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Contraceptive Choice and Switching Pattern among Married Women in
Family Medicine & Medical Science Research

Family Medicine & Medical Science Research
Open Access

ISSN: 2327-4972

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Research Article - (2014) Volume 3, Issue 3

Contraceptive Choice and Switching Pattern among Married Women in Rural Community of South East Ethiopia

Tolesa Bekele1, Alem Gebremariam2* and Papelon Tura3
1Department of Public Health, College of Medicine and Health Sciences, Madawalabu University, Bale-Goba, Oromia, Ethiopia
2Department of Public Health, College of Medicine and Health Sciences,, Adigrat University, Adigrat, Tigray, Ethiopia
3Department of Nursing, College of Medicine and Health Sciences, Madawalabu University, Bale-Goba, Oromia, Ethiopia
*Corresponding Author: Alem Gebremariam, Department of Public Health, College of Medicine and Health Sciences, Adigrat University, Adigrat, Tigray, Ethiopia, Tel: +251-910-35-29-15 Email:

Abstract

Background: Expanding access to long acting and permanent contraceptive methods has multiple benefits. They give women greater choice in selecting a contraceptive that meets their needs for delaying, spacing, or limiting pregnancy. They have the highest continuation rates of all family planning methods, and are more effective in actual use than short-acting methods for preventing unintended or closely spaced pregnancy. The study assessed the contraceptive knowledge, choice and switching pattern of married women in Agarfa District, Oromia, 2014.

Method: A community based cross-sectional study was conducted in Agarfa district. A total of 788 married women aged 15-49 years were involved in the survey. They were selected through systematic random sampling technique. The data were collected by using structured interviewer administered questionnaire, and analyzed by using SPSS version 21.

Result: The most ever known (98.5%) and ever used (81.5%) type of modern contraceptive was Depo-provera. Permanent methods were rarely recognized as contraceptive method. Three forth (75.9%) of the participants were on modern contraceptive during the interview time. Twenty nine percent of those who want to limit their birth were not taking any modern contraceptive (MC). Nearly half (45%) of the participants stated fear of side effect was their main reason for non use of MC. Thirty percent (29.4%) of the participants had history of method shift from one MC to other MC method. The highest shift was observed from pill to depo-provera (49.1%), followed by depo-provera to implants (26.7%).

Conclusion: Women’s awareness and choice of contraceptives is limited to short acting methods. There is perceived fear of side effects of modern contraceptive. Women desiring no more children were not using any method. Therefore, strengthening the FP counseling to address fears of side effects and increase client awareness of expected and unexpected side-effects of all methods is essential.

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Keywords: Contraceptive switching; contraceptive choice; Agarfa; Bale zone; Oromia; Ethiopia

Introduction

Women and couples who want safe and effective protection against pregnancy would benefit from access to more contraceptive choices. Modern contraceptives (MC) include short acting, long acting, and permanent methods. Long acting and permanent contraceptive methods (LAPMs) are convenient for users and effectively prevent pregnancy and cost-effective for programs over time, can result in substantial cost savings for couples, governments, and contribute directly to reaching national and international health goals by providing longlasting contraceptive protection. This includes methods like implant, intra uterine device (IUD), and sterilization [1]. Long acting reversible contraceptives are safe and reversible, require little to no maintenance, and have much better compliance rates than other hormonal methods [2]. In contrary, the utilization of these methods is very low. A discrepancy exists between the proportion of women who wish to stop having children and the proportion who are using LAPMs [3].

The national prevalence rate of MC use among currently married women was 29 %. Thirty seven percent of women want no more children but only 2% of married women were using IUD, 3% implant and less than 1% reported having been sterilized. Injectables (21%) were the most popular methods [4]. The magnitude of modern contraceptive (MC) utilization in Mojo town was 38.3%. Injectables was the most frequently used (55.45%) followed by pills (26.06%), condom (7.1%), IUD (5.21%) and Norplant (0.95%) [5]. A study conducted in Goba South East Ethiopia, showed that the overall utilization rate of LAPMs was 8.7% [6].

Fewer people have knowledge of IUD, tubal ligation and vasectomy than of other methods [7,8]. The 2011 Ethiopian demographic health survey (DHS) showed that the knowledge of any MC among currently married women was high (97%). But specific knowledge of each LAPMs was very much low. The finding indicated that female sterilization (39.8%), male sterilization (10.8%), IUD (26.4%) and implants (69.2%) [4].

