Unmet Need for Modern Family Planning and associated factors among Women Attending HIV Care Services at Rural Area Public Health facilities in South Gondar, Ethiopia.

Introduction: To achieve the elimination of mother to child transmission of the human immunodeciency virus (HIV), preventing unintended pregnancy and reducing the high unmet need for family planning among HIV positive women was crucial. Despite being crucial little has been known on the unmet need for family planning and its determinants among women living with HIV in the rural area. Therefore, this study aimed to assess the prevalence of unmet need for modern family planning and its determinants among women Attending HIV Care Services at rural Public Health Facilities. Methods: An institution-based cross-sectional study was conducted from March to April 2020 in rural South Gondar. A total of 931 respondents were included in the study. To recruit respondents a multi-stage sampling technique was used. The data were collected using a pretested and semi-structured questionnaire. Data were entered by Epi data version 4.6 and exported to Stata version 14 for analysis. Variables with a p-value<0.2 in the bivariable logistic regression model were tted to the multivariable logistic regression model. Adjusted Odds ratio with 95% CI was computed and variables with P-value < 0.05 in the multivariable analysis were taken as signicant determinants. Results: The prevalence of unmet need for family planning was 25.67% with 95% CI (22.96 28.58). Age group (35 49) (AOR=6.5,95% CI (2.86,14.66)), education status (9 12) (AOR=0.25,95%CI (0.10,0.61)), history of ever use Contraception (AOR=3.9, 95%CI (2.28, 6.67)), having ve and above parity (AOR=5.1, 95%CI (2.08, 12.43)) and not Counselling for contraception (AOR =4.2, 95 CI, (1.91, 9.37)) were determinant for unmet need of contraception among HIV positive women in South Gondar. Conclusion: prevalence of unmet need for family planning was high. It was mainly Inuenced by last reproductive age group (35-49)), education (9-12), having no experience of contraception use, having ve and above parity, and no counseling for contraception. Therefore, family planning programs need to focus on old (35-49) reproductive age women, and multi-para women.


Introduction
Contraceptive use increased in many parts of the world, especially in Asia and Latin America(1). Of 1.9 billion reproductiveage women worldwide, 1.1 billion need family planning; of these, 842 million are using contraceptive methods, and 270 million have an unmet need for contraception (1,2), but in developing countries, 214 million women of reproductive age who want to avoid pregnancy were not using a modern contraceptive method (1,2). In Latin America, Asia, and Africa, 10.7%, 10.2%, 24.2%, of women of reproductive age have an unmet need for modern contraception respectively (1,3). More than one in ten married or in-union women worldwide have an unmet need for family planning and In Africa, one in ve women has an unmet need for family planning (1,2).In Ethiopia based on the general population survey among reproductive age , the prevalence of unmet need for family planning was 22%among reproductive age group, lowest in Addis Ababa (11%), highest in the Oromia region (29%), and 17% in Amhara region (4).
Contraception is a highly cost-effective HIV prevention strategy than the provision of ART and prophylaxis (5). Contraceptive use averts about 230 million births every year globally (6). Spacing children can reduce mortality among under-ves by 10% and among pregnant mothers by 32% (6). Approximately 120 000 HIV-positive births per year would be averted if the family planning needs of all HIV-positive women in sub-Saharan Africa could be met (7).
In Ethiopia 2,728 unintended HIV-positive births annually are averted by using contraception (8), and decrease an estimated 20% − 30% of newborn HIV infections will be averted if unintended pregnancies are prevented among HIV-positive women by using modern family planning (8). From 21 focus African countries, the Vertical transmission rate exceeding 17% in Ethiopia (9).
One of the most effective approaches to prevent mother to child HIV transmission is decreasing the rate of unintended pregnancy and decreased the unmet need for family planning (10,11). The concern of effective use of family planning (FP) can help couples achieve the desired number of children they want, prevent the number of unwanted pregnancies and abortion, reduce the risks of sexually transmitted infections (STIs), improvement in maternal and child health, and reducing infant HIV infections and the number of children needing HIV treatment and support (12)(13)(14).
Several reasons for the high prevalence of unmet need for modern family planning among HIV positive reproductive women include limited choice of methods (23); limited access to services (23), particularly among young, fear or experience of sideeffects; cultural or religious opposition (12,(22)(23)(24); poor quality of available services; users' and providers' bias against some methods (22,23); desire for more children (12,22)and gender-based barriers to accessing services (12,(22)(23)(24).
The World Health Organization's (WHO) four-pronged strategy for prevention of mother-to-child HIV transmission (PMTCT) includes the Prevention of unintended pregnancies among HIV-positive women through FP and reduced the unmet need for family planning among women living with HIV infection is a highly cost-effective HIV prevention strategy (25). Ethiopia also adopts the WHO four-prong strategies to eliminate vertical transmission of HIV and national adolescent and youth health strategy to address the health of reproductive age women (26,27).
However, the prevalence of unmet need for modern family planning among Ethiopian married women living with HIV was high (19,21,28). However, to estimate the prevalence of unmet need for modern family planning single study area in the referral hospitals is not enough. Little is known about the prevalence and associated factors of unmet need for family planning among reproductive-age women living with HIV at the rural general hospital, primary hospital and health center levels in the study area. Therefore, the objective of the study is to determine the prevalence and contributing factors of the unmet need for modern family planning among HIV-positive reproductive-age women in the rural area general hospital, primary hospital and health centers.

