Long-Acting Reversible Contraceptive Use and Associated Factors Among Extended Postpartum Women in Eastern Ethiopia: An Institution-Based Cross-Sectional Study Design

doi:10.21203/rs.3.rs-3726015/v1

Background: Long-acting reversible contraceptives have provided birth control for at least 2 years. A lack of contraception by couples during the postpartum period can result in unwanted pregnancies and social and economic consequences. Despite the multiple impacts of these practices, limited studies have been conducted on the prevalence of long-acting reversible contraceptive use and associated factors among postpartum women in the study area. This study aimed to determine the prevalence of long-acting reversible contraceptive use and its associated factors among postpartum women in public hospitals in the East Hararghe Zone, Eastern Ethiopia.

Method: An institution-based cross-sectional study was conducted among 614 study participants in the East Hararghe Zone, eastern Ethiopia. Systematic random sampling was used to select the study participants.

A semi structured questionnaire was used to collect the data. The collected data were coded and entered into Epi Data version 3.1 and subsequently exported to SPSS version 22 software for analysis. Descriptive analysis was computed using frequency, percentage, mean and standard deviation. Multivariate logistic regression was applied to identify the factors associated with long-acting reversible contraceptive use among extended postpartum women. The adjusted odds ratio (AOR) and its 95% confidence interval were computed to show the strength of the association between the dependent and independent variables. The goodness of fit of the model was tested by using the Hosmer–Lemeshow goodness of fit test, and the results were not significant (p=0.194). The results were then presented in tables, figures, and narratives.

Results: The prevalence of long-acting reversible contraceptives was 33%. Women’s educational level (AOR= 11.32, 95% CI=4.672–27.393), counseling (AOR=3.648, 95% CI=1.88–7.08), prior use of long-acting reversible contraceptives (AOR=7, 95% CI=3.79–15.202), and discussion with husbands (AOR=2.75, 95% CI=1.56–4.84) were significantly associated with long-acting reversible contraception usage.

Conclusion: Overall, the current study showed that the use of long-acting reversible contraceptives among extended postpartum women was low in eastern Ethiopia. Women’s educational level, prior use, discussions with husbands, and postnatal counseling were identified as significant associated factors for low use of long-acting reversible contraceptives among extended postpartum women. Therefore, strengthening counseling on the use of long-acting reversible contraceptives, improving women’s educational status, and providing postnatal counseling through discussion with spouses are important measures for enhancing the utilization of long-acting reversible contraceptives among extended postpartum women in the East Hararghe Zone, Eastern Ethiopia.

Long-acting reversible contraception

Extended postpartum period

East Hararghe Zone

According to the World Health Organization ⁽¹⁾, “long acting reversible contraceptives (LARCs) are methods of birth control that provide effective contraception for an extended period without requiring user action for at least two years. These methods include intrauterine devices and subdermal contraceptive implants and are among the most effective, safe and low failure rates of reversible methods of contraception and after the fertility of women is removed”. ⁽²⁾

Globally, 44% of unintended pregnancies are estimated to occur mostly in developing countries; 65% of those pregnancies are in developed countries, and approximately 270 million women have an unmet need for contraception. ^{(3, 4)} Evidence from 27 countries’ analyses of demographic and health surveys showed that 95% of women who are 0–12 months postpartum want to avoid pregnancy for the next 24 months, but 70% of them are not using contraception despite the availability of various types of modern contraceptives. ⁽⁵⁾ According to different studies and reports on the utilization of LARC globally, 14.2% of the drugs are utilized by married and postpartum women; this utilization varies from country to country; for instance, the most common utilization occurs in China (33%). However, its utilization is low, especially in sub-Saharan Africa (0.8%), Malawi (9.76%), Rwanda (5.6%), Cameroon (1.6%), Chad (1.8%), Zambia (8.5%), Zimbabwe (8.5%), Ghana (4.3%), and Mali (2.8%), including Ethiopia (11%). ^(6–8) Evidence from different parts of Ethiopia has also shown a low prevalence of postpartum LARC use, which accounts for 12.4–36.7%. ^{(1, 9–12)} The most commonly used contraceptive methods were Depo ProVera (59.2%) and oral pills (22.5%). The major factors related to nonutilization of LARCs were sociodemographic, economic, maternal healthcare service utilization, and obstetric factors. ^(13–15) Many attempts have been made in Ethiopia to adopt different strategies to reduce maternal mortality, such as the Millennium Development Goal (MDG) and Sustainable Development Goal (MDG), to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by using family planning. However, it is still difficult to achieve these goals because LARC methods are effective for only 11% of reproductive-age women in Ethiopia. ^{(5, 6)} However, using modern contraceptives plays an essential role in decreasing unwanted pregnancies and unsafe abortions, preventing preterm delivery, and reducing maternal and infant death by 30% and 10%, respectively. ⁽⁴⁾

Despite the multiple impacts of LARC use, limited studies have been conducted on the prevalence of LARC use and its associated factors among postpartum women in Ethiopia, particularly in the study area. Hence, this study aimed to determine the prevalence of LARC method use and its associated factors among postpartum women in public hospitals in the East Hararghe Zone, Eastern Ethiopia.

