Keywords

Family planning; Infertility; Contraceptive; Sterilization

Abbreviations

CSA: Central Statistics Authority; EC: Ethiopian Calendar; EDHS: Ethiopian Demographic Health Survey; FP: Family Planning; GC: Gregorian Calendar; IUCD: Intra Uterine Contraceptive Service; KAP: Knowledge, Attitude and Practice; LAFPMs: Long Acting Family Planning Methods; PI: Principal Investigator; TFR: Total Fertility Rate; UNESAPD: United Nations Economics and Social Affairs Division; USAID: United Nation Aid for International Developments; WCA: Women of Child Bearing Age; WHO: World Health Organization.

Introduction

Background

Family planning is defined as the ability of individuals and couples to anticipate and attained their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility [1].

Family planning is voluntary use of natural or modern contraceptive by individual or couples. This approach helps the users to have the number of children they want to have and to assure the wellbeing of children as well as parents. The goal of FP is to decrease the rapid growth of population so that if will be compatible with living standard of the people. It also contributes for the effort to create sustained and efficient use of countries resources [2].

There are traditional methods of family planning, which is divided in to withdrawal and rhythm, and there are modern family planning methods, which is divided in to three: long acting reversible contraceptive methods (IUCD and Implants); permanent contraceptive methods (Tubal ligation for females and vasectomy for male) and short term contraceptive methods (oral pills, injectable, male and female condoms, foam tablet and cervical cup [3]. Intra uterine contraceptive devices [IUCD] and implants are long acting reversible contraceptive methods (LARCM); when removed, return to fertility is prompt [4].

Modern family planning methods account for the majority of current global contraceptive practices; almost nine out of every ten contraceptive users rely on a modern method. Female sterilization, intra uterine device and oral pills account for more than two-third of all contraceptive practice worldwide [5].

Globally, female sterilization is the single most used method and alone accounts for one-third of all contraceptive use worldwide. The IUCD is used by (22%) of all contraceptive users and the oral pill by (14%). The use of modern contraceptive methods differs significantly between the developing and developed areas. In the developing areas modern methods account for much larger share of total contraceptive use (90%) than in the developed areas (70%) [5].

In Ethiopia, the progress of contraceptive prevalence rate (CPR) is increase to 42 percent and total fertility rate of four [6]. Understanding the magnitude of need for modern family planning services, the Federal Ministry of health (FMOH) has considered the important role of long acting contraceptive methods and aim to provide all family planning clients with the long acting and permanent methods [7].

Currently, family planning becomes an important issue throughout the whole world. This is because of the unexpected and unwanted of population growth, as a result exposes to high maternal mortality and even the level of economic development and health care demands that uncontrolled fertility rate negatively effects on the family and the society as a whole [8].

Starting from the 1960, family planning service has become the major worldwide activity to influence fertility in the year 1965 family planning was accepted as an issue by only 21 countries, but in less than two decades, to mean that in 1983, access to family planning method in its modern way was limited in only seven countries useable, it is less than 1% of the world’s population [9].

Ethiopia’s population policy has been promoting the family planning method since 1989. Family planning contribute in the reduction of maternal and child mortality and morbidity, unwanted pregnancy and its consequence. In addition to this family planning encourages women to actively participate in production? In some regions community based on FP service have shown a significant progress in political, economic and social aspects. Therefore, in order to enhance the access of FP for house hold at community level Family planning extension package was designed [10]. This package is also important strategic tool to decrease maternal death by spacing or preventing pregnancies that occur too early or too close. This could avoid about 20% of maternal death or over 2500 maternal death and pregnancy related death over year in Ethiopia [11].

Long acting and permanent methods are by far the most effective type of modern contraception (with success rate of 99% or higher) and they are very safe, convenient and cost effective in the long run. This includes IUCD, Implants. They are all clinical methods and must be provided in health facilities by trained health professionals.

Statement of the problem

Currently, the world population growth is increasing through time to time in fastest manner. Such kinds of problems are much significant in developing countries like that of Ethiopia. This is true because currently Ethiopia is one of the most populated countries in Africa [1].

