Modern Family Planning Utilization and Its Associated Factors among Currently Married Women in Rural Eastern Ethiopia: A Community-Based Study

Background The use of modern family planning methods among women of reproductive age (15-49 years) is of public health importance in Ethiopia. Nationally, modern family planning method use remains as low as 35%. Understanding factors associated with the use of modern family planning methods may help to improve maternal and child health. Hence, this study is aimed at assessing modern family planning method use and its determinants among women of reproductive age in the rural districts of Eastern Hararghe zone, Eastern Ethiopia. Methodology. A community-based, cross-sectional survey was conducted among 577 randomly selected, currently married, reproductive-aged women in selected rural districts of Eastern Hararghe, Eastern Ethiopia. Data were collected using a pretested, interviewer-administered questionnaire about women's sociodemographic information, knowledge about contraception, reproductive history, contraceptive use and fertility desire, couple's communication, and decision-making on family planning. Binary and multivariable logistic regression was used to analyze the association between the dependent and independent variables. Result A total of 555 study participants participated, yielding a 96.2% response rate. The overall modern family planning utilization among the study participants was 18.4%. Knowledge of modern family planning methods (AOR = 16.958, CI: 4.768, 60.316), husband approval (AOR = 3.590, CI: 2.170, 5.936), couple's discussion (AOR = 2.852, CI: 1.759, 4.623), male involvement in decisions about family planning (AOR = 2.340, CI: 1.531, 3.576), desire for additional child (AOR = 2.295, CI: 1.528, 3.447), and previous use of contraception (AOR = 0.018, CI: 0.005, 0.063) were significantly associated with modern contraceptive utilization. Conclusion Even though knowledge of modern family planning methods was very high, the overall modern family planning method use in the study area was low. The government should focus on increasing modern family planning method availability. It must also ensure family planning method security and create awareness on modern family planning methods through community-based education and proper counselling to empower women to make an appropriate choice.


Introduction
Family planning (FP) refers to the use of contraceptive methods to prevent unintended pregnancy, limit the number of children, and space childbirth. Contraceptive methods are classified as modern or traditional methods. Modern methods include female sterilization, male sterilization, intrauterine contraceptive device (IUD), implants, injectables, pill, male condoms, female condoms, emergency contraception, and lactational amenorrhea method (LAM), whereas traditional methods include rhythm (calendar), withdrawal, and folk methods [1].
Contraceptive has many benefits; it ensures couples achieve the desired family size and reduces infant/perinatal and maternal mortality. It also reduces the risk of HIV transmission and STI acquisition and prevents unintended pregnancies. Moreover, it decreases pregnancy and birth-related complications as it provides adequate time for a mother to recover from the previous pregnancy sufferings [2][3][4].
The 1994 International Conference on Population and Development (ICPD) shifted the world from one concerned with population growth to one committed agenda of reproductive rights and justice. It created a platform to help women and men to have greater access to modern contraceptive methods and affordable, convenient FP. FP is a vital element for the achievement of sustainable development goal [3], which considers reproductive, maternal, and child health as a priority agenda [5]. However, more than one in ten married or in-union women worldwide have an unmet need for family planning [3].
Currently, greater than 200 million women in developing countries want to avoid pregnancy, but they are not using any type of modern contraceptive method. Because fertility and unmet need for contraception continue to be much greater in sub-Saharan Africa , the magnitude of maternal death is much higher in this region compared to other regions. An unmet need for contraception inevitably results in unintended pregnancies. Approximately 40 percent of all pregnancies in developing countries are unintended [2,4,6].
Worldwide, the prevalence of modern contraceptive method use was 64% in 2015. According to the UN, contraceptive prevalence must be 66%-75% in developed countries and 67% in developing countries in order to achieve the desired fertility decline by 2025 [7]. However, this trend has not been seen in developing countries where the use of modern contraception among women of reproductive age is about 43% [8].
Modern FP utilization remains low in sub-Saharan Africa (SSA). In 2012, the contraceptive coverage and unmet need for contraception in the region were 25.7% and 25.1%, respectively [7,9].
The 2016 Ethiopian Demographic Health Survey reported that the overall use of FP methods among currently married women was 36%: of these, 35% were using a modern method, and only 1% were using a traditional method. Data shows that 22% of currently married women have an unmet need for FP services, 13% for spacing and 9% for limiting [1].
Ethiopia has increased FP service coverage by providing various contraceptive methods at the household level. The Ethiopian government began the ongoing Health Extension Worker (HEW) program in 2003. The HEW is a community-based intervention program, which delivers disease prevention and control, family health services, hygiene and environmental sanitation, and health education and counselling [10]. FP was incorporated into the program as one of 16 essential health services provided at the community level by health extension workers. HEWs were cross-trained to work in new health outlets, a massive investment in a country as poor as Ethiopia. These auxiliary health personnel provided injectable contraception and in recent years have begun to insert implants [2].
Although Ethiopia has been mentioned as a champion for introducing HEWs who provide modern contraceptive methods at the doorstep in rural kebeles, the utilization of modern contraceptive methods remains very low [11,12]. Research is needed to understand factors associated with the use of modern FP methods and the factors underlying modern FP utilization. Hence, the current study was con-ducted with the intent to assess modern contraceptive method utilization and its determinants among married women in the rural settings of the study area. Approximately 580,735 households were residents of this zone at the time of the study, with an average of 4.69 persons to a household and 560,223 housing units [13]. This study was conducted on January 1-30, 2019.

