Original article Improving the range of contraceptive choices in rural Ethiopia
Mengistu Asnake1, Lakachew Walie2, Yilma Melkamu3 Abstract Background: Despite the reality of a high unmet need, the utilization of family planning services in Ethiopia could be described as very low. Besides this, the knowledge and practice of family planning is limited merely to the usage of shorter-term contraceptive methods. Therefore, there is a need to expand access to family planning services in rural Ethiopia by making available more choices to family planning clients. Objective: The aim of this study is to examine the pattern of family planning method mix overtime and to assess the impact of combining strategies, such as community and facility based approaches, in improving access to family planning services and choices. Methods: A cross-sectional, descriptive study was conducted in September 2000 in Tehuledere woreda, in South Wollo zone, Amhara Regional State. A census was done on all clients who live in 15 kebeles in the woreda and who used long-term and permanent family planning methods which included IUD, Norplant and male and female sterilization methods and were interviewed. Results: Among the 218 family planning clients interviewed, 11 (5%) were males who had undergone vasectomy. Almost 81% of the clients using long-term and permanent methods were in the age group of 25-44 years. The mean age was 34.2 years with a range of 18-70 years and the mean number of children ever born to the study subjects was 5.6 with a range of 0-14 children. Knowledge of modern family planning methods was found to be over 90%, the majority (73.9%) of the respondents getting information on family planning from the community based reproductive health (CBRH) program. Fifty two percent have undergone voluntary surgical contraception, followed by Norplant (39.0%) and IUD (8.7%). Among the major reasons mentioned for the use of the current family planning methods were limiting family size (45.9%), spacing (27.5%), and side effects of the previous method (12.4%). For most clients (90.8%) the source of information for their current use is the CBRH program. Conclusions: Improving the usage of wide range of contraceptive method mix improves the quality of family planning services rendered to the community and ensures sustainability of the services. A coordinated effort among facility based and community based providers can assist in ensuring client choices and improving the method mix. [Ethiop.J.Health Dev. 2006;20(2):74-78] Introduction
currently use either modern or traditional methods to
Ethiopia is one of the countries with the highest maternal
space or permanently stop having children. Contraceptive
mortality, which is estimated at 871 per 100,000 live
method mix usage differs from program to program and
births (1). The major causes of maternal mortality and
region to region based on the availability of the methods,
suffering are unsafe abortion, hemorrhage, and affordability of the services and other barriers such as obstructed labor (2). With an estimated current socio-cultural factors. Generally, contraceptive users in population of over 64 million people (3), Ethiopia is the
Africa rely on shorter-term methods such as pills, while
second most populous country in Africa next to Nigeria.
the usage of long and permanent methods is more
The population is growing at a rate of 3.2 and is expected
common in Asia and Latin America (6, 7).
to reach over 173 million in 2050. Contraceptive prevalence in the country is very low with only 8% of
All modern methods which provide a wide range of
married women using any type of contraception (1). This
protection from durations of as short as days to
eventually leads to large numbers of unwanted permanent protection such as voluntary surgical pregnancies every year.
sterilization, intra uterine device, pills, injectables,
condoms and other barrier methods are available in
Close to 64% of the Ethiopian population can access
Ethiopia. However, utilization is limited very much to the
modern health services. Only around 41% of pregnant
shorter-term methods such as pills and injectables (1, 4).
women have the chance to have antenatal checkups and
less than 10% get the opportunity of attended delivery
Currently in Ethiopia, in addition to health facility based
service delivery, programs are focusing on alternative
service delivery strategies such as the community based
The delivery of family planning services is one of the
reproductive health (CBRH) approach. The CBRH/CBD
important strategies for reducing maternal morbidity and
program was developed to enhance access to
mortality worldwide (5). Families and individuals contraceptive use and knowledge by taking the services
_______________________________________________________________________________________________ 1Pathfinder International Ethiopia, P.O. Box 12655, Addis Ababa, Ethiopia; 2Mozambique National Family Planning (IPPF); 3Department of Community Health, Medical Faculty, Addis Ababa University
75 Ethiop.J.Health Dev. ______________________________________________________________________________________ closer to the community level through the participation of
collection. Field supervisors checked each completed
the communities themselves and by mobilizing questionnaire and the survey coordinator reviewed the community volunteers. In a country like Ethiopia where
instruments to ensure data quality. The data were
the health service coverage and utilization is low the
analyzed using SPSS/PC version 5.0 and EPI-INFO
CBRH approach is vital in ensuring access to services
version 6.04 software packages. Frequencies, means and
and increasing knowledge of individuals and families to
proportions were used to present the data.
