Barriers to contraceptive utilization among Reproductive Age Women of Eritrean Refugee in North West Tigray, Ethiopia: a mixed study

doi:10.21203/rs.3.rs-3815580/v1

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Barriers to contraceptive utilization among Reproductive Age Women of Eritrean Refugee in North West Tigray, Ethiopia: a mixed study

https://doi.org/10.21203/rs.3.rs-3815580/v1

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Universal access to family planning could prevent nearly one-third of the estimated 300,000 maternal deaths. Contraceptive utilization is low in humanitarian settings. Currently, there is a dearth of information on the use of contraceptives among refugee women in many low-income countries including the study area. A community based cross sectional study with qualitative data was employed from January 1 to February 1, 2017. Systematic and purposive sampling techniques were applied. Data was entered to Epi Info version 3.3.2 and transported to SPSS version 20.0 software for analysis. Significance was declared at p-value of < 0.05. Odds ratio along with 95% confidence interval was computed to ascertain the strength of the association. Among the 532 respondents who experienced sex, 192(36.1%) were using contraceptive method. Exposure to media (AOR = 2.207, 95% CI = 1.244, 3.917), residence (AOR = 2.593, 95% CI = 1.513, 4.444), discussion on reproductive goals (AOR = 2.817, 95% CI = 1.681, 4.721) and longer duration stay in camp (AOR = .4.065, 95% CI = 1.845, 8.956, AOR = 2.200, 95% CI = 1.084, 4.466) were significant factors. Prevalence of contraceptive utilization in refugees was low. A lot of obstructing factors to access the service were identified in this study. This gap will intensify the existing maternal and child mortality dire in refugee settings.

Health sciences/Health care

Health sciences/Risk factors

Background

An estimated 103 million population have been forcibly displaced worldwide by the middle of 2022 as a result of persecution, conflict and violence [1]. Eritrea contributed around 507,300 of refugees to the world in 2018 and most of (57%) these refugees were hosted by Ethiopia (174,000) [2]. Women and girls accounted for 48% of these refugees [2].

Access to information and high-quality family planning (FP) service are fundamental to realize the rights and well-being of women, men and adolescents. Universal access to effective contraception safeguards a sustaining sexual life and can avoid the adverse health and socioeconomic aftermaths of unintended pregnancy [3]. Similarly, People living in humanitarian settings are entitled to this right. FP is the most proven and cost-effective strategy in reducing maternal and child morbidity and mortality and improves schooling and economic outcomes among women [4, 5]. Universal access to FP could prevent nearly one-third of the estimated 300,000 maternal deaths yearly [6] and reduce an unintended pregnancy, abortion and newborn deaths by 70%, 67% and 77% respectively [7]. The return on investment in family planning estimated to be US$120 for every US$1 spent [7].

Many initiatives and interventions on FP promotion have been launched and implemented globally as well as nationally. The 1994 ICPD programmes which advocates on the basic right of all couples to decide freely and responsibly on the number of children they would have and the means to do so [6]. The Sustainable Development Goal (SDG) 3 targeted to reduce maternal mortality ration to less than 70 per 100,000 live births by 2030 through universal access to sexual and reproductive health care services, including for FP[8]. The FP2020 also aimed to address 120 million additional contraceptive users by 2020 [9] Likewise, Ethiopia produced essential strategic planning documents in FP over the past decade. The Health Sector Transformation Plan (HSTP II) which aimed at scaling up FP to reach an additional 6.2 million users and to increase contraceptive prevalence rate (CPR) to 55% and reduced fertility to 3 by 2020 [10]. The country has also developed a FP Costed Implementation Plan in 2015 which serves as a blueprint for the implementation of the FP goal outlined in the HSTP [11].

Ethiopia has been made a significant progress in improving the access to quality FP in the past two decades through a right-based approach [11]. As a result, maternal mortality has declined from 871 in 2000 to 412 per 100,000 live births in 2016 [12] and CPR increased from 14% in 2005 to 41% in 2019 [13].

Despite encouraging progress has been made in FP coverage; women found in developing countries, especially in humanitarian settings, encountered many challenges in accessing and utilizing FP services. Occasionally, national strategies and programs failed to address effectively the refugees reproductive health needs [14]. Early or forced sex, sexual exploitation, transactional sex, risk-taking behaviors and exposure to high-risk situations are characterstics of refugees due to loss social structure and protective mechanisms [15]. Over 220 million women, most of who are from developing countries, have unmet need for modern contraceptive methods [7, 16]. CPR is reported at averagely 42% in Sub-Saharan Africa [16] where as in Ethiopia, it is reported at 47.7% [17] and 17.8% [18] from refugee settings.

Low CPR is associated with religion, distance to health facilities, knowledge on FP, lack of information, mistrust in the safety of contraceptives, prior negative experience, age, educational status, poor quality service, decision making status, number of live children, residence, marital status, occupational status, misconceptions and language barriers in many studies [16, 17, 18, 19, 20].