Study design, setting, and period

An institution-based cross-sectional study design was used for women with an extended postpartum period. This study was conducted in the East Hararghe Zone, which is one of the Oromia regional state zones. It is located in the eastern part of Ethiopia, approximately 526 km from Addis Ababa, the capital city of Ethiopia. It covers an area of 17,935.40 square kilometers. Currently, the population is estimated to be 3,897,441. Among these, reproductive-aged women account for 861,335 people, and there are five public hospitals, 121 health centers, 548 health posts, and 175 private clinics. ⁽¹⁶⁾ The study was conducted in all public hospitals (Haramaya, Garamuleta, Deder, Bisidimo, and Chelenko Hospitals) in the East Hararghe Zone from May 1 to 31, 2020.

Study Participants and Eligibility Criteria

All extended postpartum women living in the East Hararghe Zone were the source population, and women in the extended postpartum period visiting child immunization services during the study period were eligible for enrollment. Women who were pregnant or unable to communicate were excluded from this study.

Sample size and sampling procedure

The sample size was determined based on the formula used to estimate the proportion of a single population using the Z score at the 95% confidence level (1.96), the prevalence of LARC methods from a previous study was 36.7% in Durame Town, Ethiopia ⁽¹⁷⁾; by adding a 4% margin of error and a 10% nonresponse rate, the final sample size was 614.

The total number of extended postpartum women who visited the immunization clinic within the past 6 months was used to allocate study participants proportionally to all health facilities. A systematic random sampling technique was used based on the daily case load from the total number of women who visited child immunization clinics, which was estimated by considering the immediate previous 1-month record of the extended program on the immunization chart. By calculating the K interval, which was 2, the first number (participants) was randomly selected, and every second woman was included in the study. The procedure was continued throughout the data collection period until the needed sample size was achieved.

Data collection tool and procedure

A semi structured questionnaire adapted from different studies was used to collect data pertaining to the sociodemographic and reproductive health information-related characteristics of the participants.^{(9, 18)} The questionnaire has three parts: the first part contains sociodemographic characteristics, the second part contains reproductive health information, and the third part contains contraceptive utilization practices used to assess factors associated with LARC. The adapted questionnaire was modified and contextualized to suit the local situation and the research objectives.

The data collection tool was first prepared in English, translated into the local language (Afan Oromo), and back-translated into English to maintain consistency by a person who speaks both languages fluently. The data were collected by recruiting ten data collectors and two supervisors. The principal investigator provided 2 days of intensive training for the supervisors and data collectors, and doubts were clarified in the questionnaire before the actual data collection period. When the sampled mother was absent on the day of data collection, a revisit was scheduled.

Study variables

The outcome variable was long-acting reversible contraceptive use. The independent variables were sociodemographic variables, reproductive health and demographic information (parity, fertility decision-makers, and information about contraceptives), maternal contraceptive use, and factors that can influence the nonutilization of LARC methods.

Operational definition

Extended postpartum period

First 6 weeks–12 months after childbirth. ⁽¹⁹⁾

Long-acting methods

Methods comprising the IUCD and implants. ⁽¹⁹⁾

Ever use of LARCs

Current or last year’s use of contraceptive methods. ⁽²⁰⁾

Factors

Sociodemographic and information-related characteristics can hinder the acceptance and utilization of long-acting contraceptive methods. ⁽²¹⁾

Data quality control

The questionnaires were pretested a week before the actual data collection days on 5% of the sample size with a similar study unit; however, in other hospitals that were not selected for the study, necessary modifications were made accordingly. The principal investigator trained the data collectors and supervisors. During the data collection, trained supervisors checked how the data collectors were performing their tasks. The principal investigator checked the completeness of the completed questionnaires at the end of each data collection day. The clean data were independently entered into Epi Data software version 3.1 by two data entry clerks, and double-entry data were obtained.