The world population in the year 1987 GC was 5 billion and it became 6 billion in year 2000 GC. Thus, it is increasing by 1.4% per year approximately. Therefore, if this rate of growth continues in such manner, the population will be 10 billion in 2035 [1]. If this rate of population growth continues in such manner, it will result economically, socially and health crisis throughout the world.

Unable to use modern contraceptives leads to unwanted pregnancy which intern results economic and social problem in the family. If the mother is giving birth frequently without enough gaps in between, she is stayed at home rearing her children. This problem prevents her from being active participant in the country and she will draw from social activity, it causes famine and makes the ecosystem unfavorable [12]. In terms of Health crisis unplanned pregnancy is known to represent a serious problem in Ethiopia today although only limited empirical data are correctly available. But the 2005 district hospital finding show more than 20-40% death of mothers is due to the complication of unsafe abortion. Most victim of unplanned pregnancy was adolescent. Giving birth at extreme age i.e., at early adult hood age and near to Menopause periods has health burden for both the mother and the neonate [13].

Demographic health survey conducted in Sub Saharan African countries from 2003-2005 showed that more than 20% of women in 9 of 11 countries surveyed do not want any more children. However, in each of the 9 countries less than 7% of women are using long acting and permanent methods [14]. This was due to lack of knowledge or access. This evidence suggested that a substantial unmet need for long acting and permanent family planning methods in sub-Saharan African countries including Ethiopia.

According to the 2014 GC Ethiopian mini demographic health survey (EMDHS) the total fertility rate in the mentioned year was 4.1 children per woman. The data show that the TFR decreased only slightly from 5.5 children in 2000 to 5.4 children in 2005, with a more pronounced decline to 4.8 children in 2011. This trend continues between 2011 and 2014 with fertility declining by 0.7 children per women. There are variations in TFR among regions of developing and developed once. That is ranging from 1.7 children per woman in Addis Ababa (below the replacement level of fertility) to 6.4 children per woman in Somali. Fertility levels are higher than the national average in Somali, Benishangul-Gumuz, Afar, Tigray, Oromiya and SNNP. The level of fertility is inversely related to women’s educational attainment, decreasing from 5.0 children among women with no education to about 2 children each among women who have secondary or higher education [15].

Therefore, creating awareness of family planning, increasing family planning service provision and again reducing the cost of family planning service are the basic element to minimize the fast growing of population in Ethiopia. According to the 2007 census report of CSA the population of Ethiopia was estimated to be 75.5 million. In addition to the medium variation projection of the CSA also indicated that the population number will reach 106 million 2020 [16].

This rapidly increasing number of population growth places pressure on resource, particularly by extending agricultural activities in to environmentally fragile area. This increasing number of population also simultaneously affect women. They are the most vulnerable groups of the population as a result of frequent pregnancies and child bearing that expose them to high risk of morbidity and mortality [17].

Unwanted and early pregnancies are common and usually lead them to serious complication and even to death because of abortion. The estimation of WHO indicated that 50,000 women die every year for each country due to pregnancy related cases in different countries. Among these usages abortion contributes 20-50% of the maternal death simply because of that women do not have access to safe procedure or treatment of complication of abortion [18].

However, despite many advantages long acting family planning service utilization remains relatively small and sometimes missing components of many national reproductive health and family planning method [19]. Such studies will assess the knowledge, attitude and utilization of LAFPMs among reproductive age of women in Mizan Aman town.

Significance of the study

In a country like Ethiopia with high fertility rate and unmet needs of contraceptives, shifting towards LAFPMs 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 inject able.

The Ethiopian Ministry of health has planned and is working on provision of all FP methods especially LAFPMs in the lowest service delivery level. Despite the fact those family planning services are made accessible nearly at all major urban and rural areas in Ethiopia (including the study area, MizanAman town) in most instance with no cost, the utilization and intention to use LAFPMs is low.

In south Region, there are also limited studies conducted to solve this problem. Hence this study will be helpful to show the level of knowledge, attitude and utilization of LAFPMs in MizanAman town so as the result of this study will help to plan an effective health service program which help to promote the health of the women’s in reproductive age group (15-49) as well as this study will be base line data for policy makers and for further study. So that this study aimed to assess the knowledge, attitude and utilization towards the use of long acting family planning methods among women of reproductive age group of Mizan-Aman town, South West Ethiopia.