Currently, there is a dearth of information on the use of contraceptives and factors actassociated with utilization in refugee women, particularly in the study area. The unique situation of refugee women compounded with the existed poor health system in the country, most likely results in high an unmet need for FP. A scarcity of information in such a marginalized population leads to ineffective FP service provision at place. Therefore, this study aimed to assess the barriers and challenges that are associated with the uptake of contraceptive use among refugee women.

Study setting

There were four Eritrean refugee camps namely: Hitsats, Shimelba, Adi-Harush and Mai-Aini in Tigray region, Northern Ethiopia [21]. This study took place at the two refugee camps (Mai-Aini and Adi-Harush) located in Tselemti district, the North West zone of Tigray. These refugee camps were opened in May 2008 and March 2010 respectively [22, 23]. These camps located at 367 and 384 Kms North-West of Mekelle the capital city of Tigray region respectively. The Government of Ethiopia manages all the refugee camps through the Administration for Refugee and Returnee Affairs (ARRA) [24]. Along with ARRA, United Nation Higher Commission for Refugees (UNHCR) and the International Rescue Committee (IRC) supported the health service system entirely [23]. According to ARRA 2016 report, these camps were homes to an estimated 80,422 (Mai-Aini = 31,091and Adi-Harush = 49331) registered refugees from Eritrea [24]. Women were accounted 40%-45% of this population [22, 23]. The health centers found in these camps provide Basic Emergency Obstetric and Newborn Care (BEmONC) services, including FP services. However, mothers referred to the nearby district primary hospital, Mytsebre, for Comprehensive EmONC service and surgical contraceptive methods. Sometimes women may refer to General/specialized hospital found in Shire and Mekelle for further obstetrical complications diagnosis and management. Each health centers had 1 general practitioner, 12–13 Nurses, 4 midwives, 2 lab technicians, 1 health officer and 1 pharmacist. Although there has been an influx of refugee from Eritrea to these camps, 75% of these refugees engaged in secondary migration to other countries [25].

Study design and period

This study used multi-pronged approach methods and data to insure triangulation. A community-based cross sectional (additional file 1) for quantitative and a phenomenological design for the qualitative data (additional file 2) were employed from January 1 to February 1, 2017. Triangulation of methods and data has been accepted as valid and robust ways to expand the understanding of a particular topic and enhance validity and maximizes richness of the findings [26].

Study population

Reproductive age group women, midwives/Nurses and a director from health center were participated in this study. Being a reproductive age, living in a specific camp at least for 3 months + and having residency ID were taken as inclusion criteria for participation. Adolescents below 18 years old without family/guardian were excluded from the study.

Sample size and sampling process

For cross sectional survey

The sample size estimated using a single population proportion formula considering the following assumptions: 47.7% proportion of women used contraceptive methods in refugee camp found in Ethiopia [17], level of precision 4% and a 95% Confidence interval (z/2 1.96). The final sample size was 646, considering an 8% of non-response rate. A systematic sampling technique used to recruit study participants. First, census was done in each camp to identify households with eligible women. The total number of households with eligible women was registered and a corresponding house identification number was given to develop a sampling frame. A total of 646 eligible women recruited using this technique. The probability size allocation (PPS) technique was used to distribute the total sample size to each camp based on their population size (Adi-harush, 333/1860 and Mai-Aini 313/1750).

For the focus group discussions (FGDs) and in depth interview (IDIs)

Purposive sampling technique was used to select two FGD participants composed of 8–11 from each camp at community level. A total of 5 key informants composed of health center director, midwives, Nurses and health officers from the health centers were included. Saturation level was considered to limit the sample sized needed.

Data collection tool and procedures

For the cross sectional survey

A structured closed-ended questionnaire in English (Additional file 1) were developed and translated to Tigrigna (local language). The questionnaire was containing the following parts: socio-demographic variables, reproductive and sexual health variables and source of information, and FP knowledge variables. Data were collected through face-to-face interviews. Eight data collectors and 4 supervisors whose professions were nurses and midwives were participated in data collection.

For FGDs and IDIs

A series of open-ended (Additional file 2) guiding questions; 16 questions under 5 sections and 15 questions under 4 sections were used in the FGDs and IDIs respectively. FGDs were conducted with reproductive age group women and IDIs with health care service providers at the health centers in a private setting. Homogeneity in terms of age, educational status and experience of RHS utilization was considered in the FGDs composition. Moreover, heterogeneity in religion was also considered for participation. The interviews were facilitated by the principal investigator with note takers from the research team and recorded through digital audio using tape. Key notes were taken during the discussion time by both facilitator and note taker and elaborated into more complete narratives in the debriefing cession after completion of each interview. The qualitative and quantitative data were collected side by side and participants might be participated in both interviews. Transcripts were prepared following the FGDs and IDIs data collection was completed. The FGDs and IDIs sessions lasted 1–2 hours.

