Decision Making Power Over Reproductive Health Service Utilization And Associated Factors Among Married Women In Dupa Town And Surrounding Rural Kebeles, Illuababora Zone, South West Ethiopia,2020.

Background: Decision making power of women is one of the essential factors which have inuence on maternal health service utilizations. Women’s lack of decision over reproductive health service utilization affects their protection from unwanted child bearing, unsafe sex and their consequences. Objective (cid:0) Assess decision-making power on RH-service utilization and its associated factors among married women in Illubabor zone, South West Ethiopia, 2018. Methods: Community based comparative cross-sectional study was conducted from May to July, 2018 among 584(urban 292 and rural 292) married women of reproductive age group. The data were entered into EPI data version 3.1 and exported to SPSS version 20 computer software for analysis. Both Bivariate and multivariable logistic regression analysis was used. Level of signicance was declared at a p value of <0.05 Results: A total of 288 in urban and 288 in rural married women were interviewed and yields a response rate of 98.6% both in urban and rural. Decision-making power in urban and rural was 55.2% [95% CI (52.7-64.6)] and 40.3% [95% CI (39.9-52.5)] respectively. In urban, being wives of government employed spouses [AOR 2.102 95% CI (1.16, 3.81)], knowledge on RH [AOR 3.33, 95% CI (1.20, 12.49)], above ve years in marriage [AOR 1.91, 95% CI (1.19, 7.70)], were found to be predictors of women’s decision-making power. Conclusion and recommendation: Urban women had better power to make decisions than rural on reproductive health service utilization. The study revealed that in urban settings those women who had marriage duration ve and more than ve years, being wives of government employed spouses had more likely decision making power on reproductive health utilization but not in rural settings. Reproductive health interventions in the area should be promoted by considering empowering of married women on reproductive health service utilization. Moreover, women’s decision making power also differs by their residency area; Urban versus rural residency. From the total of 288 in urban and 288 in rural married women were interviewed and yields a response rate of 98.6% both in urban and rural. Decision-making power in urban and rural was 55.2% [95% CI (52.7-64.6)] and 40.3% [95% CI (39.9-52.5)] respectively. In urban, being wives of government employed spouses [AOR 2.102 95% CI (1.16, 3.81)], knowledge on RH [AOR 3.33, 95% CI (1.20, 12.49)], above ve years in marriage [AOR 1.91, 95% CI (1.19, 7.70)], were found to be predictors of women’s decision-making power. The study revealed that in urban settings those women who had marriage duration ve and more than ve years, being wives of government employed spouses had more likely decision making power on reproductive health utilization but not in rural settings. Reproductive health interventions in the area should be promoted by considering empowering of married women on reproductive health service utilization.


Introduction Plain English Summary
Reproductive health service utilization is important for the enhancement of both maternal and child health, despites the fact that the women's right to decide on their own reproductive health issues were mastered by their respective husband. Lack of decision making power may leads to poor health outcomes, and lack of protective against unsafe sex, STI and gender based violence.
In Ethiopia, there are variations on health service utilization decision making power both intra and inter regional states.

Introduction
Understanding individuals, above all women's reproductive needs and identifying the key factors which in uence reproductive negotiation process between husband and wife are necessary to formulate policies aimed at creating conducive environment to improve women's reproductive health, general well-being and their decision-making power (1,2).
Reproductive health service utilization is important for the enhancement of both maternal and child health (3,4), despites the fact that the women's right to decide on their own reproductive health issues were mastered by their respective husband (5)Lack of decision making power may leads to poor health outcomes, and lack of protective against unsafe sex, STI and gender based violence(6, 7) In Ethiopia, there are variations on contraceptive decision making power both intra and inter regional states.
It is highly exercised in Amhara and lower Somali 54.4% and 2% respectively(8, 9). Moreover, women's decision making power also differs by their residency area; Urban versus rural residency. For instance, urban women 20% odds of make a decision than rural (10), urban married women has 55.9% odds of decision than their rural counterparts (11), in Honduras urban women has 25% odds of decision than rural (12) and in India urban has 27% odds of decision than their rural counterparts (13). Despite to this, enhancing empowerment status of women contributes best approaches to improve decision making power (14).
Moreover, multiple factors were associated with women decision making power on reproductive health service utilization among those maternal age, socioeconomic status (15), educational status (16- 19), and limited access to health services (20). In addition the community level autonomy (21), gender based violence (22), being patriarchal society (23) and residency area (24). Consequently, investigating the burden and its determinants of women decision making power on reproductive health service utilization has paramount importance to empower women on their reproductive issues. Therefore, this study aims to identify and compare the magnitude of urban and rural women decision making power on reproductive health service utilization.

Methods And Design
Study design: Community based comparative cross-sectional study was conducted from May to July, 2020 among 584(urban 292 and rural 292) married women of reproductive age group.
Study population: All randomly selected married women in reproductive age group (15-49 years of age), who were resident of Dupa Town and surrounding rural kebele.
Study unit: Randomly selected married women in reproductive age group (15-49 years of age), who actually participate to the study were the study unit.
Inclusion criteria: Women in a marriage or consensual union and lived at least for six months in the area were included in the study.

