Correlation of Unmet Need and Discontinuation in Ethiopia: a View

Abstract

A few key factors affecting usage of all methods and contraceptive discontinuation among women whom are currently married in Ethiopia are discussed. What are the factors affecting women’s contraceptive use? The aim is to explore the two regions on the basis of high total fertility rate (TFR) regions (Oromiya (5.6) and Southern Nations, Nationalities, and People’s Region (SNNPR) (4.9)) in the Ethiopian demographic and health survey (EDHS) 2011. A descriptive and comparative study using the quantitative research method is chosen to address the above research question. The study findings show that the contraceptive discontinuation rate for users of all types of methods is 37%. The highest women’s discontinuation rate is for the pill which is 70% due to side effects.

Keywords

Family planning unmet need spacing limiting discontinuation

Introduction

Ethiopia is situated in the horn of Africa with a population of approximately 87 million (Population Reference Bureau, 2012) with the largest proportion residing in Oromiya and the Southern Nations, Nationalities, and People’s Region (SNNPR). As a result of a high growth rate, the projected population of the country is expected to reach 118 million in 2025 (Central Statistical Agency (CSA), 2008). It is a multi-ethnic group country with approximately 85 nations and nationalities contributing their own cultures and languages. However, Ethiopia is considered to be the poorest country in the world. As one of the least developed countries, it is faced with many social and economic problems. Zewudu Wubalem et al. (2003) illustrate that the high fertility of the population is attributed to low levels of contraception, cultural values favoring large family size, low socio-economic development, and high infant and child mortality. In view of this, most Ethiopians are suffering from the lack of basic needs of life such as food, clothing, housing, health care, education, and a safe and healthy environment as consequences of the uncontrolled and rapid increase in population growth.

The health status indicators acknowledged the life expectancy was 50 years for females and 48 for males (CSA, 2007). The crude birth rate was 45.2 per 1000 (CSA, 2008) and the death rate was 11.8 per 1000. Infant mortality remains high, with an infant mortality rate of 82.6 per 1000 live births. The population rate of natural increase was 2.6% (CSA, 2008) and the total fertility rate (TFR) was 5.4 births per woman according to the Ethiopian demographic and health survey (EDHS) report 2005 (CSA and ORC Macro, 2005). In Ethiopia, despite a governmental program supporting family planning and despite the improvements over the last 20 years, the TFR is coming down but remains high (5.5 in 2000, 5.4 in 2005, and 4.8 in 2011) and current use of all contraceptive methods is still low, although it is more important than in the past (5% in 1999, 8% in 2000, 14.7% in 2005, and 28% in 2011). When focusing on regions with a high TFR, and relatively high birth and mortality rates, Ethiopia is still in the early stages of demographic transition. About 86% of the population lives in rural areas within the SNNPR of Ethiopia (CSA, 2010) and the TFR for the region was reported to be 4.9 children per woman (EDHS, 2011). The contraceptive prevalence rate (CPR) of the region according to EDHS (2011) is approximately 28%. The Oromiya region is one of the largest regions in Ethiopia in terms of size and population. The majority of the people in Oromiya (88%) live in rural areas (CSA, 2008). This region has the highest fertility rate in the country. The TFR was about 5.6 children per woman and 4.9 in SNNPR (Demographic health survey (DHS), 2011). The regions chosen to participate in this study were chosen via convenience selection. The proximate determinants of fertility are the biological and behavioral factors through which social, economic, and environmental variables affect fertility (Bongaarts, 1996, 1999). The determinant factors that can account for the region’s high fertility include the following: the young age at the time of marriage, closely spaced births, a large reproductive life span, and some cultural beliefs relating to children in a family (Bongaarts, 1999). The fast and large growth of the population is a consequence of giving less worth toward family planning, and it is of course related with other factors. Some studies explained the use of contraceptives because of their relationship with fertility and birth spacing. Contraceptive use has a significant impact on reducing women’s fertility levels (Ntozi and Ahimbisibwe, 2001). Family planning services have become one of the best interventions of choice to the slow population growth of a country. It is believed that child spacing and the timing of every birth can improve the survival chance of the child and can maintain good physical and emotional health for the whole family. This study tried to find out a major factor which contributes to the influence of family planning usage in the selected regions and reasons for the discontinuation of family planning usage. However, the DHS showed that in 1992 contraceptive use among married women in many African countries ranged between a low of 1% to a high of 25%. The 1990 national family and fertility survey report (CSA, 1993) indicated that the prevalence of contraceptive use among sexually active women under the age of 20 in Ethiopia was 2.6% only. Despite high knowledge of family planning (92%) only 28% of women whom are currently married are using ‘any contraceptive method’ (EDHS, 2011). This is comparatively good progress. Similarly, the CPR in Oromiya (26.2) and in SNNPR (25.8) (DHS, 2011) is significantly lower relative to the awareness of the long acting effects of family planning methods among women whom are currently married.