Study design and period
An institutional-based cross-sectional study was conducted among HIV-Positive Women attending HIV Care Service in the Rural South Gondar zone from March to April 2020.

Study area
The research was conducted in rural South Gondar Zone which is found in Amhara regional state located at 664 km from the capital city Addis Ababa. Based on the 2007 Census conducted by the Central Statistical Agency of Ethiopia, the South Gondar zone had a total population of 2,051,738 and a natural increment of 16% over the 1994 census, of which 1,041,061 are men and 1,010,677 women (29). In the South Gondar zone, there were 96 health centers, of those 07 primary hospitals and 01 general hospitals available, but only 32 health facilities provide ART services. Based on the 2019 South Gondar HIV /AIDS prevention and control o ce report 10,829 people current on ART, from the total current on ART 6781 were reproductive age women (30).

Population
All HIV Positive reproductive age married/union women (15-49 years) attending ART clinics of the health facilities in the South Gondar during the study period were considered as the study population. Seriously ill during the data collection period and infecund reproductive-age women were excluded from the study.
Sample size determination and sampling procedure The sample size was determined by using a single population proportion formula by considering assumptions 95% of CI, 4% of marginal error, 5% of non-response rate, and the prevalence of unmet need for contraception among HIV positive women was 25.1% (19), and design effect 2. Finally, the required sample size was 937.
Multi-stage sampling methods were employed to select the study population. From a total of Thirty-two ART service provide health facilities, Six Health facilities were selected by lottery method. Then the estimated sample size is proportionally allocated to health facilities based on the previous month's clients' ow number. Finally, study participants were selected by systematic random sampling method with a k interval of two.

Operational de nition
Unmet need for modern family planning The sum of the proportion of a woman who is married/ sexual union and fecund women do not want any more children or want to postpone pregnancy for at least two years, but she is not using a contraceptive method and currently pregnant or postpartum amenorrhoeic women being pregnant earlier than she desired or do not want a child at all, but don't use the contraceptive method during conception (4,31).
Unmet need for limiting the sum of the proportion of women who is married/sexual union and fecund who do not want any more children and currently pregnant or postpartum amenorrheic who do not want a child at all but she is not using a contraceptive (4).
Unmet need for spacing the sum of the proportion of women who is married/sexual union and fecund women who want to postpone pregnancy for at least two years and Current pregnant or postpartum amenorrhoeic women being pregnant earlier than she desired but, don't use a modern contraceptive method (4,31).
Knowledge of PMTCT de ned as knowing of transmission from mother to child during any of the pregnancy, delivery, and breastfeeding (20).

Data collection tool and procedure
A structured interviewer-administered questionnaire was used for data collection. The questionnaire was developed from Ethiopia demographic health survey and by reviewing national and international literature. The data collection instrument was prepared in English. Then the English version of the questionnaire was translated rst to Amharic and back to English to ensure its consistency. The questionnaire has information on socio-demographic characteristics, reproductive related factors, and HIV care-related factors.
Data was collected by 14 health professionals; three BSc and two diploma female nurses, 2 BSc, and 5 clinical midwifery and two health o cers who were working in the ART clinics and post-natal follow-up clinics of the respected hospitals and health centers. In addition to the principal investigator, 03 BSc nurse supervisors were assigned to supervise the data collectors and to check for completeness and consistency of a questionnaire.

Data quality control
The quality of data was assured through translation, and retranslation of the questionnaire as well as pretesting on 5% of the sample was done at Maraki health center for relevant amendment. Onsite training was given for data collectors and supervisors before the data collection starting on the objective of the research, data collection procedure, and ethical issues.
The supervisors and principal investigator closely followed the day-to-day data collection process and ensure the completeness and consistency of the collected questionnaire.