Study variables and measurement

Dependent variable

Contraceptive utilization was defined as when the women were utilizing any type of contraceptive during the data collection period. It was dichotomized in to “yes = 1 and no = 0”.

Independent variables

Socio-demographic variables: age, educational status, occupation, marital status, ethnicity, residence in country of origin, religion, source of income, husband education, migration status, and duration of stay in camp. Reproductive and sexual variables including decision making status: parity, number of living children, history of pregnancy, status of sexual intercourse, history of obstetrics complication, number of sexual partners, history of FP utilization in original country and decision maker status. Knowledge and practice on FP: level of awareness, source of information for FP, knowledge on the types of methods, knowledge on purpose of contraceptive and where to access the methods and the reasons why did not women use contraceptives and level of use.

Quality of data was ensured through the following measurements: questionnaire was translated into local language and back to English for its consistency. Data collectors and supervisors were nurses and midwives by profession, fluent in local language and trained for two days. The questionnaire was pre-tested among 5% of the calculated sample size in Shimelba refugee camp. Supervision and checking of filled questionnaire were made by the research team daily. Qualitative data were digital audio recorded and notes were taken to serve as backup document. Rigor of the qualitative data ware maintained through credibility, transferability, dependability and conformability measurements.

Data analysis and management

Hard copy data was rechecked for completeness and consistency. Data were entered and screened for errors and cleaned using SPSS version 20 software. The data were checked for some assumptions prior to analysis. Descriptive analysis resulted in frequency, percent, mean/median and standard deviation and presented in the form of text, tables and figures. Variables with a p-value of < 0.25 in bivariate analysis were transported for multivariable logistic regression analysis to control confounders. The goodness of fit was tested by Hosmer-Lemeshow statistics and variables with a p-value > 0.05 were fitted to the multivariable model. The odds ratio along with a 95% confidence interval (CI) was computed to ascertain the strength of association. Tests at a p-value of < 0.05 were considered as cut off points to limit the significance of the association. The audio taped qualitative data were transcribed using a verbatim method and translated in to English for analysis. The transcripts were read several times to identify key themes and developed a coding framework and the cods were grouped into similar categories. Data were analyzed using thematic analysis using ATLAS.ti software.

Ethical Issue

Ethical approval was obtained from the Institutional Ethical Review Board (IERB) of Mekelle University, College of Health Sciences with a reference number of ERC 0894/2016. Letter of permission was obtained from Tigray regional Agency for refugees and returnees affairs (ARRA) office found in Shire Endaslasie for respective camps. Informed written consent was obtained from each study participants^, after explaining the objectives, procedures, risk and benefit of participating in this study. For those whose age was less than 18 years and illiterate participants’ informed written consent was taken from legally authorized representative/guardians. Study participants were assured that all their information provided would be kept confidential and the result of the research would be published in aggregated form. Interviews were conducted in private setting. Participants also assured that participation in this study was completely voluntary.

Socio-demographic characteristics

Among the 646 sampled eligible women, 638 of them responded to the questionnaire completely, giving a response rate of 98.8%. The mean age of the respondents was 26.7 (SD + 7.2) years. More than half (54.5%) of the study participants were from Mayayni camp. The majority of the women, 528 (82.8%) were Tigrian, followed by Saho 87 (13.6%) and Tigre 23 (3.6) ethnicity. Orthodox Christianity was the predominant religion, 480(75.2%) followed by Muslim 84(13.2%), Catholic 49(7.7%) and Protestant 25(3.9%). About 366 (57.4%) of women were urban residents in their original country. All the refugees have monthly aid from UNCHR and other stakeholders. In addition to this, 145 (22.7%) have support from abroad relatives, 124 (19.4%) engaged in trade and 69 (10.8%) daily laborer (Table 1).

Table 1: Socio-demographic characteristics of the participants in the Eritrean Refugee camps in Tselemti district, Tigray, Ethiopia, March 2017

Variables

Frequency (N=638)

Percent (%)

Age

15-19

20-24

25-29

30-34

35-39

40-44

45-49

123

152

111

19.3

23.8

17.4

9.6

4.2

1.9

Marital status

Married

Single

Divorced

Separated

Cohabitated

widowed

336

184

52.7

28.8

6.9

6.3

3.3

2.0

Women Education

Illiterate

Able to write and read

Elementary(1-8)

Secondary(9-10)

Diploma⁺

152

296

120

7.1

23.8

46.4

18.8

5.8

Husband Education (n=388)

Illiterate

Able to write and read

Elementary(1-8)

Secondary(9-10)

Diploma and above

135

112

3.4

19.3

34.8

28.8

13.7

Migration status

With husband and children

With children only

With husband only

Only herself

With family

184

127

256

28.8

19.9

10.7

40.1

Time duration in camps( in months)