Sample size determination
Sample size was determined using Epi INFO version 7 considering the following assumptions: level of signi cance (0.05), power (0.80) Proportion of rural married women decision making power on contraceptive use p=43.1% and urban married women decision making power on contraceptive use p=55.9 %) (22)With the consideration of non-response rate of 15%, this yielded a total sample of 584 Urban (292) and rural (292).

Sampling technique
Census was conducted in urban area (Dupa town) which is found in Darimu district, married women enumeration was carried out to identi ed married women of reproductive age group in area were the study was employed. In order to generate sampling frame, In rural area total number of married women of child bearing age group obtained from the family folder of the community health information system (CHIS) available at health post and record number, Then recoding the record number lists in ascending order to make a frame and use table of random numbers to identify study participants. Based on these 2201 married women were identi ed from Dupa town and surrounding three rural kebeles, the three surrounding rural kebeles were selected randomly from the total of nine (9) surrounding rural kebeles within 10km radius of the town health center, proportion allocation for the three surrounding rural kebeles was based on number their married women of reproductive age group.
In this respect, from both urban and rural area the eligible identi ed married women of childbearing age were interviewed with simple random sampling technique, until the number of sample populations completed. In some conditions like married women of reproductive age group were away from home, the interviewer re-visited the household at least three times and if failed to get the respondent, it was excluded from the survey and noted as non-response.

Measurement
Structured questionnaire was used for interviewing selected participants. Four questions were used to construct composite score on decision-making power over RH-care service utilization. Based on these the women were asked "who in her family usually has the nal say on the following decisions: 1.Skilled birth 2, antenatal care (ANC), 3, post-natal care (PNC) and 4.Modern contraceptive use. For each items the response was scored as: 2 if a woman made sole decision, 1 if she was involved with someone (husband/partner or someone else) and 0 otherwise; For non-users of modern contraceptives and ANC; if their main reason for non-use is opposition from others (husband, mother in law, relative, religion etc.) the value was assigned as 0 and 1 if otherwise. Eventually, married women decision-making on RH service utilization among study units was set as binary outcome variable by merging the two groups of women together those scored above the mean categorized as higher decision making power whereas those who score less than mean score categorized as women with low decision making power on RH care service utilization after developing mean score independently for each. [10,20,31].
Women knowledge of RH-service was assessed by considering knowledge regarding the components of RHservices essentially that addresses services such as modern contraceptive, safe child bearing, reproductive tract infections, cancers, sexually transmitted infections. HIV/AIDS, safer sexual behavior and key danger signs during labor and childbirth. The desired answer was coded as 1, otherwise 0. Totally 40 questions were asked to assess knowledge on RH, therefore, those mothers who scored above 70% (≥28) were knowledgeable, less knowledgeable otherwise [20].

Data collection procedure
The data were collected using semi structured pre tested questionnaire. The questionnaire was prepared in English then translated to Afan Oromo then back to English by different language expertise. The data were collected using interviewer administered questionnaire to feet majority of the respondent's characteristics. The study subjects were interviewed about their reproductive health service utilization history and sociodemographic variables, decision-making power on RH-care service utilization.

Data quality management
Data collection instrument was developed after thoroughly revising related literatures and adopting questionnaires used in other similar studies by considering local conditions. The English version of the questionnaire translated to Afan Oromo/ naïve local language/ and translated back to English to check consistency by language expert. Before the actual data collection, the questionnaire was pre-tested on 5% of similar populations which reside in other adjacent district (Alge Sachi) not included in the survey and necessary modi cations was made speci cally on the understandability of speci c item. Six Midwife nurse local language naïve data collectors & One Supervisor were recruited for actual data collection.
One day training was given to data collectors and supervisors. Completeness and consistency of the collected data was reviewed and checked every day by supervisors. Discussions were made with the interviewers at the end of the day and in the morning; corrective actions was taken timely to minimize errors committed during interview.

Data Entry and Analysis
The collected data were cleaned, edited, coded and entered into Epi data version 3.1 then exported to Statistical package for social sciences (SPSS) version 21.0. Descriptive analysis was carried out for each of independent variables. Multivariable Logistic regression model was used and variables with p-value less than 0.25 with bivariate analysis were entered into multivariable logistic regression; variables with p-value less than 0.05 at 95% Con dence interval were declared as statistically signi cant with outcome variable.
Adjusted Odds ratio was used to test the degree of association and Goodness of t of the nal model was

Source of Reproductive health information
More than fty presents of the respondents in urban and rural area their source of information about reproductive health was health extension workers 60.2% in urban and 53.1% in rural (Table 3). Other, Books and school*

Level of decision making power over reproductive health service utilization
The study showed that, decision making power on reproductive health service utilization among married women in the study area urban and rural 159(55.2%) and 116(40.3%) respectively had decision making power over reproductive health service utilization (Table 4).

