Contraceptive Use and Its Associated Factors among Women Who Gave Birth within 12 Months in Dubti Town, Pastoral Community, of Afar Region Northeast, Ethiopia

Introduction Substantial numbers of women are not using contraceptives in their postpartum period and die due to avoidable causes related to birth complications. Contraceptives use within 12 months of childbirth has given less attention in Ethiopia. Thus, this study is aimed to assess contraceptive use and its associated factors among women who gave birth within 12 months in Dubti town, pastoral community of Afar region, Ethiopia. Methods A community-based cross-sectional study was conducted among 342 women in the Dubti town. A systematic random sampling technique was employed to identify and enroll women. Data were collected using a pretested, structured, and interviewer-administered questionnaire. Descriptive statistics were done, and logistic regression analysis was employed to identify the factors associated with contraceptive use. The statistical association was measured by odds ratio with a 95% confidence interval. p value < 0.05 was considered as statistically significant. Results In this study, 103 (30.1%) [95% CI: 25.4%, 35.1%] women have used contraceptives. Women who had secondary educational level (AOR = 3.53, 95% CI (1.68, 7.36), had antenatal care follow-up (AOR = 1.93, 95% CI (1.01, 3.69), and visited by health worker after delivery (AOR = 2.54, 95% CI (1.37, 4.68) were associated with increased odds of contraceptives use. Conclusions This study revealed that the prevalence of contraceptive use was low compared to the national recommended figure. Secondary educational level, having antenatal care follow-up, and being visited by health workers after delivery were predictors of contraceptive use. Thus, increase the educational status of women, antenatal care follow-up service, and visiting after delivery by health workers are important interventions to promote the use of contraceptives in the postpartum period.


Introduction
Family planning is a means of promoting the health of mothers, families, and reduce high maternal, infant, and child mortality. Postpartum contraceptive is the prevention of unintended and closely spaced pregnancies during the first 12 months after childbirth [1]. Substantial numbers of women are not using contraceptives in their postpartum period, which leads to a risk of pregnancy [2]. A systematic review and meta-analysis of postpartum contraceptive use among women in low-and middle-income countries indicated that the overall pooled modern contraceptive preva-lence was 41.2% and the lowest in West Africa (36.3%). The pooled prevalence of unmet need was 48.5% and the highest in South Asia/South East Asia (59.4%) [2]. Ethiopia has the lowest postpartum care coverage of 13% compared to Sub-Saharan Africa country, and the Afar region has 6.5% postpartum care coverage which is the lowest compared to other regions of Ethiopia. Moreover, the national contraceptive coverage is low among currently married women 35% and, in the Afar region, has the lowest 12% compared to the national figure [3].
Pregnancies occurring within a year of the mother's previous birth are riskier for the health of both the mother and the child, and these increase childhood and maternal mortality [4,5]. Contraceptives use can avert more than 30% of maternal deaths and 10% of child mortality [6].
In Ethiopia, though the World Health Organization (WHO) and Ethiopian family planning program recommend an interval of at least 2 years following a live birth [17,18], still fertility is high about 5.8 particularly in pastoral regions [3]. Moreover, though improvement in increased contraceptive utilization coverage and reduction of maternal mortality 412 per 100,000 live birth due to strategies implemented by government and nongovernmental organizations [3], women still die due to avoidable causes related to pregnancy and birth complications. Contraceptives use during postpartum the period has given less attention and no indicator measurement in Ethiopia's health management information system. Thus, this study aimed to assess contraceptive use and its associated factors among women who gave birth within 12 months in Dubti town, pastoral community of Afar region, Northeast Ethiopia in 2018.

Study Setting and Period.
Dubti town is located in Dubti district which is one of the eight districts of Zone one. It is 595 km northeast of Addis Ababa. Dubti town has 1 kebele (the lowest administrative structure of district) which has 38 ketenas (the lowest sub administrative structure of kebele). Based on the 2007 Census population projection, the number of women in the reproductive age in Dubti town was 2586, and the number of women within the last 12 months of childbirth was 1091. Dubti town has 1 health center and one general hospital.

Study Design and Population.
A community-based crosssectional study was conducted among all systematically selected women who give birth within the last 12 months in Dubti town. The women, who were ill during the study period and were unable to respond, were excluded from the study.

Sample Size Determination and Sampling Techniques.
The sample size was determined by using the single population proportion formula with the following assumptions: considering 5% type one error, 95% confidence interval (CI), and 29.3% proportion of contraceptive use within 12 months of childbirth [19]. Then, we added 10% nonresponse, and the final sample size was 350 participants.

Study Variables.
The outcome variable of this study was contraceptive use. It was defined as if mothers used contraceptives to prevent unintended and closely spaced pregnancies within the first 12 months period following birth. It was coded as "1" for "yes" response while "0" for "no" response during analysis.
The independent variables were sociodemographic characteristics (age of mothers, religion, ethnicity, marital status, birth interval, family size, parental education, parental occupation, and household income), reproductive and health services related characteristics (ever used contraceptive, number of children, history of abortion, menses resumed, started sex, planned birth, current pregnancy status, antenatal care follow-up, place of delivery, and postnatal care), and knowledge and attitude on contraceptive use. Good knowledge was measured if mothers scored 75%-100% of the total knowledgerelated questions unless considered as having poor knowledge (scoring of <75%). The attitude of mothers to words contraceptives was measured by asking mothers about their subjective opinion, outlook, position, and ideas towards contraceptive methods. Mothers were classified as having a positive attitude if scored 75-100% from total attitude questions and considered as having a negative attitude if scored ≤75% attitude questions [16].