practice family planning. This model of service delivery
was adopted in recent years in Ethiopia mainly by NGOs
on a on a pilot basis & gradually expanded to wider
Among the total of 218 family planning clients
geographical area. The program uses community interviewed, 11 (5%) were males who had undergone volunteers that undergo two weeks of training that vasectomy. Almost 81% of the clients who used long-enables them to educate the community on family term and permanent methods were in the age group of planning and other reproductive health care services, 25-44 years. The mean age was 34.2 years with a range provide pills and condoms and refer those who need
of 18-70 years. The majority of the clients (89.4%) were
longer and permanent contraceptive methods (8).
predominantly Muslim. As shown in Table 1, 26.1% of
the respondents had no education, 54.1% had some
This study was conducted in Tehuleder Woreda in south
informal education, and 19.7% had some formal
Wollo zone of Amahara Regional State. The population
education. A majority (58.3%) of the clients reported that
of the woreda is close to 136,000 and the residents are
predominantly muslim by religion. The CBRH program
was started in the woreda in 1996 by the Family Table 1: Distribution of respondents by demographic Guidance Association of Ethiopia by deploying 34 characteristics CBRH agents in 15 kebeles. Financial and technical Variable (n=218)
support was secured for the program from Pathfinder
International and USAID. A baseline study that was
conducted just before launching the project indicated that the CPR was 12% with a method mix of 84% pills, 14%
Injectables and 2% condoms and long term and
permanent methods such as IUD, while Norplant and
sterilization were not part of the method mix (9).
The aim of this study was to examine the pattern of
contraceptive method mix overtime and to assess the
benefit of combining strategies such as community and
facility based approaches in improving access to family
Religion
planning services and choices. The study is also intended
to describe the characteristics of users of long and
Education
A cross-sectional descriptive study was conducted in
September 2000 in Tehuledere woreda of south Wollo
Occupation
zone in Amhara Regional state. A census of all clients
living in 15 kebele of the wereda using long-term and
permanent methods that include IUD, Norplant and male
and female sterilization were interviewed. This was not
difficult to undertake as all the family planning users in a
kebele are known and receive regular visits by their Table 2 indicates that almost 96% of the respondents are
respective CBRH agent. Accordingly 218 users from the
married. The mean age at first marriage among long term
15 kebeles were identified. A structured questionnaire
and permanent method users is 15.3 years with a range of
was developed and pre-tested. The questionnaire was 10-30 years. Almost 38% were married before the age of
designed to capture socio-demographic variables such as
15 years. The mean number of children ever born was 5.6
age, religion, marital status, educational level and with a range of 0-14 children. Almost 30% of the
occupation. Additionally, variables such as fertility, respondents had four or more children during the time of
knowledge and practice of family planning were the survey. Among the respondents, 42.7% didn’t desire
included. The data collectors were selected from the local
the birth of their last child. Over 50% wanted to have an
area and were, thus, well aware of the local culture and traditions and they were given adequate training in data
Improving the range of contraceptive choices in rural Ethiopia 76
______________________________________________________________________________________ ideal number of 2-4 children and 36.2% were undecided
Among the major reasons mentioned for the use of the
current family planning methods were limiting family
size (45.9%), spacing (27.5%), and side effects of the
Table 2: Distribution of clients by marital status and
previous method (12.4%). For most clients (73.9%) the
fertility patterns
source of information is the CBRH program.
Variable Marital status
Table 3: Distribution of clients by modern family planning knowledge and practice Variable Knowledge of specific FP method Age at first marriage Number of births Source of information Children alive Previous use of specific FP method Children died Duration of use Ideal number of children Current FP method on use Reason for current method use
Except for foaming tablets (70.0%), knowledge of
modern family planning methods was over 90%. The
majority (73.9%) of the respondents got their information
on family planning from the CBRH program. As shown
in table 3, the majority of the clients were on temporary
family planning methods such as pills (72.9%) and
Source of information for current use
injectables (41.3%) before they shifted to long-term and
permanent methods. Twenty eight (12.8%) of the clients
never used modern contraceptives before the present
method. The mean duration of use before the current
method was 16.7 months with a range of 0-87 months.
