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Microsoft word - volume 20 no 2 final.doc

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 ______________________________________________________________________________________
References
6. John B, Elof J, Future trends in Contraception in the 1. Demographic and Health Survey, Ethiopia, 2000. developing world: Prevalence and method mix, 2. Barbara E. K., Roger W. R and Widad K., Maternal Policy Research Division, Population Council, 2000 mortality in Addis Ababa, Ethiopia, Studies in 7. Farzaneh R-F, Iran’s family planning program: 3. 2003 World Population Data Sheet, Population Responding to a nation’s Needs, Population 4. Health and Health Related Indicators, Federal 8. CBRH Training Curriculum, Federal Democratic Democratic Republic of Ethiopia, Ministry of Republic of Ethiopia, Ministry of Health, Addis 5. www.safemotherhood.org/init_facts.htm, accessed 9. Baseline Survey Report for CBD Projects, FGAE, 79 Ethiop.J.Health Dev. ______________________________________________________________________________________

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