Demand for long acting and permanent contraceptive methods and associated factors among married women of reproductive age group in Debre Markos Town, North West Ethiopia

As of July, 2012 world population is estimated to be above 7 billion. Africa accounts around 1 billion people, 15% of the world’s population. The total fertility rates (TFR) worldwide ranges from 1.1 children per women in Taiwan to 7.1 in Niger [1].

Ethiopia is the second most populous country in sub-Saharan Africa (SSA), with an estimated population of over 82 million people, with an average growth rate of 2.6% per year. The population is projected to increase to 166 million by 2050 which makes Ethiopia the 10^th most populous country in the world [1, 2]. Ethiopia has a TFR of 4.8; ranging from lowest 1.4 children per woman in Addis Ababa to highest 6.2 in Oromia [3]. Studies in countries where fertility is high have showed that, maternal, infant and child mortality rates are high [4, 5]. In Ethiopia there are high maternal mortality ratio (676/100,000 live births), high abortion rate (23/1000), and unwanted pregnancy rate (42%) [2, 3, 6].

The SSA region’s unmet need for family planning (FP) is the highest in the world (48.8 million women), nearly half the married women of reproductive age (MWRA) want to space or limit the number of children they have. However, less than one in seven MWRA (14.7 million) are using a modern method of contraception, of which only 2.7 million MWRA use long-acting or permanent contraception [7, 8]. Reasons for unmet need are lack of knowledge about contraceptive options and their use, unavailability of services, limited supplies everywhere or choices, fear of social disapproval or partners’ opposition, fear of side effects and health concerns [9].

The 2011 Ethiopian demographic and health survey (EDHS) showed that 38% of women wants child after two years and 37% reported they want no more children. Only 25% of currently married women have an unmet need for FP (16% for spacing and 9% limiting). Total unmet need is highest in Oromia (30%) and lowest in Addis Ababa (11%). Only 29 percent of currently married women are using a method of FP; despite the government is working toward a contraceptive prevalence rate (CPR) of 60% by 2010. Prevalence of LAPMs use constitutes 3.4%, 0.3% and 0.5% for Implant, IUD and sterilized respectively [3, 10].

Better availability of FP services, including long acting & reversible methods (LARMs) would fulfill the need for healthier timing and spacing of pregnancies [11]. Four contraceptive methods are categorized under LAPMs: intrauterine devices (IUDs), implants (Implanon, Jadele), female sterilization, and vasectomy. IUDs and implants are long-acting temporary methods; when removed, return to fertility is prompt; and female sterilization and vasectomy are permanent method. Implants are effective from 3 to 7 years depending on type and IUDs are effective for at least 12 years [12].

LAPMs are the most effective (99% or greater) methods of contraception available and are very safe and convenient for protection against unintended pregnancy [9]. Experience in countries where LAPMs are available shows; they are highly popular than short acting methods [12]. According to world health organization (WHO) eligibility criteria, almost all women are eligible for IUDs, implants and sterilization [13]. They are also cost effective for programs over time and with lowest discontinuation rates. Despite these advantages, LAPMs remain a relatively small and sometimes missing component of many national reproductive health and FP programs [8, 11, 12]. Global experience including the SSA countries confirmed that without widespread availability and use of LAPMs of contraception, a country cannot meet its lowering fertility goals, reducing maternal and child mortality. Investing in FP specifically on LAPMs is one of the key for reducing child and maternal mortality; and to halt/combat HIV/AIDS directly and to achieve other MDG goals indirectly [11, 12].

In Ethiopia despite the fact that the practices on long acting and permanent methods are believed to be low, there are limited recently available evidences on the real magnitude and associated factors of the demand for LAPM. Thus, there is a need to assess the demand for LAPMs and associated factors among married women of reproductive age in the study area.

The study revealed that more than half (52.4%) of respondents had demand for LAPMs; of which 32.9% had an unmet need for LAPMs (16.4% for spacing & 16.6% for limiting) and 19.5% were using the methods (11.0% for spacing & 8.5% for limiting). Among the total demand only 37.1% were satisfied where as majority (62.9%) were unsatisfied for the demand of LAPMs in which they required it for spacing or limiting but were not using LAPMs.

The unmet need was lower than study in Congo in which 21% had unmet for spacing and 31% for limiting; and in Rwanda 27% wanted to stop having children of which 57% were not practicing using any contraception or were having an unmet need for permanent methods of FP [15, 16]. The reason for this may be due to the differences in time, socio cultural, geographical and study settings. EDHS 2011 showed 25% unmet for FP and total demand of 54% (33% were for spacing and 21% for limiting). From survey in southern nation, nationalities, and peoples’ region (SNNPR) the total demand for FP in the region was 49.3% of which 37.4% had unmet need and 11.9% had met need for FP [3, 17]. The reason for this might be the difference in time and study setting in which those studies were conducted in both rural and urban setting and for the general FP methods. However, this study is only for urban and on demand of LAPMs. On the other Hand the current study’s demand, unmet need and practice for LAPMs were higher than studies done in Goba [demand for LAPMs was 18.12% and 9.4% had unmet need] and Batu Jira [total demand for LAPMs among FP service users was 24.4% (3% satisfied and 22.4% unsatisfied)] towns [18, 19]. This might be due to the time differences in which currently deferent Medias are promoting LAPMs, so that they may increase the acceptance/practice of LAPMs.