In a country like Ethiopia with high fertility rate and unmet need of contraceptives shifting towards one of the long acting or permanent contraceptive methods is an important strategy. But the situation is controversial. The contraceptive method mix is dominated by short acting methods like pills and injectables [9-11]. The Ethiopian reproductive health (RH) strategy has been planned and is working on the provision of all FP methods, especially LAPMs. There are at least two health extension workers and/or community-based agents in every Kebele with the training, knowledge, and skills needed to provide basic FP services and refer for LAPMs [12]. Despite of this and the presence of all modern contraceptive methods, utilization is very low especially LAPMs and limited very much to the short term methods such as pills and injectables [10].

A better understanding of patterns of contraceptive use will help inform program and policy approaches for encouraging consistent and effective contraceptive method use. It is, therefore essential to examine the pattern of method shift and contraceptive choices so that well targeted interventions could be undertaken. The result of this study can be used as a baseline information for further studies in that area and provide important information for program managers and other concerned bodies to enable them provide proper health services to these segments of the population and the community at large.

Methods

During March to May 2014 a community based cross sectional study was conducted in Agarfa District which is one of the Districts found in Bale Zone, Oromia National Regional State in Ethiopia. A total of 788 married women (15-49 years of age) with history of modern contraceptive use found in Agarfa district were included in the study. Married women with history of modern contraceptive use but were severely ill or unable to respond for the questionnaires were excluded from the study. Out of 21 Kebeles in the district, 10 Kebeles were selected using simple random sampling technique. Then the sample was proportionally allocated to the size of the Kebeles. After calculating the sampling interval (K value), the households (HH) with married women with history of modern contraceptive use was selected by systematic random sampling technique. When there was no eligible woman in the selected HH, the next HH was selected for interview. When two or more eligible women were present in one household, only one woman was considered by lottery method.

Questionnaire was prepared first in English then translated to local language (Oromifa) by language expert. To ensure consistency of the translation with the English version; the questionnaire was translated back to English by another language expert. Before the actual data collection, the questionnaire was pre-tested on 5% (39 women) of the sample size in the same district from those Kebeles not included in sample. Based on the pre-test, the time needed for the completion of interview was estimated, questions were revised, edited, and those found to be unclear or confusing were modified. Data were collected using structured and pretested interviewer administered Oromifa version questionnaire. Ten Oromifa speaker who had a minimum 12th grade completed were collected the data. Two Bachelor degree holders supervised the data collectors. Data collectors and supervisors were trained for one day on the study instrument and interviewing techniques. The interviews were conducted in a place where the woman feels free to express her feelings and ideas. Moreover, in occasions where the sampled women are not accessed for absence, up to three visits was considered for interview to minimize the non-response rate. Daily close supervision and spot checks of filled in questionnaires was made by the field supervisors and investigator deployed with the data collectors.

Data were first entered to Epi-Info version 3.5.1 and cleaned. Then data were exported to Statistical Package for Social Sciences (SPSS) version 21.0 for analysis. Descriptive analyses were carried out for each of the variables. Ethical clearance was obtained from Ethical and Rreview Ccommittee of Madawalabu University. Official permission letter was obtained from Madawalabu University, College of Medicine and Health sciences to Bale Zone Health Office then to Agarfa Health office. Oral informed consent was obtained from all study participants after the explanation of study objectives. All the information obtained from the respondents remained confidential and anonymous.

Results

Socio-demographic characteristics of the participants

Table 1 shows the socio-demographic characteristics of the participants. The mean age of the participants was 31+ 6.3 years. Most of the participants were Oromo (86.3%) by Ethnicity and Muslim (49.4%) by religion (Table 1). About three fourth (73.9%) and 29.9% of the participants had radio and TV in their home, respectively. Almost all (96.4%) of the participants were living with their husband during the interview time. Ninety four percent (94.3%) of the participants reported as their husband have only one wife. Whereas the rest 41 and 4 of the participants reported as they were the second and third wife of their husband, respectively.