Data management and analysis
The data were entered using Epi Data version 4.6 by the principal investigator and then exported to Stata version 14 for cleaning and analyzing. Descriptive statistics were used to describe the socio-demographic characteristics of the respondents, reproductive related factors, individual-related factors and the prevalence of unmet need for contraception. The association between the unmet need for family planning with predictors was checked by chi-square. Binary logistic regression was used to identify the factor associated with the independent variable. The variables of the p-value < 0.2 in the bivariable logistic regression model were tted to a multivariable logistic regression model to identify factors associated with unmet need for family planning. Adjusted Odd ratio with 95% CI was computed and variables with P-value < 0.05 in the multivariable analysis were taken as signi cant determinants. Hosmer-Lemeshow test was checked and the p-value was 0.1058 and multicollinearity was checked and the result was a mean VIF 1.25.

Socio-Demographic Characteristics of the Study Participants
From a total of 937 HIV positive reproductive age women in the selected health centers and hospitals, 931 study participants were included in the study, with a response rate of 99.4%. The mean age of the respondents was 31.3 years with (SD of ±   Prevalence of unmet need for modern family planning Unmet need for Family planning was calculated from the proportion of pregnant/amenorrheic women whose current pregnancy/ last birth was mistimed or unwanted and the proportion of fecund none pregnant women who were not using any form of family planning method but do not need any more children or want children later.  infrequent sex (Fig. 3).
Factors associated with unmet need for modern family planning among HIV positive reproductive-age women From eleven variables which were signi cant at p-value < 0.2 in the bivariable logistic regression analysis (age, religion, residence, education, occupation, parity, duration on ART, ever use of family planning, wealth quantile, knowledge for PMTCT and Receiving any FP counseling), ve variables(Age, education, parity, ever use of family planning and Receiving any FP counseling) were signi cantly associated with unmet need for modern family planning among HIV positive reproductive-age women at p < 0.05 with 95% con dence interval (Table 4). Key **=signi cant at p -value < 0.001, *=signi cant at p < 0.05, ART = Anti-retroviral therapy, PMTCT = Prevention of Mother to Child Transmission, HCP = health care provider, FP = family planning In the multivariable analysis, the odds of having unmet need among women in the age group of 35-49 years was 6.5 times higher as compared with women in the age group of 15-24 years (AOR = 6.5, 95% CI = 2.86-14.66). The odds of unmet need for family planning among women with secondary educational status (9-12) was reduced by 75% compared to women who have college and above educational status (AOR = 0.25, 95%CI = 0.10-0.61). The odds of unmet need for family planning among women who do not ever use contraception was 3.9 times higher than those who ever used contraception (AOR = 3.9, 95%CI = 2.28-6.67). The odds of unmet need for family planning among women who had ve and above parity was 5.1 times higher than those women who had none parity (AOR = 5.1, 95%CI = 2.08-12.43). The odds of unmet need for family planning among women who are not counseled about contraception during HIV follow-up was 4.2 times higher than those women who were counseled about contraception (AOR = 4.2, 95%CI = 1.91-9.37).