The unmet need for family planning remains high, with one in three women whom are currently married not able to meet their family planning needs (EDHS, 2011). An unmet need for family planning of 33% means that one-third of women in the country want to stop childbearing or space their next birth by at least two years, but they are not currently using contraception. As usual, lack of access to family planning, less knowledge, and the attitudes of Ethiopian women are contributors to these women having more children than they want. Besides this, the unmet need for family planning services of women whom are currently married is still slightly declining from 34% in 2005 to 32% in 2011. Most Ethiopians seem to want a relatively large number of children, and this may continue until there is greater economic development and urbanization, improved literacy levels, and culturally sensitive community-based family planning promoted throughout the country especially in rural areas where poverty, illiteracy, and rural residence inequalities are widening (Hailemariam and Teller, 2007). A study conducted in Kenya has shown that the unmet need among couples seemed to decline with increasing education (Omwago and Khasakhala, 2006). This study further stated that couples who are more educated can afford to buy contraceptives, are more likely to reside in the urban areas where contraceptives are more accessible, are more informed about the available methods, and are more likely to prefer small families than their less educated counterparts. As a result, those with no education had the greatest unmet need.

However, notably the DHS (2011) findings show that two in five contraceptive users among those who began contraceptive use from 3–59 months preceding the survey have discontinued contraceptives within 12 months of beginning use. The reasons for recent discontinuation include a desire to become pregnant (14%), a switch to another method (13%), or another reason (19%). Only 2% of users discontinued due to method failure. Injectable contraceptives had a discontinuation rate of 37%. Users who discontinued use of contraceptives over the five years preceding the survey did so because they wanted to become pregnant (35%) or because they had health concerns about the method (26%), particularly regarding intrauterine contraceptive devices (IUDs) (52%) and the pill (70%). Unfortunately, in Ethiopia the total female sterilization use was in total 28 women only, with Oromiya and SNNPR at 3 and 5 respectively; the rest of the cases are distributed among the other regions (EDHS, 2011). Many studies have debated different issues with regards to contraceptives use—whether there is a low use rate or high contraceptives use rate among users. But none of the studies have analyzed contraceptive user’s discontinuation or side effects of all contraceptive methods of users in Ethiopia. Therefore, the aim of this study is to explore a major factor affecting women’s contraceptive use and discontinuation in the selected two regions of Ethiopia. The study also examines contraceptive behavior following a discontinuation and the fertility consequences of contraceptive discontinuation and failure. Many research findings show that women are having more family planning knowledge and a low contraceptive use rate. Many studies focused on the intention to use, the future use, and the unmet need for family planning including the spacing of births and limiting the total number of births. However, there is a lack of (or few) side effects or discontinuation studies and information is very limited especially in Ethiopia where none of the previous studies have focused on these specific issues.

Methodology

Method

Bivariate and multivariate analyses are also undertaken to study the relationship of a set of explanatory (independent) variables with contraceptive use, discontinuation, and the unmet need for family planning and to determine which variables have the most effect on the dependent variables.

Variable Selection

The explanatory variables to be included in this study are selected by reviewing the available related literature. The response variables are current use and the unmet need for family planning methods. The current use of contraceptives refers to the use of any traditional and modern contraceptive method reported by the women at the time of the survey and the unmet need for family planning refers to women who either want to wait at least two years before having their next birth (unmet need for spacing) or stop childbearing entirely (unmet need for limiting) but are not using contraception. Independent variables are grouped into three categories. Note that both dependent variables have two categories which are use and non-use for contraceptive use and are met and unmet need for family planning, and all the predictors are categorical variables. Once the factors affecting the dependent variables are identified using bivariate analysis, binary logistic regression could be employed to determine the relative importance of these factors. In EDHS 2011 (2011), variable denotes the last method discontinued in the last five years (by different methods) and the variable reason of the last discontinuation. The respondents addressed many reasons for discontinuation such as became pregnant, wanted to become pregnant, husband disapproved, side effects, health concerns, access, availability, wanted more effective method, inconvenient to use, infrequent sex, husband away, cost, fatalistic, difficult pregnancy, menopause, marital dissolution, other, and do not know. The variable coded as last method discontinued (in last five years) was set equal to ‘1’, unless the response was other, then it was set equal to ‘0’. There are three other important variables which were included in these analyses: 1. visited by family planning workers in the last 12 months (yes = 18% and no = 82%); 2. visited health facility in the last 12 months (yes = 36.9% and no = 63.1%); and 3. while at health facility told about family planning (yes = 28.3% and no = 71.7%). The reference category of each measured independent variable has a value of ‘1’ and the values for the other categories are compared to that of the reference category. A value less than one implies that individuals in that category have a lower probability of reporting discontinuation and the unmet need for contraceptives than individuals in the reference category.