Data processing and analysis

The collected data were checked for completeness and consistency. The data were also coded, entered, and cleaned using Epi Data Version 3.1 and subsequently exported to SPSS version 22 software for further analysis. Descriptive statistics were used to calculate frequencies and percentages. A multicollinearity test was performed to check the linear correlation between independent variables using standard error and collinearity statistics. A variance inflation factor > 10 and standard error > 2 were considered to be dropped, but there were no variables that had collinearity. Bivariable logistic analysis was used to determine the crude association between independent and dependent variables, and the strength of the association was expressed as odds ratios (ORs). Variables from the bivariable analysis with p < 0.25 were considered candidates for multivariable analysis. Finally, multivariable logistic regression analyses were used to control for possible confounders and determine the predictors of LARC using a stepwise technique. For multivariable logistic regression analysis, a p value of < 0.05 and a 95% confidence interval (CI) were considered to indicate statistical significance. The Hosmer–Lemeshow goodness of fit was used to check the model’s fitness. The omnibus test was significant (p < 0.0001), and the Hosmer–Lemeshow test was not significant (p = 0.194), indicating that the model was fit. The results were then presented in tables, figures, and narratives.

Sociodemographic characteristics of the study population

In this study, out of 614 respondents, 602 women were included, yielding a response rate of 98%. The age of the respondents ranged from 15 to 48 years (mean age = 26.3, SD = ± 6 years). More than half (335; 55.6%) of them were rural residents, and the majority (532; 97.8%) were married (Table 1).

Table 1

*Socio-demographics characteristics of the respondents in health facilities of East Hararghe zone, Eastern Ethiopia, 2020 n = 602*
Variables		Fréquences	Percentage
Age	15–19	58	9.6%
	20–24	179	29.7%
	25–29	173	28.7%
	30–34	120	19.9%
	35–39	52	8.6%
	40–44	15	2.5%
	45–49	5	0.8%
Women’s Educational Status	Post-secondary	140	23.3%
	Secondary	38	6.3%
	Primary	214	35.5%
	No forma éducation	210	34.9%
Marital status	Married	532	88.4%
Marital status	Others	70	11.6%
Place of residence	Urban	267	44.4%
Place of residence	Rural	335	55.6%
Media use	Yes	540	89.7%
Media use	No	62	10.3%
Type of media use	Radio and Television	345	64.0%
	News Paper	13	2.4%
	Other’s	53	9.8%
	Use more than one media	127	23.6%
Otherscohabited, divorced, separated, single and widowed, other* Facebook, telegram

Utilization of LARCs and Reproductive Health Care Services among Extended Postpartum Women in the East Hararghe Zone, Eastern Ethiopia

Of the total respondents, only 200 (33%) were reported as ever users of LARC methods. The major reasons for nonutilization of LARCs were religious beliefs (50.6%), husbands’ influence (31.8%), and a lack of information about LARCs (13.6%) (Fig. 1).

Regarding reproductive health care services, 342 (56.8%) respondents had given birth more than five times, while 148 (24.6%) had given birth two to four times. Of those who gave birth, 292 (48.5%) women had one to two live children, and 310 (51.5%) had more than three live children. Concerning fertility decision-making in the family, 37 (6.14%) decisions were made by the woman herself, 225 (37.2%) were made by her husband only, and 340 (56.4%) were made by both of them. Regarding the place of delivery, 93 (15.4%) women delivered at home, and 509 (84.5%) delivered at health facilities (Table 2).

Table 2

Contraceptive use and reproductive health care services used related factors to LARC methods among extended postpartum women in public hospitals in the East Hararghe zone, Eastern Ethiopia, 2020 (n = 602)
Variables		Frequencies	Percentage
Heard about contraceptives	Yes	540	89.7%
Heard about contraceptives	No	62	10.3%
Overall contraceptives use	Yes	309	51.3%
Overall contraceptives use	No	293	48.7%
Types of contraceptives used during extended postpartum period	Intrauterine devices	14	4.5%
	Implant	186	60.19%
	Other (depo, COC)	109	35.3%
Long-acting reversible contraceptive use	Yes	200	33.2%
Long-acting reversible contraceptive use	No	402	66.8%
Types of LARC used	IUCD	14	7%
	Implant	186	93%
Source of information about contraceptives	Television/radio	292	54.1%
	Health extension	201	37.2%
	Family/friends	42	7.8%
	Other	5	0.92%
Parity	1	112	18.6%
	2–4	148	24.6%
	5 and more	342	56.8%
Number of alive children	1–2	292	48.5%
Number of alive children	3 and more	310	51.5%
Future children need	0	16	2.6%
	1–3	125	20.7%
	4 and mores	461	76.5%
Birth interval (in months)	0–23 months	553	91.5%
	> 23 months	49	8.1%
Time to reach a health institution	< 15 min	176	29.2%
	Between 16–30 min	327	54.3%
	> 30 min	99	16.4%
Place of delivery	Health facility	509	84.5%
	Home	93	15.4%
Decision on Fertility	Myself	37	6.14%
	My husband	225	37.2%
	Both	340	56.4%