Study Design.
A community-based cross-sectional study was conducted.

Source and Study Population.
Currently married reproductive-aged women living in rural parts of the Eastern Hararghe zone were the source population, and currently married reproductive-aged women living in selected kebeles of the study areas were the study population.

Sample Size Determination and Sampling
Procedure. The single population proportion formula, n = ðZα/2Þ 2 pq/d 2 , was used with the proportion (35%) which was taken from EDHS 2016, which showed that 35% are using a modern method [1]. A confidence level of 95% and a 5% degree of precision were used. By considering the 1.5 design effect and 10% nonresponse rate, the final sample size was 577. Multistage sampling techniques were used. Among woredas (districts) in the study area, three woredas were selected by lottery methods. Then, one kebele (the smallest administrative unit) from each woredas was selected by simple random sampling. Proportional allocation for each kebele was used to give equal chance. Using systematic random sampling, all eligible households in each selected kebele were selected. From the eligible households, study participants (currently married women) were selected by simple random sampling. If there was more than one eligible woman within the selected household, one woman was picked at random. Women with mental and serious health problems, pregnant women, and those who reported infertility were excluded from the study.

Data
Collection. Data were collected using a pretested, interviewer-administered questionnaire asking about women's sociodemographic information, knowledge about contraception, reproductive history, contraceptive use and fertility desire, couple's communication, and decisionmaking about FP. Three HEWs were recruited for data collection. To control the data quality, one-day training was given for supervisors and data collectors. The tools were pretested, and modifications were made to our set-up based on the pretest results. Collected data were reviewed for quality assurance on a daily basis, and double data entry control was done.
2.6. Data Analysis. Collected data were entered into the computer by using EpiData Version 3.0.2. Data analysis was done by using Statistical Package for the Social Sciences (SPSS) software version 21. Frequencies of variables were generated; tabulation and percentages were used to illustrate study findings. Bivariate and multivariate logistic regression analyses were used to analyze the association between the dependent and independent variables. The outcome variable (current modern FP use) was coded to yes/no response, and each explanatory variable was tested for association in bivariate analyses. Covariates with a P value < 0.2 were retained and entered into the multivariable logistic regression analysis using a forward selection and backward elimination approach. Hosmer and Lemeshow's goodness-of-fit test was used to assess whether the necessary assumptions were fulfilled. An adjusted odds ratio (AOR) with 95% confidence intervals (CI) using a P value < 0.05 was considered statistically significantly associated with the outcome variable.

2.7.
Measures. Modern family planning: use of modern medicines (hormonal) or artificial material (condom) and minor surgery (voluntary sterilization) to space or limit birth.
Current modern FP method utilization: a woman was considered a current user if she is using any modern FP method during the survey.
Ever use of modern FP methods: a woman was considered ever using modern FP methods if she had used any modern FP methods previously before the survey.
Knowledge of modern FP methods: a woman was considered knowledgeable if she knew at least one type of modern FP method.
2.8. Ethical Consideration. The ethical approval was obtained from the Haramaya University College of Health and Medical Sciences institutional health research ethics review committee. Formal letters were written to all concerned authorities, and permission was secured at all levels. After explaining the purpose and procedures of the study, informed, voluntary, written, and signed consent was obtained from each respondent. All the basic principles of human research ethics (respect of persons, beneficence, voluntary participation, confidentiality, and justice) were respected.