A number of socio-economic, demographic, and family planning variables should be used for the log-linear model fitting and analyzing in order to examine the factors affecting the unmet need and contraceptive discontinuation in the study regions. The regression models are also estimated separately for the SNNPR and Oromiya regions to see if the factors affecting discontinuation of contraceptive use and the unmet need are basically similar in the two regional settings. Data analyses were performed using Statistical Packages for Social Science (SPSS) version 22.0.

Data

At present Ethiopia is administratively structured into nine regional states—Tigray, Affar, Amhara, Oromiya, Somali, Benishangul–Gumuz, SNNPR, Gambela, and Harari—and two city administrations, Addis Ababa and Dire Dawa Administration Councils (EDHS, 2011). The study is based on the analysis of secondary data obtained from the 2011 EDHS (2011) and it is used to complement the quantitative results. The 2011 EDHS is the latest and the second nationally representative, large-scale dataset on demographic and health information in Ethiopia. As this study focuses on the two regions which have a sample of 2135 Oromiya women, of which 2034 SNNPR are women whom are currently married and the rest of the regions have a lower number of married women. The total number of contraceptive methods discontinued in the last five years was 1790 for women whom are currently married in Ethiopia which is 675 women from Oromiya and 644 women from SNNPR and the remaining number are from the other regions. Among women aged 15–49 who started an episode of contraceptive use within the five years preceding the survey, the percentage of episodes discontinued within 12 months by specific methods are the pill (70%), injection and other methods such as implants (34%), male condom (63%), and the rhythm method (24%). Note this article is specifically focused on women’s use of the pill and injections. The numbers for other method users are significant but none of these cases were reported as discontinued within the last 12 months.

Results

Bivariate Analysis

The χ² test for independence is used to determine whether there is an association between two categorical variables. For this reason a preliminary assessment was used using the χ² test in order to determine the factors which are significantly correlated with the dependent variables by region. Results for the bivariate analysis are presented in Table 1. We can realize that the obtainable variables are of the socio-economic and demographic factors. Furthermore, family planning factors considered age, fertility preference, and ethnicity (P ≤ 0.05), age at first marriage, educational level, place of residence, employment status, knowledge of family planning, and heard of family planning (P ≤ 0.001) were found to have statistically significant association with SNNPR women’s current contraception use. For the Oromiya region, the results showed that there was a significant association between current use of contraceptive and the age of the women, the number of living children (P ≤ 0.05), and ethnicity, religion, educational level, place of residence, knowledge of family planning, and heard of family planning (P ≤ 0.001). There were some variables that had significant association with the unmet need for family planning. The bivariate result indicates that the women’s age at their first marriage is significantly associated with the unmet need for family planning in SNNPR (P < 0.05) and it was not statistically significant with the unmet need in the Oromiya region. As indicated in Table 1, except religion (SNNPR) and employment status (Oromiya), all other socio-economic characteristics are statistically significant with the women’s unmet need for family planning. The main problem with the bivariate approach is that it ignores the possibility that a collection of variables, each of which could be weakly associated with the outcome, can become an important predictor of the outcome when taken together (Hosmer and Lemeshow, 1989). Hence, a multivariate logistic regression approach that takes into account the drawback mentioned of the bivariate technique is considered in the following analysis. Consequently based on the bivariate results, variables, which showed strong significant difference between current and continuous users and non-users of contraceptives and the unmet need, are selected for further analysis.

Table 1.

Distribution of Chi–square and P–values showing association between variables and discontinued last method and unmet need for family planning for the selected two regions in Ethiopia, 2011.