Factors associated with the utilization of LARCs among postpartum women

Discussion of LARC with husbands, prior use of LARCs, women’s occupation, husband’s occupation, woman’s level of education, postpartum counseling, and residence were candidate variables in the bivariable analysis at less than p value < 0.25. However, in the multivariable logistic regression analysis, prior use of LARCs, women’s level of education, postpartum counseling, and discussions with husbands were significantly associated with ever use of LARC methods.

The odds of ever using LARC methods among extended postpartum women who had a postsecondary education level was 11 times greater than that of women who had no formal education (AOR = 11.3, 95% CI = 4.672–27.392). The odds of using LARC methods among women who previously used LARCs were seven times greater than those among women who had never used LARCs (AOR = 7, 95% CI = 3.790–15.202). The odds of ever using LARCs among women who received counseling in the postnatal period were 3.65 times greater than those among women who did not receive counseling (AOR = 3.648, 95% CI = 1.88–7.08). The odds of ever using LARC methods among extended postpartum women who had discussions with husbands on LARCs were 2.75 times greater than those among women who had not discussed LARC methods with their husbands (AOR = 2.749, 95% CI = 1.562–4.838), as illustrated in detail in Table 3.

Table 3

*Multivariable logistic regression analysis of factors associated with LARC in the East Hararghe Zone, Eastern Ethiopia, 2020 (n = 602)*
Variables	LARC		Adjusted OR (95% CI)
Variables	Use	Nonuse	Adjusted OR (95% CI)
Women’s occupation
Public Employed (private and public)	138 (46.3%)	160 (53.7%)	0.652 (0.233–1.826)
Farmer	10 (7.9%)	117 (92.1%)	0.058 (0.014–0.241)
Merchant	41 (29.7%)	97 (70.3%)	1.007 (0.329–3.076)
others	11 (28.2%)	28 (71.8%)	1
Women’s level of education
Postsecondary Secondary Primary	96 (68.6%) 5 (13.2%) 27 (12.6%)	44 (31.4%) 33 (86.8%) 187 (87.4%)	11.3 (4.672–27.393) ** 8.948 (3.381–23.682) * 1.029 (0.508–2.082)
No formal education	72 (34.3%)	138 (65.7%)	1
Counseling
Yes	71 (55.9%)	56 (44.1%)	3.648 (1.88–7.080)***
No	129 (27.2%)	346 (72.8%)	1
Prior use of LARC
Yes	101 (44.3%)	127 (55.7%)	7 (3.790–15.202)**
No	99 (26.5%)	275 (73.5%)	1
Husbands’ occupation
Private	26 (16.8%)	129 (83.2%)	0.034 (0.008–0.155)
Public Employed	126 (58.6%)	89 (41.4%)	0.571 (0.140–2.320)
Farmer	20 (14.1%)	122 (85.9%)	0.042 (0.009–0.191)
Merchant	18 (26.1%)	51 (73.9%)	0.161 (0.036–0.724)
Others	10 (47.6%)	11 (52.4%)	1
Spousal discussion
Yes	119 (46.3%)	139 (53.8%)	2.749 (1.562–4.838)*
No Residence Rural Urban	81 (23.5%) 57 (17%) 143 (53.6%)	263 (76.4%) 278 (83%) 124 (46.4%)	1 0.028 (0.013–0.060) 1
Significant at p≤0.05, p≤0.01, **p = 0.000, 1 = reference.

This study showed that the prevalence of ever-used LARCs among extended postpartum women was 200 (33%, n = 602), which was low in the study area. Factors such as education level, postnatal counseling, prior use of LARCs, and spousal discussions were significantly associated with the utilization of LARC methods. This finding is in line with a study conducted in the Afar region (33.4%). ⁽¹⁰⁾ The prevalence of LARC use in postpartum women in this study was lower than that in studies conducted in Jimma Town (53%) ⁽²²⁾ and Harar City (38%). ⁽²³⁾ This slight variation might be due to the nature of the participants. As in a study conducted in Harar city, more than 55% of the participants were from urban areas; however, in this study, most participants were from rural areas (57%). As a result, providing information and access to healthcare services for contraceptive behaviors may be better for urban residents. In addition, counseling provided by healthcare providers and awareness creation provided to the community about LARC methods may be effective in urban areas.