6-12

13-24

25-36

37-60

>61

158

113

102

15.2

13.3

24.8

17.7

Having TV/Radio at home

Yes

143

496

22.4

77.6

Reproductive characteristics and decision making status

Among the total study participants, 532 of them had history of sexual intercourse. Of these, 59 (11.1%), 159 (29.9%) and 314 (59%) participants had started sex at the age of less than 15, 15 - 17 and 18+ years old respectively. About 242 (37.9%) of respondents had history of reproductive health service utilization in their original country. Two-thirds, 424(66.5%) of participants had history of pregnancy. Among these, 245 (57.8%) of them were multiparous (2-4), 139(32.8%) primiparous, 30 (7.1%) grand multipara (5+) and 10 (2.4%) nulliparous. Around half, 315(49.4%) of the respondents decided themselves to use FPS, 90(14.1%) dependent on their spouse, 214(33.5%) jointly with their husbands and 19(3%) decided their family on behalf of them. About 246 (46.2%) of participants had discussion with their husbands about their reproductive goals.

Knowledge of respondents on family planning

The majority of the respondents, 569 (89.2%) have awareness on FPS. Source of information for participants was: 278 (48.8%) health professionals, 51(8.9%) media, 90 (15.7%) friends/neighbors and 150(26.5%) had multiple sources. The majority, 501(88%) of respondents know injection among the contraceptive methods (Table 2). About 461 (81.0%) and 138(24.3%) of respondents reported that the purpose of contraceptive methods are to space and limit births respectively. About 518 (90%), 172 (30.2%), 93 (16.3%) and 90 (15.8%) of respondents know that contraceptive methods are available in public health facilities, community pharmacies, supermarkets and private clinics respectively.

Table 2: Family planning knowledge characteristics of the participants among the refugee women in Tselemti district, Tigray, Ethiopia, March 2017

Variables

Frequency(n=569)

Percent (%)

Know pill

Yes

360

209

63.3

36.7

Know injection

Yes

501

88.0

12.0

Know surgical method

Yes

548

3.7

96.3

Know emergency contraceptive

Yes

139

430

24.4

75.6

Know condom

Yes

260

309

45.7

54.3

Know Intra uterine contraceptive Device (IUCD)

Yes

113

456

19.9

80.1

Know implant

Yes

150

419

26.4

73.6

Know natural method

Yes

528

7.2

92.8

Contraceptive use

About 344 (64.7%) of participants had ever used any contraceptive methods: 66(19.2%) in their original country and 278(80.8%) in the current refugee camps. In this study, Only 192(36.1%) of participants were using contraceptive methods: 140 (72.9%) for spacing and 52(27.1%) to limit birth at all. Injection type of contraceptive was the prevalent method utilized 115(59.9%), followed by implant 31(16.1%), IUCD 5(2.6%), condom 15(7.8%), pill 14(7.3%), EC 6(3.1%), surgical 2(1.1%) and natural methods 4(2.1%). About 150 (78.1%), 13 (6.8%), 5 (2.6%), 8(4.2%) and 16(8.3%) of respondents obtain contraceptive methods from health centers of the camps, public health facilities of the host community, private clinics, pharmacies and supermarkets respectively. The dominant reported reason for not using contraceptive methods was fertility desire 71(20.9%) (Figure1) and more than half 174(51.8%) of these had intention to use contraceptive methods in the future.

Figure 1: Reasons given by the respondents why they did not use contraceptive methods in refugee camps 2017.

Barriers associated with contraceptive use

Cross tabulation and logistic regression analysis were carried out. Hence, age, residence, educational status, husband education, had discussion with their husbands, having Radio/TV at home, awareness on family planning and time duration in camps were made significance association on bivariate analysis at a p-value of <0. 25. These variables were exported into multivariable analysis. Therefore, having Radio/TV at home, place of residence at original country, having discussion with spouse focused on reproductive goals and time of duration in camps were significantly associated with contraceptive use at a p-value <0.05.

The odds of having Radio/TV at home were about 2.2 (AOR=2.207, 95% CI=1.244, 3.917) and living in urban areas in their original country were 2.6 more likely to use contraceptive methods when compared to their counterparts (AOR=2.593, 95% CI=1.513, 4.444). The odds of discussion with husbands on reproductive goals were 2.8 (AOR=2.817, 95% CI=1.681, 4.721). Living in camps about 2-3 and 3⁺ years were 4.1 and 2.2 times more likely to use contraceptive methods when compared to respondents lived in these camps for less than 1 year respectively (AOR=.4.065, 95% CI=1.845, 8.956, AOR=2.200, 95% CI=1.084, 4.466) (Table 3).

Table 3: Factors associated with contraceptive use among the Eritrean refugee women in Tselemti district, Tigray, Ethiopia, 2017.