As shown in Table 4, the majority of the clients (83.0%)
Almost over 60% of the clients have used some form of
took 1-3 months before deciding on the current method.
modern FP methods for over six months. Close to 52.0%
Moreover, 60.0% of the respondents encouraged others
have undergone voluntary surgical contraception, on the use of long term and permanent methods. Among followed by Norplant (39.0%) and IUD (8.7%).
these clients 57.3% have confirmed that one or more
77 Ethiop.J.Health Dev. ______________________________________________________________________________________ Table 4: Distribution of clients by factors associated with current use Variable Discussion with others before current method use Duration before decision on the method Encouraged others on use Number used with your effort Discussion
availability of methods and adequate awareness creation
During the baseline survey, the utilization of in the community. It is clear that, in addition to health contraceptive methods was totally dominated by the use
service providers, the contribution of CBRHAs was quite
of shorter-term methods such as pills and injectables, and
at the time of this study the methods used have significantly shifted towards the long and permanent In a country like Ethiopia where it is difficult to sustain methods of contraception. Contrary to the findings in this
services and ensuring constant supply of contraceptives is
study, the contraceptive method mix of the country from
a challenge, shifting towards the long and permanent
the DHS and data according to the MOH, a majority of
methods is an important strategy to ensure continuity of
the family planning clients are users of short-term services. From the client perspective, using the methods methods - especially the pills (1,4). The report by MOH
gives them confidence as they are not expected to worry
shows that the use of IUD and Norplant ranged 0.1-0.4%
about the timing of taking methods and becoming
and 0.1-0.3% respectively in three consecutive years (4).
pregnant. It also relieves them from repeated visits to
This could be explained by different factors and needs
health facilities by walking long distances.
detailed investigation. Some of the reasons could be the
unavailability of the long-term methods, the lack of Generally, to ensure the quality of services and address trained personnel to provide the methods, as they demand
the different contraceptive needs of clients, programs
special skills and providers' bias towards the methods as
should make all methods available and try to harmonize
they need pre-procedure special preparations and as they
health facility and community based interventions.
are relatively time taking. Countries in Middle East and
Different strategies that are based on local context
Asia such as Iran have managed to bring the share of the
including training of all staff in long-term contraceptive
long and permanent methods to over 50% of the total
methods provision at a health facility should be designed
and implemented. In conclusion, the achievement of this
study area could be replicated to other areas.
In the DHS, knowledge of family planning was generally
good both in the rural and urban settings, but was low for
The study focused only on the users of long and
methods such as Norplant, IUD, and VSC for both men
permanent methods due to limitation of resources and a
and women (3). Compared to the DHS, knowledge of all
larger scale study that includes users of both short and
methods in general and long and permanent methods in
longer/permanent methods and non-users is
particular is quite high and almost all are above 90%.
recommended to provide detailed information that would
Encouragingly, CBRHAs were the main initial sources of
provide detailed information for the expansion of method
information. The fact that 60% of current users were
trying to encourage others to use the long and permanent
methods shows that there is satisfaction from the users'
Acknowledgement
side and probably extent of the quality of services We would like to acknowledge the Family Guidance provided.
Association of Ethiopia and Pathfinder International
Ethiopia for providing financial and technical assistance
This study demonstrated that there is very high demand
for long and permanent contraceptive methods given the
Improving the range of contraceptive choices in rural Ethiopia 78
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79 Ethiop.J.Health Dev. ______________________________________________________________________________________
Description Product # Used in Research Packaging Product is packed in 12.5 kg box. Each box is identified with the Ingredient Lead Time Gamma-Irradiation Shelf Life Control Diets Used as a control diet for D12451and D12492Formulated by E. A. Ulman, Ph.D., Research Diets, Inc., 8/26/98and 3/11/99. *Typical analysis of cholesterol in lard = 0.95 mg/gram. Cholesterol (mg
European Journal of Neurology 2011, 18: 1115–1121E F N S G U I D E L I N E S / C M E A R T I C L ETreatment of medication overuse headache – guideline of theEFNS headache panelS. Eversa and R. JensenbaDepartment of Neurology, University of Mu¨nster, Mu¨nster, Germany; and bDanish Headache Center, Department of Neurology, GlostrupHospital, University of Copenhagen, Copenhagen, DenmarkBack