Litrature review

All over the world about 350 million couples do not have access to information and service of FP including LARCMs. At the same time 120 million women would practice modern FP methods if they were available, affordable and acceptable by her husband, family and community [20].

Research conducted in India, which carried out 2005-2006 found that knowledge of at least one method of modern contraceptive is 97% of women and 95.5% of men of 15-49 years heard of female sterilization but the other methods are less popular. More than half of currently married women at national level (56%) reported use of some methods of contraceptives. Female sterilization accounts for more than 77% of all modern method use [21].

A health facility based, cross sectional study on knowledge and attitude of LARCM among women and reproductive age conducted in Uganda showed the mean age (standard deviation) and current use of LARCMs was 26.34 and 31.7% respectively and participants awareness of effective duration of effectiveness of IUCD, implant and injectable contraceptives was (68.5%), (69.9%) and (87.4%) respectively. Knowledge of prevention of IUCD and implant was (75.9%) and (80.2%) respectively. Despite of this, their myth on LARCM as it can cause permanent infertility is (32.9%) [22].

A study conducted on family planning service quality as determinant of use of IUCD in Egypt showed that nearly 40% of married women do not believe in practicing contraception and more than half believe that family size should be left up to God [23].

The cohort study undertaken on knowledge and use of family planning methods and services in Kenya revealed that the most popular methods among the informants were pills and injection, mentioned by (66.2 %) and (64.4%) respectively. It also showed that (69%) of women used of modern contraception while the use IUCD and implant were 14.4% and 17.9% respectively [24].

A finding in Malawi showed that positive attributes of LAPMs attributed that study participant’s increased desire in contraceptive were naturally associated with LAPMs [25].

About nine in every ten currently married women have heard about the pill and injectables. LAM is the least known modern method. Only 2 percent of currently married women have heard of this method. The overall knowledge of contraceptive methods among currently married women has increased from 86 percent in 2000 to its current level, a 13 percent increase over the last fifteen years. Knowledge has remained steady at 97 percent in the last three years. However, knowledge about IUD and implants has increased by 43 percent and 11 percent, respectively, while knowledge about male condoms decreased by 6 percent, over the same period [15].

Knowledge about FP and HIV is higher among men than among women. Knowledge among all women about any method of contraception is 86.1%, compared with 91% among all men. The average number of contraceptive methods known is 2.7 among women, compared with 3.6 among men. Yet women bear most of the burden of using FP methods: Male-dependent or maledominated contraceptive methods account only for 1.1% among the 13.9% CPR. This is despite better knowledge about maledependent methods than about female-dependent methods [26].

Different factors affect choice of LAFPMs by family planning clients. Marie stops international Ethiopia has conducted assessment of knowledge, attitude, practice (KAP) in five regions of Ethiopia among women of reproductive age show that 52% of were aware at least one types of long term method. The study documented that age of women, ethnicity, education, number of live birth, ever give birth, spousal/partner support, and, spousal/ partner communication ware found predictors factors of modern family planning use [27].

A study conducted to assess determinant of contraceptive use urban youth in Ethiopia reported that there is along discrepancy between knowledge and actual practice of contraceptive, only 39% female was used modern contraceptive [28].

A study conducted in Abidjan showed that level of knowledge about FP methods was vary in sampled women. Contraceptive knowledge was generally higher among in the middle age group, Christian and married women. Despite this awareness only 28% of women were using it. Use of contraceptive method was increased with educational level [29].

According to 2014 EMDHS preliminary report; 42% of currently married women are using a method of family planning. Nearly all uses modern methods. The most popular methods are Injectable (31.1%), Implants (4.9%), pills (2.7%) and IUCD (1%), only 1.6% of currently married women are using a traditional method. Information on where women obtain their contraceptive methods is important from a program and policy perspective. The public sector continues to be the major source of modern contraceptive methods in Ethiopia and serves 87 percent of users. In contrast, only 12 percent of users reported that their source of a modern method was the private medical sector [15].