Factors affecting decision making power of married women
Bivariate analysis reveals: attending formal education of respondents and husbands, husband occupation, women occupation, knowledgeable about RH, and more than ve years marriage duration shows statistical signi cant association for both urban and rural settings (Table 5).
In the multivariable logistic regression: urban attending formal education of respondent, being knowledgeable about RH and duration of marriage, occupation of husband and for rural women Rhknowledge and formal education of husband were found to be signi cant of women decision making power on RH service utilization (Table 5). were less likely to be decision making power over Rh-health service utilization (Table 5).

Discussion
This study showed that Women in urban setup had greater decision making power over reproductive health service utilization than the rural counterpart. 159(55.2%) with [95% CI (52.7-64.6)] of urban currently married women had higher decision making power on reproductive health service utilization compared to 116(40.3%) with [95% CI (39.9-52.5)] of married women in rural area (22). The variation might be due to the fact that, in most parts of rural Ethiopia, women usually attained low education; low involvement in their healthcare decisions than urban women.
The nding of urban married women decision making power is comparable with a cross sectional study conducted in southern Ethiopia, decision making power on contraception use found that, 53.8% (25)and in Amhara region 54.4% (26). Higher than other mutual consent for contraceptive use, such as in (27), 30.7%, study done in Bangladesh 35%(28) incomparable with Ethiopian Somalia region mutual consent for contraceptive use (2%) (29).
The nding of rural married women decision making power has similarity with a cross sectional study conducted in Bale found that, 39.5% regarding maternal and child health care decision (30) consistent with southern Ethiopia rural women decision-making power over contraceptive use 43.1% (31). Higher than the study conducted in Bangladesh 35% [11)], SNNPR 30.7% [9], Honduras 25% [12], Malawi 28.75% [32] And Pakistan 28 % [33].The variation might be from Social factors and cultural difference contributes on decision making power on RH-service utilization.
The nding of this study is lower in both urban and rural settings when compared with the cross sectional studies from Southern Ethiopia on married women that, 64.8% of urban women had decision-making power over contraceptive use [16]. The Ethiopian national level study that revealed 71.6% of rural women participate in own health care decisions [34]. This might be due to this study added other different components of RH components as composite variables. This discrepancy might be due to the fact that this study considered both rural and urban women in one district, whereas others might be regional, urban or rural. It might also be due to the difference in educational status, and cultural norms of the women in the study settings.
This study also revealed that, being wives of government employed spouses in urban, more likely to deiced over RH service utilization than their counterparts, the nding of the study were comparably similar with the cross sectional study done in Mizan-Aman, being wives of government employed spouses were two times more likely to decide on family planning use [17].
This study revealed that urban married women who had formal education were less likely to decide over reproductive health service utilization than counterpart. The nding of this study were comparably lower than the study conducted in East Wollega Zone, January, 2015,reveled than those respondents had formal education were more likely to decide on ANC [14] and Honduras [12]. Variation of the study could be Ethiopia, strong cultural and traditional backgrounds can in uence, regarding women formal education.
This study also revealed that, being wives of husbands who had formal education were less likely to women's decision making power in rural area those with husband did not had formal education. This study were comparably lower than, study conducted in Mizan-Aman, South Ethiopia, Women whose husbands had attended formal education were more likely to have a decision as compared to their counter parts [17].
This study revealed that urban women those in marital union for ve and more were more likely to be higher decision making power on RH service utilization than those who stay less than ve years in marital union.
This nding was consistent with study from Nekemte, West Ethiopia; which reports that women with more than ve years duration were more likely to be decision maker than those who were in marital union less than ve (32) The study also indicated that both urban and rural married women were knowledgeable about RH components had three times in urban and four folds in rural had more likely to diced over reproductive health service utilization than those who had not knowledgeable. This nding is higher when comparing with study conducted in Gedo zone, revealed that, married women knowledgeable on contraceptive were decide two times more likely to than lowly knowledgeable [35]. This variation might be from socio cultural difference.

Conclusion
Urban-rural difference was found in the study area on decision making power of reproductive health service utilization. Urban women had better power to make decisions on reproductive health service utilization than rural women. The study revealed that in urban settings those women who had marriage duration ve and more than ve years, being wives of government employed spouses had more likely decision making power on reproductive health utilization but not in rural settings, in both settings urban and rural, married women were knowledgeable about RH components had more likely to decision making power over reproductive health service utilization than those who had not knowledgeable. Hence, public health interventions targeting married women should be implemented. to communicate respective administrative bodies in the study area. After getting letter of permission to carry out the study from each administrative body, informed verbal consent was taken from each study subject prior to interview after the purpose of the study was explained. Privacy of the respondents was maintained and Con dentiality of the information was kept.

Data sharing
The original data is available from Action for M.E. in an excel spreadsheet.

Funding
No funding was obtained for this study