Variables (N=638)

Contraceptive utilization

Crude OR

(CI= 95%)

Adjusted OR (CI=95%)

No n (%)

Yes n (%)

Age at interview

15-19

20-24

25-29

30-34

35-39

40-44

45+

33(58.9)

86(68.8)

92(62.6)

61(57.0)

36(61.0)

22(84.6)

10(83.3)

23(41.1)

39(31.2)

55(37.4)

46(43.0)

23(39.0)

4(15.4)

2(16.7)

.651(.339, 1.250)

.858(.458, 1.608)

1.082(.562, 2.084)

.917(.435, 1.934)

.261(.079, .858)

.287(.057, 1.434)

1.102(.336, 3.610)

1.073(.337, 3.420)

1.534(.474, 4.962)

1.821(.522, 6.359)

.789(.132, 4.719)

.301(.040, 2.237)

Residence

Urban

Rural

178(59.1)

162(70.1)

123(40.9)

69(29.90

1.622(1.128, 2.334)

2.593(1.513, 4.444)**

Educational status

Illiterate

Elementary(1-8)

Secondary(9-10)

Diploma⁺

134(74.40

145(60.4)

49(53.8)

12(57.1)

46(25.6)

95(39.6)

42(46.2)

9(42.9)

1.909(1.250, 2.914)

2.497(1.468, 4.247)

2.185(.865, 5.520)

1.576(.860, 2.887)

1.972(.834, 4.664)

1.991(.389, 10.191)

Husband Education

Illiterate

Elementary(1-8)

Secondary(9-10)

Diploma and above

69(79.3)

85(63.4)

63(56.2)

28(53.8)

18(20.7)

49(36.6)

49(43.8)

24(46.2)

2.210(1.181, 4.135)

2.981(1.574, 5.649)

3.286 (1.548, 6.974)

1.742(.815, 3.725)

1.753(.761, 4.038)

1.366(.487, 3.827)

Back to home without getting service

Yes

6(37.5)

334(64.7)

10(62.5)

182(35.3)

.327(.117, .914)

.303(.090, 1.024)

Had discussion on reproductive goals with spouse

Yes

131(53.3)

209(73.1)

115(46.7)

77(26.9)

2.383(1.659, 3.422)

2.817(1.681, 4.721)**

Had Radio/TV at home

Yes

58(50.4)

282(67.6)

57(49.6)

135(32.4)

2.053(1.350, 3.122)

2.207(1.244, 3.917)*

Awareness on family planning service

Yes

304(61.5)

36(94.7)

190(38.5)

2(5.3)

11.250(2.678,47.264)

10.039(1.267, 79.558)

Time duration in camps (in months )

<12

12-24

25-36

37+

107(72.3)

41(68.4)

46(49.5)

107(61.5)

41(27.7)

37(31.6)

47(50.5)

67(38.5)

1.207(.710,2.052)

2.666(1.549, 4.589)

1.634(1.019, 2.620)

1.698(.784, 3.677)

4.065(1.845, 8.956)**

2.200(1.084, 4.466)*

** Significantly associated at p-value <0.001 and * significantly associated at p-value<.029

COR=crude odds ratio, AOR=Adjusted odds ratio, CI=Confidence interval

Focus Group Discussions result

Two FGDs from each camp were conducted with a total of 41 participants using local language.

Belifes, Accessibility of FP services and source of information for FP

Most of discussants believed that a woman/girl can start using contraceptive methods since the age of 15-18 years old, especially if she is married. They also highlighted the importance of especial counseling for underage girls about contraceptives use. All discussants from both camps revealed that availability of certain contraceptive methods like; Depo-Provera and progesterone only pills (POP) were inturupted occasionally. FPS were available from Monday to Friday however sometimes interuptued due to meeting. All the participants confirmed that adolescents were get FPS in the same room with adult clients. The sources of information for RHS were community health workers (CHW) and health facilities and the education was supported with mini-media. The CHWs teach the community about RH issues by moving from block to block at community level. They have a coffee ceremony program and select family models for recognition among the community based on their RHS seeking behavior.

Decision making status

Almost all the women agreed that a joint decision made with their husbands to use contraceptives. However, they did not close that there were some husbands who are autocratic toward their wives in using contraceptive methods.

‘‘In fact, in marriage joint decision is important; especially husband should understand the problem of their wives. There are some women who couldn’t use family planning services. Because their husbands consider that the whole purpose of marriage is to produce children and most of these husbands are illiterate” (Para- 5, 38 years old).

Contraceptives use and challenges

Majority of the women reported that contraceptive methods were more utilized by married women or who had history of delivery as compared to underage and unmarried girls. Participants disclosed that most of under age (<18) girls were not using the FPS due to embracement and the community stigma; rather they preferred to use services in private clinics and pharmacies found in the district.

“For example, of course there is no restriction based on age and marital status to access and use the RHS, but the attitude of the community is not the same for me and if a 15 years old lady comes to health center looking FPS” (A 30 years old woman, para-3). The other woman also said “How can underage girls use contraceptive methods since community health workers taught them to avoid sex at early age?” [Para 2, 36 years old]

Few women underlined that there were infidelity women who used contraceptive methods secretly from pharmacy and private clinics due to fear of stigma from the community.

