Magnitude and determinants of unmet need for family planning in Ethiopia from 2013- March 2020: Meta-analysis and systematic review

Unmet need for family planning is a major problem in developing countries. Millions of women want to delay or avoid pregnancy but are not using Contraception. Addressing the unmet need for family planning provides an opportunity for policymakers to respond to existing choice problems. Simultaneously improving maternal and child health, slowing the rate of population growth, and contributing to the achievement of national goals. This study aimed to determine the pooled Magnitude and determinants of unmet need for family planning in Ethiopia. Ten articles with 19312 study participants were identied through electronic search of reputable databases: Google Scholar, PubMed, Cochrane library, MIDLINE, EMBASE, and Ovid Maternity and Infant Care Databases. 10 studies were selected based on a comprehensive list of inclusion and exclusion criteria. The analysis was done by using STATA 14 statistical software. To assess heterogeneity, the Cochrane Q test statistic and I2 tests were used and a random effect model was also used to estimate the pooled prevalence of perinatal mortality rate. The pooled prevalence of the unmet need of modern family planning among reproductive-age women in Ethiopia was 19.99,95% CI(16.53,23.45).Age at rst marriage less than 18, OR = 1.37, 95 CI :( 1.04–1.18),discussion with husbands, OR = 0.24, 95%CI :( 0.12–0.49), having two and less children OR = 0.49,95CI:(0.35–0.67), illiterate partner OR = 3.61, 95 %( 2.63–4.95), good attitude of partner OR = 0.11,95% CI:(0.05–0.26), history of discussion with health care worker OR = 0.31,95%CI: (0.14–0.68), a poor knowledge OR = 3.15,95% CI:(1.75–5.69) were signicantly associated with unmet need for family planning. Unmet need for planning in Ethiopia is high as compared to world unmet need according to the United Nations World family planning report of 2017 which states one in ten reproductive age women have an unmet need for family planning but this study revealed one in ve the same age group women had an unmet need for it. Early marriage, women’s discussion with husbands and health care workers about family planning, having children greater than two, education status and attitudes of husband, and knowledge of women about family planning were signicantly associated with unmet need for family planning. So great effort is needed from all stakeholders to involve males in family planning decisions, alleviate early marriages, and structured health education interventions for both husbands and women to reduce the unmet need for family planning.


Background
Family planning has many bene ts. It reduces maternal and child mortality as well as reduces poverty; empowers women by lightening the burden of excessive childbearing and it reduces environmental degradation by reducing the population of the planet [1,2] Women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child [3] More than 100 million women in less developed countries, or 17 percent of all married women, would prefer to avoid a pregnancy but are not using any form of family planning [4] Unintended pregnancy-related to unmet need is a worldwide problem that affects women and their families and societies at large. About 40 % of all births that occurred globally in 2012 were unwanted that causes hardships for families and health problems in millions of women and children [5] Serving all women in developing countries who currently have an unmet need for modern methods would prevent an additional 54 million unintended pregnancies, including, 26 million abortions (of which 16 million would be unsafe), 21 million unplanned births, and seven million miscarriages; this would also prevent 79,000 maternal deaths and 1.1 million infant deaths [6] This study aimed to determine the pooled prevalence of unmet needs for family planning and to identify the determinants of unmet needs for family planning in Ethiopia.

Study design and search strategy
We developed this protocol by following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) statement [7]. We have used the Preferred Reporting Items for Systematic review and Meta-analyses (PRISMA-2009) statement to report the ndings [8].
We have been developed an appropriate and comprehensive search strategy with relevant search terms and pilot test it before the nal search. We have been searched PubMed, Google Scholar, MEDLINE, EMBASE, and Ovid Maternity and Infant Care Databases.
We included articles published from the start of 2013to March 2020.
"Prevalence of unmet need for family planning OR magnitude of unmet need for family planning OR factors associated with Unmet need for family planning OR determinants of unmet need for family planning OR predictors of unmet need for family planning AND Ethiopia" were used separately and combined as keywords to search eligible articles. To ensure comprehensiveness, we consulted an expert librarian. We utilized snowballing to screen the references of identi ed articles for potentially relevant studies. The searched records were managed by EndNote X7 software. Articles were searched from March to April 2020 and all the articles which ful lled the inclusion criteria from 2013 to March 2020 were included in this systematic review and meta-analysis to get current and updated study outcome which will be vital for policymakers and other stakeholders for intervention Study selection and eligibility criteria: The following criteria were used to decide the eligibility of the studies