Family planning service that provides accurate and complete information about contraceptive methods meets the needs of their clients. Still early marriage and producing too many children which are close to each other is a common practice of developing countries including Ethiopia. Long acting and permanent FP methods of contraceptive use have lowest rates nationally. It accounts IUCD 0.3%, Implants 3-4% and female sterilization 0.5%. The contraceptive prevalence rate of national level was 28.6% currently. The unmet need for family planning was 25%. Hormonal Implants are frequently underutilized FP methods [29,30].

A community based cross sectional study complemented by qualitative method was conducted in Adigrat town, Tigray Region, revealed that the prevalence of long acting contraceptive methods (LACMs) use among the women taking modern contraceptives was 19.5%, which Implants constituted for the highest (10.2%) [31].

Another study conducted in mekelle showed that 53.6% of married women had negative attitude towards LAPMs and 15.5% and 26.8% of married women perceived that implant causes irregular bleeding and severe pain during insertion and removal. On the other hand, 29.7% of married women have a belief that IUCD causes shame while it is inserted to cervix by health professional and 19.6% felt that it prevents from doing normal activities Study. And it also showed a LAPMs prevalence of only 12.3%. The majority of women (87%) used implants followed by IUCD users which were only 13% [32].

Another study done in Debremarkos Town in 2012 among married women also showed that the prevalence of LAPMs use was 19.5%, of those 83.2% was implant user, while the rest IUCD users [33].

Study conducted in Mekele showed Concerning the level of attitudes, more than half (53.6%)of the married women had negative attitude towards practicing of LAPM and those who had positive attitude used more LAPMs than those who had negative attitude (15). Finding in Jimma showed that positive attitude increased the utilization of family planning service [32].

Currently, research conducts in Debreberhan seen that the specific utilization of long acting contraception is found women users for implant 16.4% and 2.8% IUCD [34]. In addition, the EDHS’s research report that the women who are specific users of long acting contraceptive are implant 3% and IUCD 2% [29]. Knowledge of specific contraception methods among women 15-49 years in Ethiopia, on pills 77.5% and 82.6%, IUCD 11.1% and 14.8%, inject able 65.3% and 80.9%, condoms 33% and 46.5%, implant 13.6% and 22.6% on 2000 and 2005 GC respectively. Currently use of modern contraceptive method in 2005 is 14% [19].

A study conducted in north western Ethiopia among out of school youth related that the proportion of sexuality active never married adolescent who used modern contraceptive was 57% compared to only 12% of those who had ever married [27].

A study conducted in Addis Ababa June 2015, long acting reversible contraceptive methods use among modern family planning users in health center is 34.8%, knowledge of respondents 21.3%, 19.1% and 59.3% were high, moderate and low respectively. And regarding their attitude 32.7% and 67.3% were had positive and negative attitude respectively. Among several factors that would affect use of long acting reversible contraceptive methods study participants who had supportive attitude towards LARCM and contraceptive shifting or switching were found to be determinants of LARCM use [35].

A study conducted in Ambo town, Oromo region JUNE 2014, assessment of factors influencing utilization of long acting and permanent contraceptive methods among married women 31.8% and 24.5% of the women aware of that IUCD has no influence on sexual intercourse and it results in immediate pregnancies after removal, respectively. The majority (62.2%) of the married women aware of that implants result in immediate pregnancy after removal. With regard to attitudes about LAMPs, 50.5% and 46.6% married women agreed that implant can result in irregular bleeding and cause severe pain during insertion and removal respectively. Above (40.6%) of the married women agreed that insertion of IUCD can result in shame while it inserted to cervix by health professional [36].

A study conducted on Long Acting Contraceptive Method Utilization and Associated Factors among Reproductive Age Women in Arba Minch Town, Ethiopia revealed that Long acting contraceptive method utilization was 13.1% [37].

A study conducted in Mizan-Aman district, south west Ethiopia June 2014, assessment of men’s involvement in long acting and permanent contraceptive use among currently married men aged 20-60 years, 33% of study participants had high knowledge [38].

Objectives

General objective

• To determine the knowledge, attitude and utilization towards the use of long acting family planning methods among women of reproductive age group of Mizan-Aman town, Bench- Maji Zone, South West Ethiopia, 2016.

Specific objectives

➢ To determine the level of knowledge of women of child bearing age towards long acting family planning methods in Mizan-Aman town,

➢ To determine the level of attitude of women of child bearing age towards long acting family planning methods in Mizan-Aman town,

➢ To assess the level of utilization of long acting family planning methods among women of child bearing age in Mizan-Aman town.

