Prevalence unmet need for family planning and its associated factors in Ethiopia 2019: sytematic review and meta analysis

unmet need for family planning is a common cuase of uninteded pregnancy which mostly end up with abortion. Many fragmented studies were conducted on unmet need in Ethiopia but no single evidence was present. So this meta analysis was established to estimate the pooled prevalence of unmet need for family planning in Ethiopia. using Systematic Meta-Analyses checklist Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was applied for critical appraisal of included articles. Random effect model meta analysis was done to estimate the pooled prevalence of unmet need for family planning with their respective Odds Ratio (OR) and 95% confidence interval (CI). Cochran’s Q statistic, Egger’s and Begg’s test and meta regression were carried out to assess heterogeneity, publication bias and to identify associated factors respectively.

This meta analysis revealed the prevalence of unmet need for family planning in Ethiopia was high. Early marriage, illiteracy and absence of open discussion were factors affecting the prevalence of unmet ned for family planning. Therefore, the responsible body inlcuding family health guiadance should strength women empowerment interms of education (equal accessible eduaction for all), avoid early marriage (before 18yrs) and facilitate open partners discussion within house hold.

Background
Unmet need for family planning is the percentage of women of reproductive age, either married or in a union, who have an unmet need for family planning to stop or delay childbearing [1]. It shows the gap between childbearing desires and contraception use and taken as useful indicator towards the target of achieving universal access to reproductive health [2]. Early family planning was planned as a program to alleviate environmental, economic and societal impact of rapid population growth. But later run to help women and men to achieve their preferences and have their children when they want them as well play major role in maternal mortality reduction [3].
The Food and Drug Administration has approved a wide range of modern contraceptive including emergency contraceptives methods for preventing unintended pregnancy. But unintended or unplanned pregnancy is still the major incapacitating problem which affects million women and their families worldwide particularly in developing countries [4]. In 2017, around 800 million reproductive age pregnant women in developing countries wanted to avoid pregnancy from which an estimated 214 million women have an unmet need for family planning services. Globally 43% of unintended pregnancy occurred in developing world and 74% of them were related to unmet need for family planning while in East Africa unmet need for family planning responsible 86% unintended pregnancy [5].
Abortion is a frequent consequence of unintended pregnancy, an estimated 18 million unsafe abortions take place each year in the developing world and, can result in serious, Sub Saharan Africa has women with the highest number of unmet need for family planning as evidenced by 25% of reproductive age married or union women has unmet need for family planning [12]. So this is the reason why it share the highest burden of maternal mortality related to unwanted pregnancy and unsafe abortion than other regions.
Modern contraceptive use by currently married Ethiopian women has steadily increased.
But still 22% of currently married women have an unmet need for family planning [13]. In Ethiopia different studies were conducted to assess prevalence of unmet need and associated factors [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. The reports of these fragmented revealed a wide variability of prevalence of unmet need for family planning with the highest prevalence reported in South Nation and Nationality People region(SNNPR) (52.4%)[23] while the lowest reported in Amhara region (17.4%) [21]. Those studies also addressed some factors associated with the prevalence of unmet need for family planning; age, age at marriage, female and male education, discussion with partner and health care provider on family planning and occupation were considered as a common contributor to unmet need.
So these few findings in Ethiopia about prevalence of unmet need for family planning and associated factors indicated inconsistent and inconclusive results. Therefore, this metaanalysis and systematic review was conducted to estimate the pooled prevalence of unmet need for family planning and associated factors in Ethiopia.

Search strategies
This systematic review and meta-analysis was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) checklist guidelines [29]. Published available studies were searched using international data bases; PubMed/MEDLINE, EMBASE, CINAHL, Google Scholar, HINARI portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases), and Cochrane Library. All studies conducted till June 10, 2019 were included in this review. "Prevalence of unmet need for family planning OR factors associated with unmet need for family planning AND Ethiopia" were used as a key word to search. Additionally articles found on local shelves and institutional repositories were considered. The references of already identified articles were also checked to dig out additional articles for this systematic review. Endnote citation manager software version X7 for Windows was utilized to collect and organize search outcomes and for removal duplicate articles.