Socio- demographic characteristics Frequency (n) Percentage (%)
Age group of participants
15-19 8 1
20-24 86 10.9
25-29 270 34.3
30-34 175 22.2
35-39 156 19.8
40-44 71 9
45-49 22 2.8
Religion
Orthodox 347 44
Muslim 389 49.4
Protestant 21 2.7
Catholic 31 3.9
Ethnicity    
Oromo 680 86.3
Amhara 105 13.3
SNPP 2 0.3
Summali 1 0.1
Educational level of participants
Can’t read and write 178 22.6
Can read and write 68 8.6
Grade (1-4th) 227 28.8
Grade (5-8th ) 215 27.3
Grade (9-12th) 87 11
Grade 12+ 13 1.6
Educational level of their partner
Can’t read and write 54 6.9
Can read and write 44 5.6
Grade (1-4th) 165 20.9
Grade (5-8th ) 287 36.4
Grade (9-12th) 177 22.5
Grade 12+ 61 7.7
Occupation of participants
House wife 616 78.2
Government employee 36 4.6
Private employee 108 13.7
Daily labourer 16 2
Farmer 12 1.5
Occupation of their partners
Government employee 88 11.2
Private employee 245 31.1
Daily labourer 29 3.7
Farmer 426 54.1
*Family monthly income (ETB)
<300 196 24.9
300-800 425 53.9
>800 167 21.2

*income was categorized based on quartiles, ETB-Ethiopian birr

Table 1: Socio-demographic characteristics of married women in the reproductive age group, Agarfa District, May, 2014 (n= 788).

Reproductive history of the participants

Almost all (97.3%) of the participants have history of birth. The mean age at first marriage and first birth of the participants was 18.6 + 2.1 years and 20.1 +2.2 years, respectively. The mean number of alive birth was 4.3 + 2.3 children per women. The mean ideal desired number of children to have was 5.5 + 1.7 children ranging from 1 to 12 children. More than half (58.6%) of the participants do not want to have child within two years. Of those, 40.3% was to limit their birth (Table 2).

Variables Frequency (n) Percentage (%)
Age at first marriage (n=788 )
<18years 222 28.2
18 – 25 years 564 71.6
>25 years 2 0.3
Ever birth (n= 788)
Yes 767 97.3
No 21 2.7
Age at first birth (n= 767)    
<18years 104 13.6
18 – 25 years 658 85.8
>25 years 5 0.7
Number of living children (n= 788)
≤ 3 338 42.9
  4-5 227 28.8
≥ 6 223 28.3
Number of more child wanted (n=765 )
0 199 26
2-Jan 460 60.1
≥ 3 106 13.9
Wants more children with in 2 years (n=788)
  Yes 326 41.4
  No 462 58.6
Reason for not wanting (n=462)
 To space 276 59.7
 To limit 186 40.3
Discussion on FP with partner (n= 788)
 Yes 430 54.6
 No 358 45.4
How often do you discuss (n= 430)
Always 65 15.1
Sometimes 187 43.5
Occasionally 178 41.4
Decision on the number of children (n= 788)
  Husband 25 3.2
  Wife  32 4.1
  Both 513 65.1
  God 218 27.7

Table 2: Reproductive history of married women’s in the reproductive age Agarfa District, May, 2014 (n=788) Knowledge about modern contraceptives of the participants.

The most ever known type of modern contraceptive was Depoprovera (98.5%) followed by pills (82.5%). Female and male sterilization were recognized as contraceptive method by only one participant. The participants mentioned health professionals (70.8%) as their main source of information for the modern contraceptive they ever knew. More than one third (39.3%) of the participants had history of discussion on MC with their female friends and almost all of them were comfortable discussing FP methods with their female friends (Table 3).

Variables Frequency (n) Percentage (%)
*Types of modern contraceptives known (n= 788 each)
Pills 650 82.5
Depo-Provera 776 98.5
Implants 425 53.9
IUD 110 14
Tubal ligation 1 0.1
Vasectomy 1 0.1
Condom 213 27
Source of first information on FP (n=788)
Neighbours/friends/relatives 78 9.9
Health professionals 569 72.2
Health Development Army 130 16.5
Mass media 6 0.8
Husband 5 0.6
Best source of information about FP  
Neighbours/friends/relatives 16 2
Health professionals 558 70.8
Health Development Army 133 16.9
Mass media 31 3.9
Husband 50 6.3
Discuss about modern FP method with your female friends
Yes 310 39.3
No 478 60.7
Are you comfortable discussing FP methods with your female friends
Yes 297 95.8
No 13 4.2
Exposure to MC message  within 12 months
Yes 286 36.3
No 502 63.7
*Type of media (286 each)
Television 96 33.6
Radio 208 72.7
Print media 7 2.4

*Each of the percentages does not add up to 100.0 because respondents could choose several responses

Table 3: Knowledge about modern contraceptives of married women in the reproductive age group, Agarfa District, May, 2014.

Participants’ beliefs and perceptions on modern contraception

Eighty five percent of the participants stated that their husband supports FP use. Majority of the participants (97.1%) perceived that using contraceptive method is good for family. More than a quarter (30%) of the participants perceived that prolonged use of FP methods could lead to various diseases or even death (Table 4).