“There are women whom I know use contraceptive methods from pharmacy in the host district and I asked them why they do not use from the health center found in the camp, but they told me that some of them are married but their husband lives in abroad. And some of them were unmarried and live with their family. Therefore, they preferred private pharmacies to avoid stigma from the community“(Para-1 a 31 years old woman).

Some women stated that injection and oral pills were the predominately used contraceptive methods. However, when these methods were unavailable, health care providers insisted users to use long-acting contraceptive methods even though women are usually not convenient due to side effect like; wasting of hair, weight change; head lightness and fertility desire as reasons.

“When a woman uses implant, there is an instruction from the service providers that implants are expensive and it has to be used for 3-5 years effectively. However, the woman may want to remove this implant due to some reasons. Then what she can do? If she goes for removal, health care providers are not cooperative and they insist her to continue the method” (Para_2, a 36 years old).

All participants were explained that religion was the predominately mentioned reason followed by myths and side effects for non-use of contraceptive methods.

In-depth interview with care providers

We had conducted in-depth interview with a total of 5 key informants (3 from Adi-Harush and the rest from Mai-Aini) focusing on 4 themes similarly to FGD: believes, accessibility, use of contraceptives and challenges.

Beliefs and Accessibility of contraceptives

All key informants believed that all age groups of refugee women can use FPS because they are vulnerable for unwanted pregnancy and unsafe abortion. They also affirmed that the interruption of certain methods and closure of services during meeting hours that was reported by the FGDs participants. In addition, lack of effective counseling, negligence, shortage of midwives and lack of duty payment for extra hours were mentioned as reasons for inaccessibility.

Family planning use and challenges

Women found in the age between 18-30 years old were the most users of contraceptive methods. Depo-Provera was the most preferred type of contraceptive method followed by implants whereas FGD participants rank oral contraceptive method was the second. Some of the women use natural type of methods due to religion and side effect reasons. All key informants acknowledged that contraceptive utilization was not to the expected among refugees. Three of the key informants pointed out that rate of contraceptive utilization were unpredictable in refugee camps. When the refugees have a plan to migrate to other secondary country, a large proportion of women visit the health center for use of contraceptive methods especially implants to avoid unwanted pregnancy along the journey. On the other side, some refugees consider these camps as the right place for child delivery since they are idle. In addition, they assumed that if they would go to Europe, they would be busy as well to replace their generation in case one of the couple dies along the journey. Two key informants suggested that the low utilization could be due to the effect of pronatal policy in Eritrea. Husband influence, religion particularly Muslim and Saho and to some extent Christian followers were nominated as factors for non-utilization of contraceptives.

“For example, there was a Muslim woman whom I know she gave 3 births within 5 years of duration” (a 38 years old midwife).

Saho ethnic was the most known for non-use of contraceptive methods due to their husband’s opposition.

“I know one Muslim woman from ethnic Saho. She was using contraceptive methods anonymously and one day her husband came and told us why you had given it to my wife without my permission and told us that he would accuse us”

They also confirmed that adolescent girls and unmarried ladies were low utilizers of contraceptive methods which were mentioned by the FGDs with similar reasons. Resistance for use of contraceptive observed among the age group of >30 years.

This study is a part of a large study which was conducted on utilization of reproductive health services and barriers among Eritrean refugees. On this topic we discuss the utilization of contraceptive methods and associated factors, including the qualitative findings, especially about the hindering factors. We also discuss the implications of the findings for FP program improvement. This study showed that more than one-third of the respondents were used contraceptive methods during the interview time and large proportion of respondents had awareness on contraceptive methods. Adolescents were limited to access FP services. Use of contraceptive was varied by the following factors: having Radio/TV at home, residence, discussion with spouse and duration of stay in camps. Limited availability of certain contraceptive methods, staff meeting in working hours, religion, myths and side effects, lack of effective counseling, shortage of staffs and community stigma for adolescents and unmarried girls were mentioned as barriers to access FPS by the FGDs and IDIs participants.