Characteristics	Discontinued last method SNNPR		Discontinued last method Oromiya		Unmet need SNNPR		Unmet need Oromiya
	X²	P–value	X²	P–value	X²	P–value	X²	P–value
Present age	15.6	0.0***	13.8	0.0***	03.9	0.7	09.8	0.1
Age at first marriage	18.2	0.0**	02.8	0.7	11.5	0.0***	02.8	0.6
Number of living children	10.5	0.6	10.7	0.0***	02.9	0.4	02. 8	0.4
Total ever born	11.9	0.6	31.9	0.0***	07.9	0.1***	05.8	0.1
Ideal number of children	11.4	0.1	55.6	0.0*	06.5	0.5	38.7	0.0*
Fertility preference	08.1	0.0***	36.9	0.0*	08.0	0.1	16.2	0.0*
Ethnicity	16.6	0.0***	58.6	0.0*	15.2	0.0***	34.3	0.0*
Religion	02.5	0.6	35.4	0.0*	08.7	0.2	41.7	0.0*
Educational level	53.5	0.0*	01.6	0.0*	39.0	0.0*	01.3	0.0*
Place of residence	42.4	0.0*	01.3	0.0*	27.7	0.0*	01.1	0.0*
Employment status	27.8	0.0*	02.8	0.1	17.6	0.0*	02.5	0.5
Heard of family planning	40.3	0.0*	40.3	0.00*	–	–	–	–

P < 0.001; **P < 0.01; ***P < 0.05

Source: reproduced with permission from Ethiopian Demographic Health Survey (EDHS), 2011.

Multivariate Analysis

Fertility rates in Ethiopia declined very slowly and the level of fertility continues to be high. At an average of 5.9 births per woman, fertility far exceeds the 2.1 children per woman figure needed to maintain the population size over the long term. This rapid rate of population growth is exacerbated by the fact that one out of three births in the country is unplanned. The use of contraceptives is one and the most important way of minimizing the unplanned births and the size of the family. In developing countries such as Ethiopia, the use of contraceptives among women is less (20%) and it is influenced by several factors. The results of the analysis make it evident that contraceptive use in the SNNPR and Oromiya regions of Ethiopia is influenced by a number of demographic and socio-economic factors, and that supply related indices of family planning programs are crucial in increasing the likelihood of contraception. The analysis of the factors affecting contraceptive behavior showed that most of the women had knowledge (92%) of at least one contraceptive method. There is a wide gap between use of contraceptives (just 20%) and women having knowledge of at least one contraceptive method (92%). How can we fill that gap? We were able to investigate the question with the multivariate analysis.

A number of explanatory variables were included in the analysis of contraceptive use, the unmet need and the discontinued cases as shown in Table 2. The seven explanatory variables are those cases which are mentioned above in the bivariate analyses. However, present age, age at first marriage, fertility preference, place of residence, ethnicity, educational status, employment status, and heard of family planning are significant predictors of the current use of contraceptive methods in the SNNPR and Oromiya regions. Remarkably, the literature showed that women are less likely to use contraceptives if they are younger at the time of their first marriage. However, the result reveals that when marriages starts at an age of 15–24, there is a statistically significant association with contraceptive use in SNNPR. This age group is 1.424 times more likely to use a contraceptive than the reference group.

Table 2.

Logistic regression models predicting the odds of discontinuation of the last method and the unmet need for family planning for two regions, 2011.

Variables	Discontinued last method				Unmet need for family planning
	SNNPR		Oromiya		SNNPR		Oromiya
	β	Exp(β)	β	Exp(β)	β	Exp(β)	β	Exp(β)
Present age
15–19 ®		1.0		1.0
20–24	0.6	1.7	0.6	1.8	–	–	–	–
25–29	0.3	1.3	0.3	1.4
30–34	0.4	1.5	–0.4	0.7
35–39	0.5	1.6	0.2	1.2
40–44	0.1	1.1	–0.6	0.6
45 and above	–0.6	0.6	–0.8	0.4
Age at first marriage
≤ 14 ®		1.0	–	–		1.0	–	–
15–24	0.4	1.4***			–0.5	0.6**
25 and above	0.6	1.8			–0.4	0. 7
No. of living children
None®	–	–		1.0	–	–	–	–
1–5			19.5	3.1
6 and above			19.9	4.2
Ideal number of children
None®	–	–		1.0				1.0
1–5 children			1.1	3.0**	–	–	–0.8	0.4*
6 and above			0.4	1.6			–0.4	0.7
Fertility preferences
No. more children®		1.0		1.0	–	–		1.0
Have another one	–0.4	0.7***	–0.5	0.6***			0.3	1.3
Other	–1.3	0.3	0.3	1.3			–0.7	0.5
Educational level
Illiterate®		1.0		1.0		1.0		1.0
Literate	0.2	1.2	1.0	2.8*	–0.3	0.8	–0.7	0.5**
Ethnicity
SNNPRR	0.7	2.0	0.8	2.2	–0.4	0.5	–1.1	0.3***
Oromiyo	–0.5	0.6	0.3	1.4	0.4	1.5		0.7
Other®		1.0		1.0		1.0	–0.4	1.0
Place of residence
Urban	0.7	2.1***	1.3	3.7*	–0.8	0.5	–1.5	0.2*
Rural®		1.0		1.0		1.0		1.0
Employment status
Not working®		1.0	–	–		1.0	–	–
Working	0.7	2.0*			–0.7	0.5**
Knowledge of family planning method
Knows no method®		1.0		1.0		1.0	19.4	1.0
Knows any method	19.1	1.1	18.4	1.0	–20.3	0.0		0.0
Heard of family planning
No ®		1.0		1.0		1.0		1.0
Yes	0.7	2.0*	0.8	*2.2	–0.6	0.6**	–0.8	0. 5*

Reference Category; *P < 0.001; **P < 0.01; ***P < 0.05; — Not Applicable.