In this study age, desire for more child, duration of desire to have child, number of children ever born, ever heard of modern FP, ever use of modern FP, spousal discussion in the past 6 month about contraception, spousal discussion about which method to use and perception of partner’s approval of permanent methods after completing family size were significantly associated with demand for LAPMs.

Accordingly women whose age were in between 40–44 years were almost three times more likely to have demand for LAPMs than women whose aged were in between15-19 years [AOR = 2.81, CI:1.12-9.55]. This result is supported by study done in Batu jira town [19]. The reason for the age deference could be due to those women who were older were having more children and have more desire to limit or space the number of pregnancy than younger’s who had none or few children. This is also supported by studies done in Goba town, Oromia region, rural Ethiopia and Pakistan, in which women who want more children were younger [18, 20–22].

In this study women who had completed their family size or don’t want any more children were twenty point three seven times more likely to have demand for LAPMs than those who desire more [AOR = 20.37; 95%CI: 9.28, 44.72]. This result is supported by study done in Pakistan which revealed that woman who wanted no more child were more likely to intend using contraceptive methods particularly sterilization [22].

Our study revealed that women who wanted to have a child after two years were six point four times more likely to have demand for LAPMs than those who want within two years [AOR = 6.4; 95% CI: 3.04, 13.47]. On the other hand Women who had three, four and five or more ever born child were two point two six, two point two three three, and nine times more likely to have demand for LAPMs when compared to those who had no child [AOR = 2.26, 95% CI: 1.22, 4.17], [AOR = 2.34; 95%CI: 1.04, 5.26] and [AOR = 9.02, CI: 3.74, 21.74] respectively. This result in line with the result of study done in Batu Jira town which showed women with 1–3 and 4–12 children were having fifty one and six times higher demand than who had no child respectively [19]. The reason for deference might be due to the more child the woman is having the more likely she want to space or limit the number of child she have and the more she were using LAPMs or had an unmet need. It is also supported by studies done in Goba, Oromia, Mekelle, Egypt and Uganda [18, 20, 23–25].

The study revealed that women who have heard of at least one modern FP method were about six times more likely to have demand for LAPMs than those who didn’t [AOR = 5.73; 95% CI: 1.26, 25.91] and women who had ever used modern FP before were almost two times more likely to have demand for LAPMs than those who didn’t [AOR = 1.89, 95% CI: 1.01, 3.55]. Similarly from study in Rwanda demand was higher among women who received information about family planning at health facilities than among those who received no information or those who did not attend such a facility [16]. Also from study done in Goba town and on other Ethiopian districts, family planning practice was significantly associated with willingness to use LAPMs in the future than who didn’t and respondents who had ever used modern family planning were more than seventeen times more likely to use LAPMs than those who didn’t [18, 26].

The study indicated that spouse who had no discussion about contraception in the past six months and women who had no discussion about which method to use were one point six and about two times more likely to have demand for LAPMs than those who had discussion [AOR = 1.64; 95% CI: 1.04, 2.57] and [AOR = 2.14; 95% CI: 1.31, 3.49] respectively. On the other hand women who perceived that their husbands would approve when long Acting and permanent methods needed after completing family size were almost two times more likely to have demand for LAPMs than who didn’t know their husbands perception [AOR = 1.93; 95% CI:1.22, 3.07]. This might be due to those who had discussion were more likely to discus on the desired family size, knew their husbands perception towards LAPMs, and desired to use suitable methods than having an unmet need for the methods. The result is supported by studies done in Goba, Pakistan, mekelle and Jimma in which contraceptive practice was found to be strongly associated with spousal discussion about FP, women’s perception of husband’s approval with contraceptive practices [18, 22, 23, 27, 28].

Even though this study is one among few studies conducted to assess the demand for LAPMs and associated factors, Lack of literatures which are specifically conducted on demand for long acting and permanent methods, being conducted only in the town and cross sectional study were some of its limitations.

In conclusion, the total demand and overall practice of LAPMs in the town was higher when compared to the findings of other studies conducted in the country. Being in older age, having no desire for more child, desire to have a child after 2 years, having ever born children three or more, not ever heard of modern family planning, not ever using of modern FP, having no spousal discussion in the past six month about contraception, having no spousal discussion about which method to use and having perception of their husbands’ approval of using permanent methods after completing desired family size were significantly associated with having higher demand for LAPMs. Thus, the federal ministry of health and regional health bureau in combination with NGOs working on family planning have to work hard to increase accessibility and availability of LAPMs, because almost half of respondents had intention to use in the future and more than half had unsatisfied demand for LAPMs in the study area.