The current prevalence of contraceptive use(CPU) is similar with the findings from Amman and Syrian refugees, where 31.9% and 34.5% of women were using contraceptive methods respectively [27, 28]. It was also similar with the host country’s CPR, (41%) mini EDHS 2019 [13]. However, the current finding was higher when compared to findings from a study conducted in six countries of Africa and Asia and a study conducted in Kenya, where only 19.9% and 19.2% of respondents were used contraceptives respectively [29, 30]. It was also higher when compared to their origin country, where only 8.4% of all Eritrean women use contraceptive methods. Moreover, 27.4% of Eritrean women had unmet need for contraceptive methods [31]. This difference might be due to the intervention that has been taking place by ARRA, IRC and other stockholders on this community. There were about 42 community health workers in each camp whose main task was to mobilize the community and promote RH service utilization in the community. In addition to this, the host country’s strong policy on FP promotion and the intervention taken might also influence these refugees. On the other side, CPR in refugee camps of Shimelba, Ethiopia and Jordan were 47.7% and 43% respectively, which was higher in prevalence than this study [17, 32]. This could be as a result of difference in setting and the health care workers commitment. In general, the level of contraceptive utilization in this community was far away from the global and national aspirations. Moreover, both the FGDs and IDIs participants also affirmed that contraceptive use in respective camps was low. This indicates that coverage of FP utilization is not on track to achieve the goals outlined in the universal and local documents, like the goals of ICPD advocacy for universal access to FP, FP2020, SDGs and the Ethiopian health sector transformation plan [6, 9, 8, 10]. The limited availability of certain contraceptive methods reported in this study similarly observed in other studies conducted elsewhere within similar refugee settings [14, 29, 33, 34]. The combination of this low utilization and limited availability of contraception increases the risk of unintended pregnancy, unsafe abortion and its morbidity. Improving the access to contraception and effective use of contraceptive methods in humanitarian setting could avert about 90% of unsafe abortion-related morbidity and 29% of maternal deaths [15].

By method, Injection was the most utilized contraceptive method followed by implants. This finding is consistent with the EDHS, 2019 of the host country and other local studies conducted in refugee camps [13, 17, 35, 36]. About 88% of participants in this study know injection contraceptive method; this in turn may trigger women to use this contraceptive method. However, injection was the second most utilized contraceptive method in Shedder refugee camp in Ethiopia [18]. In another refugee camp, it also revealed that IUCD was the most popular method followed by oral contraceptive pills [37]. This difference could be as a result of health workers' counseling skills and availability of the methods across the health facilities. Around 90% of women had awareness about contraceptive methods in this study. A study conducted in the same refugee camps (79%) supports this finding [33]. Other reports from shedder camp 94.5% [18], Shimelba camp 95.4% [17] and a multicounty study 74% [29] affirm this evidence.

Having TV/Radio at home was a significant factor for contraceptive use in this study. In fact, we could not get similar finding from a similar setting however in the general population, media is a significant factor [38, 39]. Obviously, we know that media is a key strategy in changing community behavior. Discussion with husbands about reproductive goals was a significant factor. Similar findings from Somali regional state of Ethiopia and Pakistan support this current study [18, 19]. Discussion regarding reproductive goals among couples might create mutual understanding between the parties; this in turn may lead them to use contraceptive methods. Living for longer duration in camps was another significant factor of this study. Even though there was no similar study in refugee setting, one study from the general population illustrated this fact. This might be justified as living for longer duration in a specific camp could provide an opportunity to be familiar with the health care system [40]. This study was also revealed that urban residency in their original country was a significant factor. This evidence is reported in many studies of the general population [41, 42]. The population and health survey 2010 of Eritrea reported that use of contraceptive were high among urban residents [43]. This could be the attributions of awareness and knowledge difference in seeking contraceptive methods. Better access to service is also expected in urban areas. Participants of FGDs and IDIs were mentioned many barriers for use of FPS. Both groups underlined the husbands’ oppositions to access FPS because of desire to have many children and religious reasons. Qualitative studies conducted in refugee camps illustrated this finding [16, 20, 34, 44]. They also reported poor uptake of contraceptive methods was observed among Muslim and ethnic Saho. Many studies ascertained this fact even though there is no conclusive answer why this phenomenon happened [16, 20, 44].

Another essential deterring factors to contraceptive use were fear of side effects, misinformation and misconceptions which could be anticipated or the real ones that women encounter every day. A number of qualitative studies from different corner of the world in refugee settings have reported these findings [16, 20, 34, 44]. Erroneous information associated with contraception use could be the result of users and providers attempting to understand the contraceptive mechanism of action or sometimes the potential side effects could be the bases for a wide range of misconceptions. This could be propagated through unofficial social networks in the community. Side effects are the major reasons for discontinuation of contraceptive use, which can lead to unintended pregnancy and its consequences [45, 46].

Many studies from community and health facilities confirmed that contraceptive uptake among Adolescents and unmarried women were poor due to community stigma and norms, which are also the findings of this study [14, 29, 47].

Strengths and Limitation

This study assessed the status of FP among the vulnerable group using a triangulation method. This in turn can incite stakeholders and FP program managers to look on the existed strategies and to improve access of the service. In any study, it is natural to have risk of bias. However, we have tried to curtail these problems through triangulation of methodologies and data. Inherently, qualitative studies have limitations to generalize for the population in target. Nonetheless, we have tried to curtail this limitation through quantitative measurement at large. Among the limitations of this study, adolescents below 18 years old without family/guardian did not included in this study due to ethical issue, but they could be sexually active at the time of data collection and the may suffer the aftermath of the an unwanted pregnancy. Therefore the findings of this study may not be generalized to this group. Moreover, since the data were self-reported bias might be introduced by participants due to memory loss.