Sociodemographic Characteristics of Respondents.
A total of 555 study participants participated in the study, with a 96.2% response rate. More than half 304 (54.8%) of the study participants were between the age group of 25-35 (mean age of 28:2 ± 6 SD). A majority 459 (82.7%) of the study participants were from the Oromo ethnic group.

Maternal and Reproductive History of Study Participants.
Regarding the reproductive and obstetric history of the study participants, almost all mothers 549 (98.9%) had both histories of pregnancy and childbirth. More than half of the study participants 319 (57.5%) had four or fewer children, followed by five children and above 236 (42.5%). When asked about the desire for more children, more than half of the study participants 293 (52.8%) had no desire for more children. The most cited reason for not desiring more children was having the desired number of children 128 (43.7%) followed by limiting birth 79 (27%) (Figure 1).

Knowledge of Modern Contraceptive Methods towards
Use of Modern Contraceptive Methods. Most of the study participants 521 (93.9%) had heard about modern FP methods. The study participants heard information from health professionals 430 (80.8%) and from friends/relatives 85 (18.2%), from the church/mosque 30 (5.6%), and at school 23 (4.1%), respectively. The most popular modern contraceptive method was injection 491 (94.2%), followed by implants

Modern Contraceptive Use among Study Participants.
The study finding showed that 243 (43.8%) of study participants had ever used modern contraceptive methods. One hundred and two (18.4%) women currently used modern contraceptive methods. Among the modern contraceptive methods, 50 (49%) women said they were using injectable methods, 45 (44.1%) said they used implants, 5 (4.9%) used pills, and 2 (2%) used IUCD. However, none of the participants reported the use of condoms and permanent contraceptive methods. Most of the study participants were using current modern contraceptive methods for spacing 81 (79.4%), for limiting birth 14 (13.4%), and for health benefits 7 (6.9%).
When asked the reason for not using modern contraceptive methods, most of the study participants cited inconvenient for use 131 (41.9%) followed by want to become pregnant 99 (31.7%) (Figure 2).

Sexual and Reproductive Health Communication and
Decision-Making on Modern FP Methods. Two hundred eighty-eight (51.9%) of the respondents said they believed that a couple's discussion is important in making a joint decision regarding modern contraceptive methods. Two hundred sixty-three (47.4%) of the interviewed women perceived that their husband supports the use of a modern contraceptive method. Three hundred twenty-nine (59.3%) of the women said that the male partner/husband should be involved in FP decision-making. 61.3% of interviewed women replied that they made decisions jointly with their husbands, while 30.4% of the interviewed women made decisions alone on modern contraceptive method use (Table 2).    BioMed Research International discourage many potential or current users of family planning. Generally, 114 (20.5%) of the women perceived that using any type of modern contraceptive is a sin or against religion. The study also showed that 122 (22%) women responded that the use of contraceptive pills causes infertility. 29.2% of interviewed women feel that the injectable method causes infertility, and 25.2% feel that it causes menstrual disorders. Concerning implants, 226 (40.7%) perceived that they cause a menstrual disturbance and 78 (14.1%) of the women replied that IUCD causes infertility. Regarding condoms, 111 (20%) women responded that using condoms is a sign of promiscuity (Table 3).

Factors Associated with Modern Contraceptive Method
Utilization. The findings from the multiple logistic regression analysis revealed that couple's discussion, the desire for additional child, male involvement in the decision of family planning, husband approval, ever use of the modern contraceptive method, and knowledge of modern contraceptive methods were independently associated factors of modern contraceptive utilization (Table 4).

Discussion
This study showed that modern FP utilization in the study area was very low despite universal knowledge of modern contraceptive methods by the community. The study revealed the overall modern FP utilization among the study participants was 18.4%. This finding is consistent with the study conducted in Bale zone, Southeast Ethiopia (20.8%) [12], but much higher than that of Afar Region, Eastern Ethiopia (8.5%) [13]. The variation might be due to the study population, as the first study was conducted among the pastoralist community. The low use of modern FP in the current study is below that of the national survey (35%) [1]. The low coverage in the study area could be due to the influence of husbands, cultural taboos, and religious prohibition in an area where most (84.9%) of study participants are Muslims. Moreover, this study was conducted in a rural area with little public health and education infrastructure and high misperceptions towards modern contraception, compared to urban areas.
The study revealed that 91.4% of study participants knew at least one modern FP method. This finding is in line with a study finding from Bale zone (95.3%), Southeast Ethiopia [12], and Jimma zone (94%), Ethiopia [14]. This higher percent of information might be due to house-to-house FP information dissemination by health extension workers.
Our study finding is relatively higher than that of Dembia District (78.1%), Northwest Ethiopia [15], and Afar Region (62%), Eastern Ethiopia [13], but lower than studies from Uganda (98.1%) [16], Tanzania (98.8%) [17], and Butajira (99%) in Central Ethiopia [18] which reported almost universal knowledge of modern FP methods. The difference may be attributed to the wide variation in culture and socioeconomic characteristics of study participants.
Our study showed that women who know modern FP methods were about seventeen times (AOR = 16:958, CI: 4.768, 60.316) more likely to utilize modern FP methods than those women who do not know any type of modern

