter (26.2%) of the participants perceive that LAPMs could harm the womb. Similarly, 53.6% of married women had negative attitude towards practicing of LAPM in Mekelle [9], and 27.5% women in China believe that sterilization is harmful to health [21]. A qualitative study in Scotland found that IUCD was perceived negatively [4]. The qualitative result in this study also indicated the presence of misinformation, fears and rumors on LAPMs which are keeping many women from intending to use LAPMs.

Partner’s education was one of the most important factors positively related to intention to use LAPMs. Similarly, this was positively associated with contraception utilization in Butajira district [7]. Increasing education might help in discussion on modern contraceptive and would increase knowledge about modern FP methods and hence, increase predisposition to their intention and use of LAPMs.

Women who did not desire additional children within the next two years were more likely to intend to use LAPMs. Similarly, the proportion of women intending to use LAPMs declines with increasing ideal desired number of children. This could be explained by the participants’ fear of fertility return after the use of long acting methods. Desire for more children was significant predictor of intention to use contraceptives [16,22]. Participants’ who knew at least one method of LAPMs had higher odds of intention to use LAPMs compared to their counterparts. Similarly, mothers who had knowledge were more likely to use LAPMs in Mekelle [9].

Women who perceive that contraceptives; especially LAPMs could make a woman sterile or harm her womb had 76% lower odds of intention to use LAPMs. In Pakistan, this perception was significantly associated with lower intention to use female sterilization (OR = 0.70), and IUCD (OR = 0.75) [16]. In this study, participants who perceive that their husbands do not support the use of LAPMs had 80% lower odds of intention to use LAPMs. Similarly, study in Butajira also revealed significant association between men’s support to FP and current use of contraceptive [7].

The study used a mixed design which helps to triangulate the quantitative findings with qualitative findings. However, cause and effect relationship was difficult to establish for the factors dealt in the study since it is cross-sectional study. Although an effort was made to ensure representativeness of eligible currently married women in the town, it does not include non married women or ever-married women. Moreover, the study did not ascertain the providers’ attitudes and behaviors on LAPMs use. Further detailed investigation of the FP service providers’ attitude and behavior on LAPMs, and quality of FP counseling sessions in the town should be conducted.

Conclusions

Based on the findings of the research it is concluded that the magnitude of intention to use LAPMs in the study area is low (48.4%) and the main reasons to this were fear of side effect and fear of fertility return after use. The principal factors affecting intention to use LAPMs were women’s perception that LAPMs can harm womb, and husband’s support of LAPMs use. Other factors which were significantly associated with intention to use LAPMs were knowledge of any of LAPMs, partner’s educational level, participants working status, women’s desire to have additional children within the next two years or soon, and ideal number of children wanted to have. The study has also clearly evidenced that knowledge of LAPMs, especially permanent method, was low accompanied with misconceptions.

The Federal minister of health, regional health bureau and other responsible organizations should continue the promotion of LAPMs through mass media. The woreda health office should design educational programs that promote and reduce barriers to modern contraceptive use especially LAPMs at community level in the town. The FP services should also be relevant for husbands to participate. Every woman who seeks FP information or services should be counseled on all methods of contraceptives to address misconceptions and fears that exist about LAPMs.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

AG carried out the conception and designing the study, performed statistical analysis and wrote the manuscript. AA participated in designing the study, analysis, reviewing and editing the final draft of the manuscript. Both authors read and approved the final draft of the manuscript.

Authors’ information

AG (MPH in Epidemiology), lecturer at Madawalabu University, AA (MD, MPH, MA) working in Addis Ababa University School of Public Health.

Supplementary Material

Acknowledgements

This study was financed by United Nation Population Fund (UNFPA). We would like to acknowledge the Regional Health Bureau of Tigray and Adigrat Zonal Health Office for their cooperation in conducting this study. We are very grateful to the study participants for their willingness to participate in this study and to the field data collectors for their hard work and sincere contribution.

We would also like to thank Ato Achenif Motbinor for his valuable comments starting from proposal development to writing up.