Inclusion criteria
Population: studies conducted on reproductive age women were included.
Study area: the review considered only studies conducted in Ethiopia.
Language: articles reported in English language were eligible for this meta-analysis.
Observational studies (cross sectional, case control and cohort) which has clear outcome about unmet need for family planning were considered for final review. In addition, family planning was taken as an exposure and unmet need for family planning as final outcome.

Exclusion criteria
After careful reviewing those searched articles, irrelevant studies and those didn't report outcome of interest were excluded from this meta-analysis.

Data extraction
Two authors (TG and AN) extract the data independently using the extraction tool developed according to Joanna Briggs Institute Reviewers' Manual 2014[30] based on potentially eligible criteria already settled. Authors, Region, study setting, study year, study design, sample size, response rate, participant's age, prevalence and common factors associated with unmet need for family planning were included in the extraction tool. Discrepancies between authors were discussed to reach consensus. For final analysis the authors considered articles which fulfilled the already settled criteria.

Outcome of interest
The primary outcome of this systematic and meta-analysis was the prevalence of unmet need for family planning. Unmet need for family planning is the percentage of women of reproductive age, either married or in a union, who have an unmet need for family planning to stop or delay childbearing[1]. The second outcome was factors associated with unmet need for family planning. Those factors extracted from included studies were; age of women (<25 years V S ≥25 years), age at marriage (<18 years V S ≥ 18years), education (illiterate V S educated), occupation (house wife V S others) and discussion with partner (no discussion V S open partner discussions).

Heterogeneity and publication bias
Cochran's Q statistic and inverse variance (I 2 ) for quantification with its corresponding pvalue using random effect model of analysis were considered to check heterogeneity. I 2 statistics of 25%, 50% and 75% was used to declare low, moderate and high heterogeneity respectively [31]. Heterogeneity was considered when p-value less than 0.05. In addition Egger's and Begg's tests were done to assess the presence of publication bias, and a pvalue less than 0.05 were considered as statistically significance [32, 33].

Statistical analysis
Microsoft Excel spread sheet format was used to extract the selected articles. Then, extracted data were exported to STATA version 14 software for meta-analysis. For heterogeneity and publication bias assessment, Cochran's Q statistic and I 2 (for quantification) and Egger's and Begg's tests and its corresponding p-value with random effect model (since it minimizes heterogeneity of the included studies [31] were considered. Comparison of original articles using tabulation was computed to assess some clinical or methodological heterogeneity even though always considered to be present (Table-1). The pooled prevalence of unmet need for family planning and its 95% CI were presented using forest plots. Factors associated with unmet need for family planning were computed and presented using forest plots with their respect of OR and 95%CI. Subgroup analysis was also conducted by region of the study, study year, sample size and study 8 setting of studies.

Article selection
From electronic data base searching, 350 articles related to unmet need for family planning and associated factors were retrieved. From those records, 60 studies were removed after reviewing their titles due to duplication. Then after reviewing titles and abstracts of the remaining articles, 271 articles excluded because of irrelevance. Fifteen articles were assessed for eligibility and considered for the final review after 4 articles [34-37] removed due to inaccessibility of full articles even after email request for the full document till three times ( Figure-1).

Characteristics of included articles
A total of 17, 585 reproductive age women were included in this meta-analysis to estimate the pooled prevalence of unmet need for family planning and associated factors in Ethiopia. All studies included were cross sectional and community based except two articles done at institution level [15,27]. The majority of the included studies were conducted in Amhara region [14,16,18,21,25,27]  computed, but none of them were significant. However, publication bias was nonsignificant using Begg's and Egger's test (p=0.458 and p=0.258 respectively) (Figure-2).