Source: reproduced with permission from Ethiopian Demographic Health Survey (EDHS), 2011.

Discussion

Age and Age at Marriage

According to the study findings, most of the women were at a young age. Altogether, 49% of them were below the age of 30. There was a significant relationship between the age of the women and the current use of contraceptives in both regions. A supported study also mentioned that the contraceptive prevalence in Indonesia showed younger women were more likely to be currently using or used contraceptive than older women. Age differentials in contraceptive use among women whom are currently married were also significant. Many results supported that Ethiopian women are married at an early age and it was also found to be the same in this study. In Ethiopia, the median age at marriage among women is estimated at 16.1 years, and 79% of them were already married by the age of 20 (EDHS, 2011). The bivariate analysis proved that the age at first marriage is significant in SNNPR and it was also found that there is a significant association with current use and the unmet need for family planning for the age range of 15–24. Women who got married younger were less likely to use contraceptive and had a higher level of unmet need for contraception. When women become married they want to have children soon, as such they do not want to use contraceptives.

Fertility Preference

Fertility preference is one of the factors which have an effect on a women’s reproductive scenario. It is found that there is a significant association between fertility preference and the predicted variables. This variable is negatively associated with the current use of contraceptives. Those women who prefer to have another child were less likely to be currently using contraceptives than those who did not prefer another child in both regions. Having any children, the number of living children, and the ideal number of children are important demographic factors which determine the size of the family and a woman’s reproductive life. As discussed earlier, in Ethiopia the fertility rate is high compared to other sub-Saharan countries. According to this study, this factor did not have that much effect on women’s use of contraception.

Ethnicity

In Ethiopia there are approximately 85 ethnic groups. Evidence shows that the ethnic groups also play a major role in the discontinuation of contraceptive method use. The ethnic differences in the unmet need reflect variation in the levels of contraceptive use and the stage in fertility transition. It further compares well with the results of the regions, whereby areas with low fertility and high contraceptive prevalence are less likely to have a high unmet need (Omwago and Khasakhala, 2006). As we stated in Table 2, exposed women from the SNNPR ethnic group were less likely to have a totally unmet need for family planning. In addition, there was a high CPR, low TFR, and low unmet need for family planning in the SNNPR relative to the Oromiya region.

Religion

Religion shows enormous differences between the SNNPR and Oromiya residents. In the SNNPR, 83.8% were Orthodox Christians while the Muslims constituted 15.8% of the responding women. In Oromiya the Orthodox Christians and Muslims constituted 30% and 49.9%, respectively, followed by Protestants at 15.5%. The contribution of the other religions was only 0.5% in SNNPR and 4.7% in Oromiya. We are not interested in discussing more information on religious factors at this stage, because our aim is to focus on the unmet need and discontinuation cases only. Another specific reason does not exist.

Women’s Educational Level

Education is one of the most important key factors that had a strong effect on women’s knowledge and preconception of contraception methods and on usage (National Population Commission and ORC Macro, 2004). More than half of the women had no formal education (85% of women in SNNPR and 77% of women in Oromiya). Women who were literate used contraceptive more than women without an education. According to the bivariate analysis, education had a positive effect on the current and unmet need for family planning in both regions. A supported study shows that those women who are literate were found to be more likely to be associated with the current use of any contraceptive method (Koc, 2000). Also found is that there is a positive association between the educational level of women and the use of contraceptive methods in Turkey. On the other hand, women who were more educated were less likely to have an unmet need for contraception. It is expected that respondents with better education have a lower unmet need and this may be due to the indirect effect of education on contraceptive use through knowledge of contraceptives and awareness of the source of supply (Getaneh, 2003). These finding are supported by the result of Mohmood and Dure-E-Nayab (2000) which shows that a higher level of education of women results in a lower number of children.