Inclusion criteria
Those articles which come across with the following criteria were included in the study. Population: Articles conducted among reproductive age groups (15- All included 10 studies are published in peer-reviewed journals.

Exclusion criteria
Studies conducted in speci c target groups like women's with a disability, HIV/AIDS care in ART clinic, intellectual disability, etc. were excluded Studies did not report study outcome of interest and incomplete articles were also left out.

Outcome of interest
The primary outcome of interest in this systematic review and analysis was pooled prevalence of unmet need for family planning and the secondary outcome of this study was determinants of unmet need for family planning in reproductive age women's either married or in the union in Ethiopia from 2013 to March 2020 Quality assessment Three authors (DS, SD, and AT) independently conducted a quality assessment of included studies, by using the checklist of the adapted version of NOS for cross-sectional studies. Based on NOS, we awarded studies a maximum of ve stars within the selection, two stars for comparability, and three Stars with outcome categories [9] The qualities of the articles were assessed based on the criteria; those with a medium sore (50% of Quality assessment criteria) and high quality (≥6 out of 10 scales) were considered for this study. The quality score of the study was determined by taking an average of three reviewers to mean score Data extraction and management Using the Joanna Briggs Institute (JBI) data extraction form for experimental/observational studies [10]. We extracted relevant data and pretested the data extraction form on four studies of each type, to ensure that it adequately facilitates the collection of all necessary data required for an effective systematic review and meta-analysis. Three review authors (DS, AT, and SD) extracted the data independently using a standardized data extraction form prepared in Microsoft Excel spreadsheet 2013. Discrepancies between data extractors had been discussed to reach consensus and the fourth reviewer (YT) consulted for those di cult to reach consensus. . For each included articles, we recorded the rst author's last name, year of study, year of publication, the setting where the study was conducted, study design, study period, sample size, the response rate, the sample size, outcome and study quality score

Heterogeneity and publication bias
To examine the possible risk of publication bias, we used funnel plots and Egger's test [11]. A p-value < 0.10 be considered indicative of statistically signi cant publication bias. We assessed heterogeneity by using the chi-squared test on Cochran's Q statistic with a 5% level of statistical signi cance [12] and I2 statistic, assuming that I2 value of 25%, 50%, and 75% is representative of low, moderate, and high heterogeneity, respectively [13]. We used a xed-effect model for the studies that had low heterogeneity and a random effect model for moderate and high heterogeneity.

Data synthesis and analysis
We performed a narrative description of the study population, the studies included, the risk factors identi ed, and the magnitudes of unmet need for family planning as well as the outcome characteristics. We used tables and gures to summarize the selected studies and results. By using Microsoft Excel spreadsheet 2013 and STATA 14 statistical software, we carried out the data entry and statistical analysis respectively. We determined the pooled magnitude and determinant factors of unmet need for family planning in Ethiopia from 2013 to March 2020.

Result
Selection of eligible studies Three authors (SD, AT, and DS) reviewed the studies, based on inclusion and exclusion criteria. The review had been followed three stages. During the rst stage, we had assessed the titles of the studies identi ed from the search. In the second stage, abstract screening and the third stage abstracts of these selected titles had been included for the nal stage of full-text screening. During the full-text screening, we screened the full texts of abstracts selected in the previous stage. In the review, we included those studies approved by three authors.
The authors resolved the disagreements through discussion or consultation with a fourth reviewer (YT). We provided a reason for exclusion for all excluded studies.
From the outset, we searched a total of 11,126 records by the electronic search through a search engine of PubMed, MEDLINE Google Scholar, EMBASE, the worldwide web of science, and Cochrane Library, 562 of them were removed due to duplication from the inclusion. After the remaining 10,564 retrievals, Then from the remaining 10564 records, 10524 were excluded since they were not related to the study in general. Then in the last 40 full-text studies were considered and tested for eligibility based on the pre-set eligibility criteria. The last 10 studies were considered to be eligible and included in this meta-analysis and systematic review analysis and all included studies have been published in peer-reviewed journals. From a total of 40 full-text studies accessed, we removed 30 of them because they were based on a single exposure to study outcome articles, in detail see (additional le, gure 1)