Sub group analysis
Subgroup analysis was performed to compare the prevalence of unmet need for family planning using study year, sample size, region and study setting. The subgroup analysis by region showed the highest prevalence of unmet need for family planning in SNNPR,

Meta regression
In order to identify factors associated with source of heterogeneity of the pooled prevalence of unmet need for family planning, meta regression was undertaken by considering both continuous and categorical data. Sample size, study year, study setting and region for each individual studies were considered in the meta-regression. But the meta regression showed that the pooled prevalence of unmet need for family planning was not associated with sample

Factors associated with unmet need for family planning
As shown below in figure-3, we tried to investigate factors associated with unmet need for family planning. Age of the women, age at first marriage, education level of both women and their partner, discussion with partner and occupation were factors assessed for association. But only age at first marriage, education level (both) and discussion were significantly associated with unmet need for family planning. Age at first marriage was reported in three articles [16,18,20]. Women with age at first marriage <18yrs were 2.3 times more likely to have unmet need for family planning than women marriage at 18yrs and above, OR=2.3 and (95% CI: 1.08, 4.87). Level of female education was another factor recorded in eight articles [14, 16-18, 20, 21, 24, 27]. The odds of unmet need for family planning was 1.9 times higher in illiterate women than literate women (read and write, primary and above educational level), OR= 0.9 and (95%CI: 1.19, 3.04). The association between male partner education and unmet need for family planning was reported in four articles [16,18,23]. The likely hood of unmet need for family planning in women with illiterate male partner was 1.78 times higher than women having literate male partner, OR=1.78 and (95%CI: 1.18, 2.68). The last but not the least factor, which was associated with unmet need for family planning was discussion, reported in six original articles [14, 16- However this result is much higher than studies conducted in Egypt and Cameroon, which reported the prevalence of unmet need for family planning as 11.2% and 20.4% [42,43].
Our meta-analysis also tried to investigate factors associated with unmet need for family planning. Age at marriage <18yrs, illiteracy and absence of discussion between partners were factors significantly affecting the prevalence of unmet need for family planning.
Those women married before 18yrs were 2.3 times more likely to have unmet need for family planning than women married after 18yrs. This may be due to as age increase independency and decision to family size increase in line with maturity and awareness.
Age is the major determinant for acquiring knowledge and gathering information through different contacting and communication ways (lower age group have restricted communication issues). So it affects the woman's ability to make her own decision regarding the reproductive health.
The odds of unmet need for family planning among illiterate women was 1.9 times higher when compared with women having education or literate ones. This finding is in agreement with study conducted in Saudi Arabia and Nigeria, reported as women with no education had higher odds of unmet need [39,44]. In addition to this, those women with partner illiterate was 1.78 times more likely to have unmet need for family planning than women with educated partners. This is also consistent with finding in Eastern Sudan, lower level of husband's education negatively affect utilization of family planning [41]. Education is the major tool to increase awareness level and better access for information in family planning so as desire for post-pone fertility. Women should be adequately empowered in education so as to improve knowledge and awareness of methods and sources of contraceptives which has been found as a major barrier to contraceptive use.
This review also showed that discussion with sexual partner was significantly associated with unmet need for family planning. Women who didn't have discussion with their sexual partner about family planning were 3.52 times more likely to have unmet need for family planning when compared with women having discussion with their sexual partner on family planning service. This association is line with finding reported in Cameroon, discussion about family planning within the couple had highly statistically significant protective association with unmet need [43]. This may be due to that women who had partner support and clear decision on family planning will have good attitude and initiative to contraceptive. Therefore women involvement in decision particularly that affect their health status is very important. As this review reported both the pooled prevalence unmet need for family planning and associated factors, it is important for policy makers to investigate the gaps on those factors.

Limitations
This review includes articles reported only in four regions and one administrative city, so didn't include all regions and administrative cities. Those articles included in this systematic review and meta-analysis were conducted in cross sectional study design in which the finding might potentially affected by confounding variables. In addition the review analyzed only studies reported in English language which might restrict our findings. Finally we like to recommend for researchers to conduct country based studies to assess other confounding factors related to health policy and service factors for the prevalent unmet need for family planning in Ethiopia.

Conclusions
The prevalence of unmet need for family planning in Ethiopia was high. Age at marriage <18yrs, illiteracy (both women and their partner) and absence of discussion with their partner were factors significantly associated with unmet need for family planning.   size, study year, study setting and region of study (Table-3).