Place of Residence

Place of residence is one of the most important factors that emerged from the logistic regression analysis as an influence on discontinued contraceptive use. Women who live in urban areas have more opportunity to get better facilities and accesses to information, communication, and education than rural women. The influence of the place of residence has also been seen on women’s discontinued use of contraception and the unmet need for family planning methods. Rural women are statistically significant and more likely to discontinue the use of contraceptive methods as compared to those women who reside in urban areas. The results showed that women who live in urban areas are less likely to have an unmet need for contraception. This is because it is easy to obtain family planning methods and services in urban areas and also it may be that rural women are less educated and tend to prefer large family sizes when compared to urban women. Many rural illiterate women are not able to discuss matters relating to contraceptive use, non-use, or discontinuation matters because of being shy or because of issues pertaining to taboos.

Employment Status

Women who are currently working had a lower unmet need for contraception (36%). The regression results revealed that employment status was significant with current use of contraceptives in SNNPR. Those women who were currently married and currently working were more likely to use contraceptive. The negative association between the unmet need and employment status confirmed that women who were employed were less likely to have an unmet need for family planning methods in SNNPR and the wider sample. The above result is supported by the previous studies which revealed the impact of economically active women on contraceptive use (Fikree et al., 2001; Hakim, 2006). The possible explanation for this relation is that maybe employed women contribute to the household income and this also raises the autonomy of women and it leads into the high use of contraceptive methods and a lower unmet need of family planning methods. Mass media are a gateway to new ideas and a source of important health information. As expected, urban residents have far more exposure to mass media than rural dwellers, especially women. Women who have heard of family planning, including side effects, were much more likely to discontinue the use of contraceptives than those who had no sufficient information about family planning. Promoting family planning on radio or television can be an important means to raise awareness, improve knowledge, and stimulate the use of modern contraceptive methods (Feyisetan and Ainsworth, 1984; Olaleye and Bankole, 1994; Parr, 2002).

Heard of Family Planning

The result reports that women who have not heard of family planning from any mass media source were less likely to have a totally unmet need for family planning methods. The population of Ethiopia is growing by more than two million per year. The study areas are known to have a high rate of growth and it has serious implications for the country’s long term development if it exceeds the rate of economic growth of the regions and the country as well. Individuals and couples need to be provided with more information and services to determine freely and responsibly the number and spacing of their children consistent with their needs, economic possibilities, and aspirations. From the results, it has clearly revealed that women of the regions wanted to achieve their fertility preferences by offering less attention to the practiced contraception (high TFR and low CPR). This situation leads to the cause of high rates of unwanted fertility and population growth. One of the major forces in driving down the fertility rate is by increasing contraceptive use among women whom are currently married. A substantial reduction in discontinuation cases in specific contraceptive use methods, resulting in high CPR, and a decline in fertility and ultimately in the decrease of the rate of population growth will occur if the independent variables are adjusted.

Unmet Need

It is essential to discuss the unmet need for family planning since it has a direct impact on the TFR. It is believed that if the unmet need were excluded, fertility would decline substantially. According to DHS 2011 (2011), one in three women who are currently married (36%) had an unmet need for family planning. The unmet need for spacing was 15.2% and the unmet need for limiting was 9.8%. Currently 50.8% and 56.1% of the demand for family planning was being met in the SNNPR and Oromiya regions respectively.

The results also indicated that there was a big gap in unmet need between urban and rural areas in both regions. Women who are currently married in the SNNPR rural areas have greater total unmet need (69.1%) than women who lived in urban areas (30.6%). It is the same for the Oromiya region (80.7% for rural and 30.6% for urban). The unmet need for spacing and limiting is higher in the Oromiya region than SNNPR for women whom are currently married with no education. The unmet need for family planning is high with regards to employment status; that is, women who were not currently working had a higher unmet need for family planning than their counterparts. It is clear that awareness-raising programs through various types of the media have the advantage of reaching a larger segment of the society. The unmet need was substantially higher among women who have not heard of family planning compared with those who have heard of it (71% versus 52%) in SNNPR and (85% versus 58%) in the Oromiya region. Women who have knowledge about any family planning methods have less unmet need than those who do not know of any method. The unmet need for spacing (44%) is a higher percentage for the Oromiya region than the unmet need for limiting (30%) with regards to women who know of any contraceptive method. Another important argument is the contraceptive discontinuation subject; here we have to dig a little bit and debate.

Does Contraceptive Discontinuation Matter in Ethiopia?