Statements regarding perceptions on MC                       Level of agreement
Agree, n(%)   Neutral, n(%) Disagree, n(%)
Your husband supports FP use 668(84.8) 15(1.9) 105(13.3)
Using contraceptive method is good for my family 765(97.1) 20(2.5) 3(0.4)
Couples who jointly decide to use contraceptive method have healthier children 727(92.3) 47(5.9) 14(1.8)
Using family planning methods will benefit your family financially 725(92.0) 38(4.8) 25(3.2)
Using family planning methods is beneficial for women’s health 674(85.5) 60(7.6) 54(6.9)
Longer use of FP methods could lead to various diseases/even death 240(30.5) 79(10.0) 469(59.5)
Access to choice of methods 713(90.5) 42(5.3) 33(4.2)
There are competent providers in the facilities 672(85.3) 60(7.6) 56(7.1)
Providers can be trusted to maintain confidentiality 646(82.0) 116(14.7) 26(3.3)
Discuss with spouse or convince spouse to use 683(86.7) 46(5.8) 59(7.5)
Contraceptives can harm a woman’s womb 207(26.3) 62(7.9) 519(65.9)

Table 4: Beliefs and perceptions on modern contraceptives among married women in the reproductive age group, Agarfa District, May, 2014, (n= 788).

Modern contraceptive utilization pattern of the participants

The most ever used type of MC was Depo-provera (81.5%) followed by Pills (38.3%). Three forth (75.9%) of the participants were on modern contraceptive during the interview time. The most common contraceptive method currently used by respondents was depo-provera (65.2%). Nearly half (45%) of the participants stated fear of side effect was their main reason for not currently using MC. About contraceptive decision making, most of all the women (83.4%) said they had joint decision with their husbands and only (8.4%) were making sole decisions (Table 5).

Variables  Frequency (n) Percentage (%)
Contraceptives ever used (n=788)    
Pills 302 38.3
Injectables 642 81.5
Implant 133 16.9
IUD  12 1.5
Emergency contraceptive 8 1
Condom 26 3.3
Your husband know you were using contraceptive
Yes 746 94.7
No 42 5.3
Was the method what you wanted
Yes 693 87.9
No 95 12.1
Ever faced difficulties b/c of out-of-stock
Yes 37 4.7
No 751 95.3
How often (37)    
Once 31 83.8
Twice 4 10.8
Three times and above 2 5.4
Opposition to MC Use
Yes 82 10.4
No 706 89.6
Who opposed you (n=82)
My religious leaders opposed me 4 4.8
My husband 20 24.4
My girl friend 25 30.5
My neighbours 16 19.5
My mother/mother in law 17 20.8
Current use (n=788)
Yes 598 75.9
No 190 24.1
Which method are you using now (n=598)
Pills 95 15.9
Injectables 390 65.2
Emergency contraceptive 1 0.2
Implant 104 17.4
IUD 8 1.3
Source of current method (n=598)
Health center 253 42.3
Government hospital 109 18.2
Private clinic 11 1.8
Health extension workers 225 37.6
Reason for not use (190)
I am pregnant 16 8.4
I want to be pregnant 48 25.3
Method fail while I am using 27 14.2
I fear its side effect 85 45
I am infecund 10 5
I stopped to use 2 1.1
Husband opposed me 2 1.1
Do you want to use for the future
Yes 688 87.3
No 100 12.7
Decide on taking of your FP methods
Husband 65 8.2
Myself (wife) 66 8.4
Both 657 83.4

Table 5: Practice of modern contraceptives among married women in the reproductive age group, Agarfa District, May, 2014.

Modern contraceptives switching pattern of the participants

Thirty percent (29.4%) of the participants had history of method shift from one MC to other MC method. The highest shift was observed from pill to depo-provera (49.1%), followed by depoprovera to implants (26.7%).The main reason stated for their shift was inconvenience of previous method (Table 6).

Variables  Frequency (n) Percentage (%)
Ever shifted (n=788)
Yes 232 29.4
No 556 70.6
Reason for shifting (n=232)
For inconveniency of previous method  122 52.6
For the convenience of the  new method  53 22.8
Due to lack of  access to the previous method 1 0.4
Due to side effect 48 20.7
Provider advised me 1 0.4
Partner influenced me 3 1.3
I forget it 4 1.7
Shifted from to (n=232)
Pill to Injectable 114 49.1
Injectable to pill 19 8.2
Pill to implant 17 7.3
Pill to IUD 3 1.3
Injectable to Implant 62 26.7
Injectable to IUD 5 2.2
Implant to injectable 8 3.4
Implant to pill 2 0.8
Condom to pill 2 0.8

Table 6: Contraceptive Method Shift among married women in the reproductive age group, Agarfa District, May, 2014.