Methodology

Study design

➢ A community based descriptive cross- sectional study was conducted.

Study area and period

This study was conducted from April 08 to April 30, 2016 EC in Bench-Maji Zone Mizan-Aman town. The zone has total population of 760,314; of which 381, 449 are males and 378,865 are Females. MizanTeferi with the neighbouring town of Aman forms a separate woreda called Mizan-Aman surrounded by south Bench Woreda. Mizan-Aman town is the largest town and administrative center for Bench -Magi Zone [39]. This town has latitude and longitude of 7°0ˈN 35°35ˈE/7.000°N 35.583°E and an elevation of 1451 m above sea level. The zone has 33 health centers, one General Hospital, and also the location of two institutions of Higher education, namely Aman Health Science College and Mizan-Tepi University. The General Hospital is located in Aman town and established in 1986. According to the South Nations Nationalities and Peoples Region Bureau of finance and economic Development, as of 2003 MizanTefere’s amenities also include digital telephone access, postal service, and a bank and a hospital. Near the town is the Bebeka coffee plantation. Based on the 2008 census conducted by central statistics Agency, Mizan- Aman woreda has a total population of 48,934 of whom 23,978 are men and 24,959 are women. The majority of the inhabitants practiced Ethiopian Orthodox Christianity, with 45.97% of the population reporting that belief, 33.8% were Protestants, 17.71% were Muslim, and 1.05% practiced traditional beliefs.

Target population

➢ All women of child bearing age living in Mizan-Aman town.

Source population

➢ All women of child bearing age living in Mizan-Aman town, in selected kebeles.

Study population

➢ Selected women of child bearing age living in Mizan-Aman town, in selected kebeles.

Study unit

➢ House hold.

Inclusion and exclusion criteria

Inclusion criteria: All women of child bearing age living in Mizan- Aman town, Kommeta and Adis ketema Kebele.

Exclusion criteria:

➢ woman who stays in the study area for less than 6 months.

➢ Women who are unable to communicate.

➢ Women who are living outside the specified Keble.

Sample size, sampling technique and sampling procedure

Sample size: The sample size for this particular study was determined by using single population proportion formula using a basic assumption of 95% confidence level, 5% margin of error and Proportion (P): proportion of long acting reversible contraceptive Method (LARCM) use was 34.8% among family planning users in Addis Ababa [35] and using the formula,

Since it is multi stage sampling technique so by using design effect and multiplying by 2 becomes 696 and Contingency (for non-response=5%) =34.8=35 so the final sample size is n_f=731.

Assumptions:

ni=initial sample size; 348; nf=Final sample size=731; Z=confidence level which were 95%; P=proportion=34.8%; d=the margin of error was taken as 5%.

Sampling technique: Multi-stage sampling Technique was used to select the study subjects.

Sampling procedure: The study was conducted in two Keble’s of Mizan-Aman town. From five Keble’s found in Mizan-Aman town, two Keble’s were selected using simple random sampling method (lottery method). The sample size was allocated to each Keble’s by proportional to size of house hold from selected Keble’s by considering that there is at least one reproductive age women per house hold. The study participants were selected by systematic sampling method from those selected Keble’s. The first house was selected by lottery method to avoid bias and was continued every K^th interval (5^th interval). The sampling interval of households in each Keble was determined by dividing the total number of house hold to final sample size. when two or more children bearing age women were present in one household, only one women was considered in the study on random to avoid intra-class correlation.

where, N=total Number of House Hold; n_f=final sample size; K=Sampling interval.

Variables of the study

Dependent Variables:

➢ Knowledge

➢ Attitude

➢ Utilization

Independent Variables: Socio-demographic Variables

➢ Age,

➢ Marital Status,

➢ Educational status,

➢ residence,

➢ Occupation,

➢ Age at 1st marriage,

➢ Age at 1st birth,

➢ No of living children

➢ High parity

➢ Abortion

Socio-Economic Variables

➢ Income,

➢ Access to media,

➢ husband and partners influence,

➢ Discussion with partners.