The most used methods are the pill and injections in Ethiopia. Other contraceptive methods are not used as much. The pill and injectable methods are more likely to be discontinued as a result of side effects or health concerns than are other methods. Other method-related reasons such as contraceptive failure are more important reasons for discontinuation than periodic abstinence, withdrawal, and condoms. Health care service-related reasons for discontinuation include the following: visiting the health center is too far, transportation, cost of the specific method, and lack of access to the particular method. These reasons are hardly mentioned by illiterate rural women as the primary reason for discontinuing the use of any method. The discontinuation of any method is of greater importance than the discontinuation of a specific method because it leaves women unprotected from the risk of unwanted teenage pregnancy (34% of mothers gave birth when less than 18 years old and 54% gave birth by the age 20 in Ethiopia (DHS, (2011)). Therefore, the contraceptive discontinuation matter is a serious issue in Ethiopia. There are two possible solutions to avoid discontinuation. Firstly, one solution is to motivate women discontinuing use of a modern reversible (temporary) method or for a service-related reason to switch to a different modern method. Secondly, another solution is to promote female sterilization in those who have a desire to limit or have achieved their family size. Health workers need to identify such groups or target women and provide proper guidance which is strongly recommended.

Conclusion

The results identified important factors affecting the use of contraception in the SNNPR and Oromiya regions of Ethiopia. In light of the above discussion, it is generally assumed that having knowledge of contraception (including side effects) might encourage women to use contraceptives effectively. In Ethiopia, women generally do not have the power to take decisions regarding their own lives. They do not have equal rights to decision-making power to space and limit their childbirths; they need the consent of their partners to practice contraception; etc. The status of the women has always been low especially in rural areas. This is reflected in their educational attainment and participation in the employment sector. However, women’s educational levels play a significant role in delaying the age their first marriage and creating better opportunities for employment. For that reason, more educated women tend to improve their knowledge and are motivated to use contraceptive methods. Women who marry early tend to initiate childbearing early, have a longer lifetime exposure to pregnancy, and have a large completed family size compared to those who marry late. There is a need to enhance the awareness of women, and generally show how it improves the life of both children and their mother when increasing their age at the time of their first marriage. Afterwards, the government and the relevant stakeholders should grant them formal education to enhance their autonomy in changing their attitudes in favor of smaller family sizes. The unmet need for family planning is the highest in the regions with the highest fertility rates. The study also identifies that education is an important factor in decreasing the probability of the unmet need. So, women must be provided with general and specific maternal education. Education increases their knowledge so that they can choose the most effective method and use it appropriately. Besides that, improvement should be taken on the availability of family planning information and services especially in rural areas where the unmet need is relatively high. Understanding and meeting these unmet needs can protect the lives and health of women and their children and help build healthier and more productive populations, and thus maintain the population growth rate. When women’s knowledge is increased with regards to family planning methods, the women can then know which methods they prefer and the side effects of using specific methods. This is also a part of a woman’s reproductive rights. When women are experiencing problems due to contraceptive side effects, then those women tend to use any particular method and this should be a concern for health-service providers who could offer essential and possible solutions. Many women addressed stated that they discontinued the use of the pill. The health-service provider, auxiliary nurse midwife (ANM), needs to work hard and socialize closely with women in the community, and they also need to inform the women about the use of other temporary methods. Follow-up care is immensely urgent. Many rural women do not have an idea of or information relating to pill manufacturing and expiration dates. Health visitors should ensure that their field visits are on time and that they schedule them on time. ANMs should try to improve rural areas’ progress based on contraceptive method success. They should also try to eliminate discontinuation issues by improving service provider’s efforts. There is no doubt that this will then enhance the progress of achieving the Millennium Development Goal 5.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author biographies

Yishak A Lailulo is a Post graduate student in the department of Statistics and Population Studies, University of the Western Cape, Cape Town South Africa.

A Sathiya Susuman has an MA, MPhil in Population Studies and a PhD in Demography. He has specialized in the social science research area of demographic analysis and reproductive health. Over the past number of years, Professor Susuman has managed to accumulate many years of teaching experience at both the undergraduate and postgraduate level, and has also successfully supervised more than 30 Masters and four doctoral dissertations. His specific research area is fertility, mortality, gender, empowerment of women, reproductive health and public health. He has published numerous scientific articles in local and international peer-reviewed journals, abstracts and research reports.

References

Al Riyami

Afifi

Mabry

(2004) Women’s autonomy, education and employment in Oman and their influence on contraceptive use. Reproductive Health Matters 12: 144–154.

Bongaarts

(1996) The supply–demand framework for the determinants of fertility: an alternative implementation Population Studies 47(3): 437–456.

Bongaarts

(1999) The fertility impact of changes in the timing of childbearing in the developing world. Population Studies 53: 277–289.

Casterline

Sinding

(2000) Unmet need for family planning in developing countries and implications for population policy. Population and Development Review 26(4): 691–723.

Central Statistical Agency (1993) The 1990 national family and fertility survey report.