Our findings showed that the contraceptive utilization in the refugee camps was unacceptable when compared to the global and national plan. This study also demonstrates the effect of media, place of residence, discussion with spouse on reproductive goals and duration of residence in camps for contraceptive use. Limited availability of certain contraceptives, lack of separate service for adolescents, fertility desire, misconceptions, side effects, husband’s opposition, resettlement, religion, community stigma towards adolescents and unmarried girls were stated as the reasons for non-use of contraceptives by FGDs and IDIs participants. This implies that many of the refugees are at risk of unwanted pregnancy with its complication and increased maternal mortality.

Recommendations

ARRA should increase the number of midwives and adjust meeting hours other than the working days in health facilities. ARRA, UNHCR and other stakeholders should strengthen contraceptives and other logistics provision to the health centers.

Health care providers should reinforce the health education system focusing on both gender empowerments, involvement of husbands during FPS provisions, counseling to couples about myths and side effects and community stigma on FP use through media as well in person.

Especial attention should be given for adolescent reproductive health service provision separately by UNHCR, ARRA and other stakeholders should involve in this program.

They should also emphasis on religion leaders to involve in health education and should focus on fertility issue and its impact on the health of mothers.

ARRA –Administration for Refugee and Returnee Affaires

AOR-Adjusted odd ratio

CHW-Community Health Workers

EDHS-Ethiopian Demographic and Health Survey

FGD-Focus group discussion

FP-Family planning

FPS-Family Planning Service

HSTP-Health Sector Transformation Plan

ICPD-International conference on population and development

IUCD-Intra Uterine Contraceptive Device

NGO-Non-governmental organization

RH-Reproductive health

RSH-Reproductive and sexual health

SDG-Sustainable Development Goal

UNHCR-United Nation Higher Commission for Refugee

UN-United Nation

Ethics approval and consent to participate

Ethical approval was obtained from the Institutional Ethical Review Board (IERB) of Mekelle University, College of Health Sciences with a reference number of ERC 0894/2016 and all methods were carried out in accordance with the principles of protocols and guidelines recommended by the Declaration of Helsinki. Letter of permission was obtained from Tigray regional Agency for refugees and returnees affairs (ARRA) office found in Shire Endaslasie for respective camps. Informed written consent was obtained from the study participants after explaining the objectives, procedures, risk and benefit of participating in this study. Informed written consent was obtained from legally authorized representative/guardians for those whose age was less than 18 years and illiterate participants’. Study participants were assured that all their information provided would be kept confidential and the result of the research would be published in aggregated form. Interviews were conducted in private setting. Participants also assured that participation in this study was completely voluntary.

Consent for publication

Not applicable

Availability of data and materials

The data that supports the findings of this study are not included in this publication as additional file because this study was assessed/includes utilization of multiple reproductive health services which are large datasets and under process for journal submission. Therefore, we consider it is not worthy publicly available. But it is available annexed with the large dataset from the corresponding author if it is necessary and timely.

Competing interests

The authors declared that they have no competing interests.

Funding

This research was funded by Mekelle University as recurrent budget for small scale grant research with a grant number of CRPO/CHS/SM/006/09. College of Health Sciences under Mekelle University was responsible in monitoring and evaluation of the project but it was not involved in any work of this study. The fund was not including for publication process.

Author contributions

The corresponding author (SWG), participated in selection of topic, development of the entire proposal, monitoring data collection; analysis, manuscript preparation and funding acquisition. GA, and AB involved in the conception of the study, data collection and analysis. KZ involved in analysis and manuscript preparation All authors read, edited and approved the manuscript draft.

Acknowledgement

We thank Mekelle University for the opportunity and sponsorship to conduct this study. We thank ARRA office for their support in providing information and letter of permission. We would like also to thank all respondents and participants of this study for their precious time invested in sharing their experience.

Authors’ details

¹Mekelle University, College of Health Sciences Department of Midwifery, Tigray, Ethiopia

²Mekelle University, College of Health Sciences, School of Nursing, department of pediatrics, Tigray Ethiopia

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No competing interests reported.

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Barriers to contraceptive utilization among Reproductive Age Women of Eritrean Refugee in North West Tigray, Ethiopia: a mixed study

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Abstract

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Introduction

Background

Methods

Study setting

Study design and period

Study population

Sample size and sampling process

For cross sectional survey

For the focus group discussions (FGDs) and in depth interview (IDIs)

Data collection tool and procedures

For the cross sectional survey

For FGDs and IDIs

Study variables and measurement

Dependent variable

Independent variables

Data analysis and management

Ethical Issue

Results

Discussion

Strengths and Limitation

Conclusion

Recommendations

Abbreviations

Declarations

References

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