Operational definitions

Long-acting family planning methods: This is a contraceptive method in which their lengths of action range from 3-12 years (intrauterine devices and implants) and return fertility soon after removal.

Knowledge: Awareness or familiarity of respondents or women with some degree of having information and range of understanding on LARCMs that stored on memory in terms of high, medium or low level on the overall knowledge questions.

➢ Good knowledge: Those who scored above 75% of Knowledge question on LAFPMs.

➢ Moderate knowledge: Those who scored 50-74% of Knowledge question on LAFPMs.

➢ Low knowledge: Those who scored below 50% of Knowledge question on LAFPMs.

Attitude: Belief or feeling hold by the women of child bearing age about the importance of long acting reversible contraceptive methods. The level of attitude is measured in terms of positive and negative attitude. The attitude of the respondent is said to be positive attitude if those who scored above the mean on attitude items. Negative attitude those who score mean and below mean of attitude assessor questions.

Utilization: To make use of actual performance of the action how women of child bearing age use the LAFPMs to prevent unwanted pregnancy and its complication like unsafe abortion. If the respondents have utilization classify as ever use and current use, and no history of using LAFPMs considered as not using.

➢ Ever users of LAFPMs - are women who used IUCD and implant any time in their life.

➢ Current LAFPMs users - are women who are using LAFPMs during the survey.

Data collection tool and procedure

The data was collected by carefully designed and standardized questionnaires which were developed from deferent literatures. The questionnaire was developed in English language originally and translated to Amharic. The study instrument was taken from studies done in Addis Ababa town [35]. The survey questionnaire was pre -tested and the necessary modifications and correction took place to ensure its validity.

The data was collected by six 4th year midwifery studentsin April 08 to 30 2008 EC from selected Keble’s. To maintain the quality and uniformity of the data we discussed on how to approach and collect the data. Then, we were taken an ethical clearance from department of midwifery, college of health science, Mizan-Tepi University, and woreda health office. During data collection, we were told the significance of the research to the respondents then take consent of the respondents. After that collect, the data using manual structure and well organized questionnaire prepared for face to face interview by translating it to Amharic language then go back to English. After collecting the data, we were checked the completeness of each question.

Data quality control

To keep the consistency of the questionnaire, it was first prepared in English and then translate into Amharic and back to English in order to keep its consistency. A pre-test was done on 10% (73) of the study unit 1 week prior to data collection outside selected Keble’s in Mizan-Aman town and modification was done according to the pre-test. The data collectors were check the completeness of the questioner before the leave each questioner. Supervision was done by principal investigators together for data quality and completeness. Each questionnaire was given a unique code by the Principal Investigator. The principal investigator prepared the template and entered data using SPSS version 20 then, the entered data were cleaned for anomalies prior to data analysis. Frequency distributions were used to check for missed values and outliers during analysis. Any errors were corrected after revision of the original data using the code numbers of the questionnaires. Data were cleaned for inconsistencies and missing values and analyzed using SPSS version 20 statistical software.

Data analysis and processing

The data was analyzed using Statistical Package for social science (SPSS) version 20. Women’s knowledge was measured by the total number of correct answers to six items of knowledge with a minimum score of zero and maximum six. Measure of knowledge was categorized based on the percent of knowledge of the distinct characteristics of LAFPMs as high those who knew 75% and above, moderate those who knew 50-74% and low those who knew less 50%. The study participant’s attitude was measured as positive and negative attitude. Three-point attitude likert scales were used with six attitude questions considered, and those that have scored above mean was grouped as positive attitude and mean or below mean were grouped as negative attitude. Frequencies and Proportions were computed for a description of the study population in relation to socio-demographic and other relevant variables (age, marital status, no children). Descriptive statistics like frequency distribution mean and standard deviation was used. The results were presented in the form of tables, figures and summary statistics (Figure 1; Tables 1-9).

Table 1: Showing numbers of student’s n each college.

Table 2: Socio demographic characteristics of MTU Tepi campus students, Sheka zone, SNNPRs, Ethiopia, 2017.

Table 3: knowledge characteristics of MTU Tepi campus students, Sheka zone, SNNPRs, Ethiopia, 2017.

Table 4: Distribution of knowledge of some basic concepts of RH and RH services among MTU students.