Characteristics of original studies
A total of 19312 reproductive-age women were included in this systematic review and meta-analysis to determine the pooled prevalence and associated factors of unmet need for family planning in Ethiopia from 2013 to March 2020. All included studies were crossectional study design and conducted in community-based. Three studies were done in the Amhara region, two studies in the Oromia region, two studies in the Tigre region, one study in the SNNP region, and two studies were done nationally. Higher unmet need was reported from the Tigre region done in refugee camps and the highest was reported from a study done in a national-level survey. The response rate of included studies had a minimum of 98.1 %, in detail see Table 1. Education status of the partner or husband Signi cant association of Educational status of partner with unmet need for family planning was reported in two studies [14,15]. A likelihood hood of unmet need for family planning in women with an illiterate partner was around 3.6 times more likely than a women's with a partner of primary and above educational status, OR=3.61, 95 %( 2.63-4.95). in detail see (additional le, gure5) History of (ever) discussion with a health worker Ever discussion with health worker was reported in six articles [14-17, 19, 20], Women's with a history of discussion with health care worker about family planning were around 70% less likely to had unmet for family planning utilization as compared to a woman with no history of discussion with health care worker about family planning, OR=0.31,95%CI: (0.14-0.68), in detail see (additional le, gure 6) Partner or husband attitude Association of partner attitude and unmet need were reported in ve studies [14,15,[18][19][20].odds of unmet need for family planning in women's with good attitude partner about family planning were 90% less likely unmet need for family planning use as compared to women's with positive attitude partner, OR=0.11,95% CI:(0.05-0.26), in detail see ( additional le, gure 7) Women's knowledge about family planning A signi cant association of women's knowledge about family planning and an unmet need was reported in two studies [14,17]. A likelihood hood of unmet need for family planning in women with poor knowledge of family planning was 2.85 times higher than a woman having good knowledge, OR=3.15,95% CI:(1.75-5.69), in detail see (additional le, gure 8)

Number of living children
A number of living children was reported in two articles [14,20]. A woman having two and less than two was around 50% less likely unmet need for contraceptive as compared to a woman having greater than two children, OR=0.49,95CI:(0.35-0.67), in detail see (additional le, gure 9)