BioMed Research International
contraceptive. This study finding is in line with the study finding from Awi zone, Amhara regional state, and the town of Debre Markos, Northwest Ethiopia [19,20]. This can be justified by the fact that better knowledge of modern FP may result in better practice of modern FP methods, i.e., the women who know modern FP methods are more likely to use the method consistently and effectively than their counterparts.
In our study, the husband's view and approval of modern contraceptives showed an independent effect on modern contraceptive's method utilization. The odds of modern FP utilization among women who perceived that their husbands support the use of modern contraception were more than three times (AOR = 3:590, CI: 2.170, 5.936) higher than those women who do not perceive that their husbands support the use of modern contraceptives. The study finding is similar to findings from Ghana, Cameroon, and Bangladesh [21][22][23].
This study showed that women who discussed with their husbands about the issue of FP or SRH were about three times (AOR = 2:852, CI: 1.759, 4.623) more likely to use modern contraceptives than those women who did not discuss with their husbands. This finding is consistent with other studies conducted in Ghana, Ethiopia, and Tanzania [12,15,21,24], and women whose partners were involved in FP decision-making were more than twice (AOR = 2:340, CI: 1.531, 3.576) more likely to use modern contraceptive methods than their counterparts. This finding is consistent with findings from Cameroon, Debre Markos, Northwest Ethiopia, and Zambia [20,22,25] and suggests that male involvement in decision-making improves spousal communication and decreases male opposition. This might be because women who discuss FP issues with their spouses may have their partner's approval on family planning; hence, they are more likely to use a modern method of contraception. This evidence is supported by a study conducted in the pastoralist community of Ethiopia that suggests that contraceptive use was influenced by both individual-/community-level characteristics [26]. This can be due to the fact that joint decisions for family planning are based on spousal communication implying that when couples communicate effectively, they are more likely to jointly agree on what type of contraceptive method to use, how many children to have, and the space between their offspring.
The current study reported that the odds of modern contraceptive utilization were more than two times (AOR = 2:295, CI: 1.528, 3.447) higher for women who do not desire an additional child than for those women who desire to have an additional child. This finding is similar to a study conducted in Zambia [27]. This is supported by responses from study participants, most of whom said they were using modern contraceptive methods for spacing and limiting birth.
The study also showed that women who had never used modern FP were only 0.018 times less likely to use modern FP methods, compared to those who had ever used modern FP methods (AOR = 0:018, CI: 0.005, 0.063), a similar finding to a study conducted in Uganda [28]. This can be due to the fact that ever users of modern FP methods were more familiar with the benefits of modern FP methods. Hence, they are more likely to use/continue the methods than their counterparts.

Limitations
Data were cross-sectional and originated from selfreported measures. In this case, it is difficult to validate claims made by respondents in the course of questionnaire administration. Moreover, there was a lack of contextual factors related to the health system, culture, religion, and societal norms of the study setting, which may affect modern FP use.

Conclusion
The present study contributes to our understanding of the determinants of modern FP utilization among women in rural Ethiopia. The overall prevalence of modern FP use among the study participants was low. Couple's discussion, the desire for additional child, male involvement in decision about family planning, husband approval, ever use of contraception, and knowledge of modern FP methods were found as significant factors that can increase modern FP method use. The results of this survey suggest that the government should focus on positive action able to increase access to modern FP methods and it should create awareness of modern FP methods through mass media, community-based education, and proper counselling. The government should emphasize empowering women to make appropriate choices and address real barriers to women's use of modern FP methods.

Data Availability
The data used to support the findings of this study are available from the corresponding author after formal communication by email, if the request is for an acceptable reason.

Disclosure
The funding organization has no role in designing the study, data collection, analysis and its interpretation, protocol writing, and submission.