Discussion

The most ever known type of modern contraceptive was Depoprovera (98.5%) followed by pills (82.5%). This is comparable with the finding obtained in Adigrate town, Northern Ethiopia [13]. Even though the study was conducted among ever users of modern contraceptives, only one participant recognized permanent contraceptive methods as a contraceptive method. Method 15 specific knowledge levels varied from 12% for vaginal contraceptives (diaphragm, foam, jelly) to 94% for pills and injectable contraceptives [14]. Majority of the participants (97.1%) acknowledged the importance of contraceptive for their family but 30% of the participants perceived that prolonged use of FP methods could lead to various diseases even death.

The most ever used type of MC was Depo-provera (81.5%) followed by Pills (38.3%). Three forth (75.9%) of the participants were on modern contraceptive during the interview time. About fifty nine percent (58.8%) of the participants want to space or limit their birth but 25.3% of them were not using any contraception methods. Twenty nine percent of those who want to limit their birth were not taking any MC. The most dominant method used was depo-provera (65.2%). In contrast to our finding, over half of the women in Nepal were using either female or male sterilization [15]. This could be due to the low level of knowledge of long acting and permanent contraceptive methods. Another explanation for this could be due to the convenience of the method (Depo-provera) in terms of decreasing number of visit and remembrance to take, and the potential secrecy to use [13].

Nearly half (45%) of the participants stated fear of side effect was their main reason for not using MC. Similarly, participants have fear or perceived side effects of contraceptives, like being infertile after use of the method [16,17]. Is indicates the need of addressing negative information about each contraceptive methods. Health providers should provide factual information about risks, potential side effects, and incorporate it into a family planning strategy that meets each client’s particular needs [18].

Reliance on ineffective and unreliable methods can lead to unintended pregnancy and unsafe abortion [18]. Thirty percent of the participants had history of method shift from one MC to other MC method. The highest shift was observed from pill to depo-provera (49.1%), followed by depo-provera to implants (26.7%). Switching rates were higher for short term contraceptives (pills and injectables). The proportion of users switching from short acting methods to long acting and reversible methods (implants and IUD) was highest for injectables followed by pills. This could indicate that the demand of long acting is increasing [13]. The main reason stated for their shift was inconveniency of previous method followed by convenience of the new method and side effect. Similarly, side effects and wanting a more effective method of contraception was the main reason of switching [19].

The finding should be interpreted taking the limitations of this study in to consideration. Since this study examined the pattern of MC utilization only among women on marriage, the sample was limited to only currently-married women at the time of the study. Hence, these results may not be able to be generalized to all women in Agarfa District. Interviewer bias may be there especially in the questions with probing. The study did not ascertain the availability of all contraceptive methods, quality of FP counseling, providers’ attitudes and behaviors on MC use. Providers’ attitude regarding family planning plays an important role, either in choosing or continuing contraception [18]. Therefore, further detail investigation on the availability of all contraceptives, quality of FP counseling and providers behavior on MC should be conducted.

Conclusion

Women’s awareness and choice is limited to short acting methods particularly depo-provera. There is perceived fear of side effects of modern contraceptives. There is a wide gap on the knowledge of the long acting and permanent contraceptive methods of the women in the community. Women desiring no more children are not using any method, and of those using contraception, many are using shortacting methods. Therefore, strengthening the FP counseling service to address fears of side effects and increase client awareness of expected and unexpected side-effects of all methods is essential. Promoting all choices of modern contraceptives especially long acting or permanent methods for women who want no more children can increase the awareness and utilization rate of contraceptives.

Acknowledgement

We would like to acknowledge Madawalabu University, College of Medicine and Health Sciences for giving us this important opportunity. Our acknowledgement also goes to our friends who give us comments on the proposal structure and arrangement. Finally, we would like to extend our heartfelt thanks to Madawalabu University, College of Medicine and Health Sciences library giving us important references when we were in need. Lastly we would like to acknowledge Agarfa District health office, our supervisors, data collectors and study subjects.

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Citation: Bekele T, Gebremariam A, Tura P (2014) Contraceptive Choice and Switching Pattern among Married Women in Rural Community of South East Ethiopia. Fam Med Med Sci Res 3:133.

Copyright: © 2014 Bekele T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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