Discussion
This systematic and meta-analysis was conducted to estimate the pooled prevalence of unmet need of family planning and determinants in Ethiopia. The pooled prevalence of unmet need for family planning was 19.99, 95% CI (16.53, 23.45). This nding is in line with the study done in Nigeria which is 21.4 % [21] and Cameroon which is 20.5% [22] but less than from study done in Iraq which is 29.3% [23], Tamilu Nadu which is 39% [24], Burkina Faso which is 40.7% [25]. On the other hand, this study nding was greater than the study done in Sudan which is 15.08 [26], Kenya which is 16.5 [27], and the United Nations World family planning 2017 report which 10% [28].
The possible difference and controversy in a general point of view might be due to study method difference, year of study, sociodemographic variations, culture, and way of attitude and knowledge share media variations for behavioral change across the nations.
Women with age at rst marriage less than 18 years were 1.37 times unmet need for family planning as compared to the rst age of marriage greater or equal to18 years. This nding is supported by a study done in Uganda and Sudan [26,29] respectively. Also, a study done in Jorda shows high in women's married less than 18 years [30], and another study has shown high unmet needs in lower age groups of women [31]. The possible reason may be due to age less than 18 years are under the control of the family and this is a barrier to their choice of family planning. Another possible justi cation may be the knowledge gap of family planning among young ages. Since age is one source of social interaction and knowledge.
This study revealed that Joint discussion with their partners decreased the unmet need of family planning by 76 % as compared to women who did not discuss it. This nding is consistent with a study done in Bangladesh, Kenya, Lucknow, and Ghana [27,[31][32][33] respectively. Unmet has been high in never discussed contraception [29]. This may be due to partners' support and a good attitude of encouraging women to get an appropriate choice of contraceptive. Since the culture of male dominance in the household decision has a great impact.
The nding of this systematic review and meta-analysis showed that poor Knowledge of women about family planning was 3.15 times higher unmet need as compared to women's having good knowledge. This nding is supported by other studies, lack of knowledge about contraceptives has increased unmet need [24,34]. Interventional education done has decreased the unmet need of family planning [35] and also study done in Burkina Faso has shown that health education is an important factor to increase knowledge and reduced the unmet need for contraceptives [25]. The possible reason might be knowledge about family planning helped them to understand from the existence of service up to the identi cation of possible advantages, disadvantages, and side effects of their contraceptive choices.
This study identi ed that women having less than or equal to two living children were approximately 50% less likely unmet need for family planning as compared to women having greater than two live children. This nding is supported by a study done in Lucknow [31], having many children who have been associated with the high unmet need [36]. This indicates wanting no more children with live existing children increases unmet need.
This study revealed that positive Partners attitude about family planning was 90% less likely of unmet need as compared to women's having negative attitude partner. This nding is supported by many studies as shown that Husband's discouraging behavior towards utilization of contraceptive has increased unmet need [31]. A study done in Uganda has shown that partner opposition has caused about 20 % unmet in rural, 12% in urban, and 15 % overall unmet need for family planning [37]. A study conducted in Nigeria also has shown husband's disapproval as the main constraint for contraceptive utilization [21] and a study done in Burkina Faso has indicated husband's approval signi cantly reduced the unmet need for contraceptive utilization [25]. Social disapproval also has shown a signi cant increase in unmet needs [34]. This implies that males involvement has a great role in contraceptive utilization and decision making.
This study indicated that the Educational status of illiterate partners was 3.6 times more likely unmet need than women's having primary and above educational status partners. This nding is consistent with a study done in Sudan [26]. similarly, in a study done in Nepal, the educational status of partners has shown increased uptake of contraceptives [38] and another study also showed that literacy of husbands decreased unmet need [39]. As the above ndings, the attitude of partner and joint discussion, education is vital for access of information, knowledge, awareness and decision making and this may in uence decreasing unmet need.
This study revealed that women with a history of discussion with a health worker about family planning were 70% less likely to have unmet needs as compared to women with never discussed family planning. This nding is supported by a study done in Pakistan and India [40,41] respectively. This might be a discussion with health worker creates awareness about family planning choices, reduces rumors and perceived risks.

Conclusion And Recommendation
The unmet need for family planning in Ethiopia was high as compared to the United Nations World family planning report of 2017. Age at rst marriage, discussion with husbands, number of living children, education status of partner, ever discussion with health care workers, knowledge of women about family planning, and husband attitude about family planning were signi cantly associated with unmet need for family planning. Effective health educational intervention and involvement of husbands during family planning service are important for reducing the unmet need for family planning.

Declarations Acknowledgment
We would like to express our appreciation to all public health staff who helped in this review, Debre Markos University, College of Health Sciences. Secondly, we would like to appreciate the authors of primary articles

Funding
We have not obtained any funds for this study.
Availability of data and materials Data will be available upon request.
Authors' contributions DS: Conception of research protocol, literature review, study design, data Extraction, data analysis, interpretation, and drafting of the manuscript. SD, AT, and YT: Data extraction, analysis, and reviewing the manuscript.

Consent to publish
Not applicable Quality assessment. All authors read and approved the manuscript.
Ethics approval and consent to participate Not applicable.

Competing interests
The authors declare that they have no competing interests.