Data Collection Tools and Techniques.
Data were collected by using a pretested, structured, and intervieweradministered questionnaire adapted from literature reviews and the Ethiopian Demographic and Health Survey [3]. The adapted questionnaire was modified to fit the local circumstances and the research objective. The questionnaire was prepared first in English and translated into Amharic by an English instructor who is fluent in both languages. The Amharic questioner was used to collect the data. The tool was pretested on 18 women other than the source population in the Samar-logia city administration. The pretest was done to ensure clarity, wordings, logical sequence, and skip patterns of the questions. Then, amendments to the questionnaire were made accordingly. The data were collected by six preparatory completed students and supervised by two diploma nurses. The supervisors checked the day-today activities of data collectors regarding the completion of questionnaires, clarity, and proper coding of the responses.
2.6. Data Quality Control. Students who can speak the local language were recruited as data collectors. The data collectors and the supervisors were trained for one and half days by the principal investigator on the study tool, objective, consent form, and data collection procedure. Journal of Pregnancy A binary logistic regression analysis was done to assess the association between the outcome variable with each  (Table 3).

Factors Associated with Contraceptive
Use. The selected variables were tested for their contribution to contraceptive utilization using binary logistic analysis. The variables that

Journal of Pregnancy
showed associations were being secondary educational level, had ANC follow-up services, delivered at a health facility, resumed menses after last delivery, and visited by health worker after delivery. Then, these variables were entered together to determine their effect on the outcome variable on multivariable logistic regression analysis. Accordingly, secondary educational l level (AOR = 3:53, 95% CI (1.68, 7.36), having ANC follow up services (AOR = 1:93, 95% CI (1.01, 3.69) and being visited by health worker after delivery (AOR = 2:54, 95% CI (1.37, 4.68), were factors statistical associated with postpartum contraceptives use (Table 4).
In this study, the odds of contraceptive use within 12 months of childbirth among women who had a secondary educational level were 3.53 times more compared to women who had no educational level (AOR = 3:53, 95% CI (1.68, 7.36). Women who had antenatal care follow-up were 93% more likely to contraceptive use within 12 months of childbirth than their counterparts (AOR = 1:93, 95% CI (1.01, 3.69). The odds of contraceptive use within 12 months of childbirth among women who were visited by health workers after delivery were 2.54 times more compared to their counterparts (AOR = 2:54, 95% CI (1.37, 4.68) ( Table 4).

Discussion
This study was aimed to assess contraceptive use and its associated factors among women who gave birth within 12 months. Based on this, we found that the prevalence of contraceptives use was 30.1% (95% CI, 25.4 to 35.1).
In this study, the odds of contraceptive use within 12 months of childbirth among women who had a secondary educational level were 3.53 times more compared to women who had no educational level (AOR = 3:53, 95% CI (1.68, 7.36). This is consistent with a study conducted in Kebribeyah, Ethiopia Somali region [12], Uganda [13], Malawi [8], other settings of developing countries [6], and the USA [9]. This might be because women's attainment of educational level benefits to a better understanding of the available methods of contraceptives during 12 months of childbirth. Besides, educations increase the level of awareness on contraceptives use and to utilize the method of contraceptives. It has been noted that women's education is an important determinant factor for increasing contraceptive use within 12 months of childbirth [13].
Women who had antenatal care follow-up were 93% more likely to contraceptive use within 12 months of . This is consistent with the study done in Kebribeyah, Somali region, Ethiopia [12]; Gonder town, Northwest Ethiopia [7]; Kenya and Zambia [10]; and the United States [15]. This might be the fact that women who attend antenatal care are more likely to get information on contraceptive use. Moreover, women who had frequent visits during ANC had more exposure to counseling and awareness on birth spacing. A previous study showed that providing education on contraceptive use during antenatal care follow-up had Positive results and women that do not attend ANC are at risk of having closely spaced pregnancies and births [9]. The odds of contraceptive use within 12 months of childbirth among women who were visited by health workers after delivery were 2.54 times more compared to their counterparts (AOR = 2:54, 95% CI (1.37, 4.68) ( Table 4). This finding is in line with the study conducted in Kebribeyah, Somali, Ethiopia [12]; Gondar, Ethiopia [7]; Tigray Ethiopia [20]; and United States [15,16]. This might be the fact that women visited by health workers after delivery can get postnatal care and counseling service on contraceptive use. It has been noted that postpartum educational and counseling services were a significant contribution to contraceptive use within 12 months of childbirth [25,26].

Strength and Limitation of This Study.
The strength of the study was being community-based, and it can represent the source population. However, the study might have a limitation like respondents' recall bias, and as it is, a crosssectional study design no causal inferences can be made.

Conclusion
This study revealed that the prevalence of contraceptive use among women who gave birth within 12 months was low compared to the national figure. A secondary educational level, having antenatal care follow-up, and being visited by health workers after delivery were predictors of contraceptive use. Thus, increasing the educational status of women, antenatal care follow-up service, and the visit after delivery by health workers are the important interventions to promote the use of contraceptives in the postpartum period.

Data Availability
The datasets supporting the conclusions of the study are included in the article, and the datasets used for analysis during the current study are available from the corresponding author on reasonable request.

Disclosure
The funder had no role in the manuscript writing, editing, approval, or decision to publish.

Conflicts of Interest
The authors declare that they have no competing interests.