In this study, previous LARC use was found to be another factor significantly associated with postpartum LARC use. These findings are in line with those of studies conducted in the Hadiya Zone, ⁽²⁴⁾ Adama town, ⁽²⁵⁾ Durame town, ⁽¹⁷⁾ Hossana town, ⁽⁹⁾ and Jimma town. ⁽²²⁾ A possible explanation is that women who had previous experience with LARC use had a better understanding of different types of contraceptives, with advantages and disadvantages that can help them decide the type of contraceptive they want to use.

According to this study, women who had postsecondary education levels were 11 times more likely to use LARCs (AOR = 11.3; 95% CI = 4.67–27.393) than women whose educational status was at the primary level. This finding is in line with studies conducted in Gondar city ⁽¹²⁾, the Bale Zone ⁽¹⁾, Adama town ⁽¹³⁾ and Durame town. ⁽¹⁷⁾ This might be due to similarities in educational status, which leads to an enhanced understanding of the characteristics of contraceptives. Additionally, education has a significant effect on changing the attitudes of women and providing a better understanding of the choices and decision-making skills of LARC methods.

As this study revealed, women who had postnatal counseling were three times more likely to use LARCs (AOR = 3.65; 95% CI = 1.88–7.08) than were their counterparts. This result is consistent with that of a study conducted in the Somali region of Kebrebeya. ⁽²⁶⁾ This might be because counseling women can change their perceptions of and misconceptions about LARCs.

Generally, the prevalence of LARC highlights the importance of empowering women to make decisions regarding their contraceptive methods. Husbands are major decision makers on reproductive issues, particularly regarding contraceptive use. This could prevent users from using them when they need to be used. This contributes to a wide range of health problems, including pregnancy-related maternal deaths. ⁽²⁷⁾

Overall, the current study showed that the use of long-acting reversible contraceptives among extended postpartum women was low in eastern Ethiopia. Women’s educational level, prior use, discussions with husbands, and postnatal counseling were identified as significant associated factors for low use of long-acting reversible contraceptives among extended postpartum women. Therefore, strengthening counseling on the use of long-acting reversible contraceptives, improving women’s educational status, and providing postnatal counseling through discussion with spouses are important measures for enhancing the utilization of long-acting reversible contraceptives among extended postpartum women in the East Hararghe Zone, Eastern Ethiopia.

Limitation of the Study

As this study was conducted at hospital level there might be Berkson bias, there were more perception among participants, they assumed better quality of care than Health Centers.

LARC, long-acting reversible contraceptive; WHO, World Health Organization; CI, confidence interval

Acknowledgments

The authors would like to thank Haramaya University and the East Hararghe Zone Health Office. Special thanks also go to the study participants as well as to all the data collectors and supervisors for their invaluable contributions.

Disclosure

The authors declare that they have no conflicts of interest.

Ethical consideration

Ethical approval was obtained from Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC) with reference number IHRERC/111/2020. A formal support letter was written to the East Hararghe Zone Health Bureau, and they also wrote an official letter of cooperation to all hospitals in which the study was conducted.

After obtaining permission from each hospital manager, the purpose, procedure, duration, and possible risks and benefits of the study were clearly explained to the study participants using the local language. Informed and voluntary consent was obtained from the participants before the interviews were conducted. Finally, eligible women were included in the study. Unwilling participants were excluded from this study. The confidentiality of the information and the privacy of the respondents were assured at each step of the study.

Funding

This study was self-sponsored.

Data availability statement

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Contribution of the Author

DN conceived, designed, analyzed, and interpreted the results and drafted the manuscript. NB, MD, and KB extensively reviewed the manuscript and incorporated intellectual input. All the authors have read and approved the final version of the manuscript.

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No competing interests reported.

Long-Acting Reversible Contraceptive Use and Associated Factors Among Extended Postpartum Women in Eastern Ethiopia: An Institution-Based Cross-Sectional Study Design

Status:

Version 1

Abstract

Figures

Introduction

Methods and Materials

Study design, setting, and period

Study Participants and Eligibility Criteria

Sample size and sampling procedure

Data collection tool and procedure

Study variables

Operational definition

Data quality control

Data processing and analysis

Results

Sociodemographic characteristics of the study population

Factors associated with the utilization of LARCs among postpartum women

Discussion

Conclusion and Recommendations

Limitation of the Study

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1