Discussion
This study assessed the prevalence of unmet need for modern family planning methods and associated factors among HIVpositive reproductive age women. The prevalence of unmet need for modern family planning among study participants was 25.67% (95%CI = 22.96-28.58) of which 132(14.46%) was for spacing and107 (11.49%) for limiting.
In this study, 25.67% reproductive age women had unmet need for modern family planning methods. This nding was in line with the ndings from studies in Ghana (27.8%) (32) and Addis Ababa, Ethiopia (25.1%) (19). However, this nding was lower than study ndings from South Africa (58.8%)(33), Nigeria (64.9%)(12) and Amhara regional state, Ethiopia (35.3%) (34).The reason for this discrepancy might be using a different study design(prospective cohort study), and unmet need de nition, in study conducted South Africa, study participants with 12 month postpartum period and age restriction(18-35)years were considered(33), in study conducted in Nigeria were not used the revised de nition for estimation of unmet need for contraception (31). In addition to this, high HIV prevalence among adults in sub-Saharan Africa may have contributed to a higher unmet need for family planning (35). The discrepancy in the study from the Amhara region might be, the previous study focuses on only women who give birth between 06 weeks to 24 months and pregnant mothers were excluded from the study. Mother on PMTCT not taking family planning due to less perception to pregnancy since breastfeeding and no menses return since last birth (19,36,37).
In contrast, the nding of the current study was higher than study ndings from India (17%) (38), Zimbabwe(19%) (39), Nigeria (20%) (40), Hawassa, Ethiopia (19.1%) (21), and Nekemte, western, Ethiopia (15.4%) (20). This discrepancy might be due to the sample size difference. The sample size of a study done in India was four times less than the current study sample size. In a study done in Zimbabwe, the participants were mothers on PMTCT(9-18 months) and different study designs (39). In a study done in Nigeria, pregnant mothers were excluded (40). In a study done in a different area of Ethiopia, the discrepancy might be due to the different health service provision and different characteristic of study participants (41) or this difference might be explained by the different distribution of PLHIV per region, 30% in Amhara, 26% in Oromia and 9% in Southern Nations, Nationalities, and Peoples' Region (42). unmet need for family planning in the general population as reported in the report of EDHS 2016 was (22%) (4). This discrepancy might be due to different study populations.
In the multivariable analysis, the unmet need for contraception was higher among old reproductive-age women. This nding was supported by study ndings from rural Uganda (43), Nigeria (44,45), Togo (46), and Ethiopia (20). This might be as the age of the women increases the risk of pregnancy will decrease (19,47). It may be due to opposition to use contraception by partners, fears of contraception side effects, health concerns, the previous negative experience of using contraception and using family planning may interfere with sexual pleasure (19,36,48).
Another factor affecting the unmet need for family planning was educational status. Education was the most important factor in increasing contraceptive knowledge to plan the desire to limit or space births. In our study, women with educational status of (9-12) have a 75% lower risk of unmet need for family planning. This nding was contradicting with ndings from Nigeria (40), Botswana (49) and western Ethiopia (20), which reports, women with no formal education and primary education had a higher prevalence of unmet need than those collages and above educational status. According to demographic health survey analytical studies, the relationship between education and unmet need for family planning was not constant across countries (31). In democratic Congo in 2007 as education increase, the unmet need for family planning also increases (CDHS,2007). But it needs further study focusing on the effect of education on unmet needs.
Ever use of contraception was also a signi cant factor affecting the unmet need for family planning. Women who didn't ever use had higher unmet need than those who had ever used. This nding was supported by study ndings from Federal Teaching Hospital Gombe, Nigeria (50), Hawassa, Ethiopia (21) and Gondar town, Ethiopia (51). This might be women on ART, contraception use may feel exacerbation of HIV disease progression (51). This might be due to a lack of awareness for contraception or fear of contraceptive side effects and heard miss information from previously experienced mothers leads to frustration (52). Previous use of family planning increases knowledge and decrease fear of family planning side effects.
Women who had ve and above parity had a higher unmet need for family planning than those women who had none parity. This nding consistent with studies done in Nigeria (50) and Northern Uganda (53). This might be due to women who had none or one child want a child soon no need of limiting and spacing or may have the desire of more children (19,54) and Multiparous mother may achieve desired family size. This might be as women have more children, the unmet need for spacing births tends to decrease, but the unmet need for limiting increases (31).
Counseling about contraception also affects the unmet need for family planning.
Women who were not counseled about contraception during HIV follow-up had a higher unmet need for family planning than those women who were counseled. This nding was consistent with Uganda and Ethiopia (19,55). The possible explanation could be family planning counseling during ART follow up can create awareness and increase knowledge to use contraception and improving information about their risk of becoming pregnant and about the choices of contraception (36,56).

Limitation Of The Study
As the study included more sensitive issues, social desirability bias could not be ruled out. Consequently, some women accessing the ART services may report higher use of condoms and other contraceptive methods. Similarly, women may report a birth or current pregnancy as wanted once the child is born. This can result in an underestimation of the true extent of unwanted births and unmet needs.
Health care provider needs to be focus patient-centered counseling to create awareness on the bene ts of contraception in the settings of HIV infection. . Support letter and permission was obtained from Amhara Regional Health Bureau and from South Gondar health zonal health department to the concerned bodies. Health facilities were approached with a formal letter written to the ward team leader. All the study participants were well informed about the bene t of the study along with their right to refuse before proceeding with the questions. Consent was obtained from each participant before starting the interview. Moreover, the con dentiality of the information was kept without the participant's name and ID. Data was not disclosed to any person other than the principal investigator.

Consent to publication
Not applicable outside of the researcher has access to any of the information collected.
Availability of data and materials Data will be available upon reasonable request from the corresponding author

Competing Interests
No competing interest Funding