Central Statistical Agency (2008) Summary report of the 2007 population and housing census, population size by age and sex.

Central Statistical Agency and ORC Macro (2000) Ethiopian demographic and health survey report 2000.

Central Statistical Agency and ORC Macro (2005) Ethiopian demographic and health survey report 2005.

Central Statistical Agency and ORC Macro (2011) Ethiopian demographic and health survey report 2005.

10.

Feyisetan

Ainsworth

(1984) The impact of the availability of price, and quality services on the demand for contraception in Nigeria. The World Bank, Policy Research Department, Washington, DC.

11.

Fikree

Khan

Kabir

Sajan

. (2001) What influences contraceptive use among young women in urban squatter settlements of Karachi, Pakistan? International Family Planning Perspectives 27: 130–136.

12.

Hailemariam

Gebreselassie

Teller

(2007) The lagging demographic and health transitions in rural. Ethiopia: socio-economic, agro ecological and health service factors affecting fertility, mortality and nutrition trends. In: Session 104, Arusha, Tanzania, 10–14 December 2007.

13.

Catherine

Hakim

(2006) Women, careers, and work-life preferences. British Journal of Guidance & Counselling 34(3): 1–17.

14.

Hosmer

Lemeshow

(1989) Applied Logistic Regression. New York: John Wiley.

15.

Getaneh

(2003) Factors associated with unmet need for family planning in SNNPR Region, Ethiopia. MSc Thesis, Addis Ababa University, Ethiopia.

16.

Guttmacher Institute (2007) Facts about the unmet need for contraception in developing countries. Available at: http://www.guttmacher.org (accessed 26/07/2014).

17.

Koc

(2000) Determinants of contraceptive use and method choice in Turkey. Journal of Biosocial Science 32(3): 329–42.

18.

Mbokane

Ehlers

(2006) Contraceptive challenges experienced by women who requested termination of pregnancy at services in the Mpumalanga province. Health SA Gesondheid 11(1): 43–55.

19.

Maja

TMM

Ehlers

(2004) Contraceptive practices of women in Northern Tshwane, Gauteng Province. Health SA Gesondheid 9(4): 42–52.

20.

Marchant

Mushi

Nathan

. (2004) Planning a family: priorities and concerns in rural Tanzania. African Journal of Reproductive Health 8: 111–23.

21.

Mahmood

Dure-E-Nayab (2000) An analysis of reproductive health issues in Pakistan. Pakistan Development Review 39: 675–693.

22.

Myburgh

Gmeiner

van Wyk

(2001) Support for adult biological fathers during termination of pregnancy. Health SA Gesondheid 6(1): 38–48.

23.

National Population Commission and ORC Macro (2004) Nigeria demographic and health survey 2003.

24.

Ntozi

JPM

Ahimbisibwe

(2001) Prospects of fertility decline in the face of HIV/AIDS in Uganda. In: Workshop on prospects for fertility decline in high fertility countries, New York, USA, 9–11 July 2001.

25.

Olaleye

Bankole

(1994) The impact of mass media family planning promotion on contraceptive behavior of women in Ghana. Population Research and Policy Review 13: 161–177.

26.

Omwago

Khasakhala

(2006) Factors influencing couples unmet need for contraception in Kenya. African Population Studies 21(2): 75–94.

27.

Parr

(2002) Family planning promotion, contraceptive use and fertility decline in Ghana. African Population Studies 17(1): 83–101.

28.

Pasha

Fikree

Vermund

(2001) Determinants of unmet need for family planning in squatter settlements in Karachi Pakistan. Asia–Pacific Population Journal 16(2): 93–108.

29.

Population Reference Bureau (2012): World Population Data Sheet, 1875 Connecticut Ave., NW. Suite 520, Washington, DC 20009-5728 USA.

30.

Rutenberg

Ayad

Ochoa

. (1991) Knowledge and use of contraceptive. Demographic and health surveys comparative studies No. 6, Columbia, Maryland, Institute for Resource Development / Macro International.

31.

Saleem

Pasha

(2008) Log–linear modeling and analysis of the factors, affecting the contraceptive use in Pakistan. Department of Statistics, Bahauddin Zakariya University, Multan, Pakistan, p 120–129.

32.

Sedgh

Hussain

Bankole

. (2007) Women with Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. New York: Guttmacher Institute.

33.

Warren

Johnson

Gule

. (1992) The determinant of fertility in Swaziland. Population Studies 46(1): 5–17.

34.

Zewudu

Wubalem

Sibanda

Dennis

(2003) The proximate determinants of the decline to below replacement fertility in Addis Ababa. Studies in Family Planning 34(1): 1–7.