Many girls and women in developing countries who do not want to get pregnant lack access to contraceptives, information, and services which, for many, will cost them their lives (11). Considering the duration, severity of illness, and treatment effect patients should be well informed before pregnancy during TB treatment. To prevent this there is a platform for FP at the TB clinics. There is limited work on contraceptive utilization studies among women on TB treatment and this report tries to provide information by determining the contraceptive utilization rate, unmet need, and FP services within the TB clinics in Addis Ababa. In this study contraceptive utilization among women was found to be 41.9% which is slightly lower than the national rate, 36.2% in the general population (Due to the limited data, it is difficult to directly compare with the general population as these groups are regular seekers of health care during their TB treatment.). However, according to the EDHS of 2016, the general contraceptive rate in Addis Ababa was 50% (12). For the general population studies in East Africa (40%), the United Republic of Tanzania (40.6%) and Madagascar (46%) reported their figures (13). At least with regular visit of health facility HIV patients on follow-up can be comparable with our finding. Accordingly in Addis Ababa among HIV positive women 40.8% was reported (14) among those who has similar privileges of visiting HCs, in North Shoa Zone (46.9%) among married women (15). However, the finding is lower than the world prevalence (64%), Europe (69%), Asia (68%), Northern Africa (53%), Southern Africa (64%), Zimbabwe (66%), Rwanda (53.5%) and Kenya (57.4%) (13). Whereas, the CPR is higher than the African continent (33%), Subsaharan Africa (28%) among female adolescents (13). This could be due to different health service seeking behavior, socio-cultural inclinations, and differences in the health service delivery system. Similarly, our finding is higher than the prevalence of Gonder and Bahir Dar towns (34.3%) among street women (16). This could be that street women do not visit HCs more often than women on TB treatments who are visiting HCs daily for Directly Observed Therapy (DOTs). As a result they could have better awareness and practice about FP than other women in the community.
Although a relatively higher percentage of rural residents utilize contraceptives than urban, no significant difference was observed. The high CPR among rural residents might be due to a small number of rural participants in the study. The finding is inconsistent with the report by Lakew Y et al. (17). In our study, women from both urban and rural settings visited HC to get TB treatment having similar access to health services provided by health facilities. As the 2015 UN economics and social affairs report on the type of contraceptives, female sterilization, and IUCD are the two most common methods used by married or in-union women worldwide, 19% of married or in-union women relied on female sterilization and 14% used IUCD. Short-term methods are less common, 9% of women used the pills in, 8% relied on male condoms and 5% used injectable (13). Similarly in the current study, the majority of women were equally using IUCD or Implant followed by injection, oral contraceptive, and tubal ligation.
Assessing the reasons why women do not prefer to use FP methods is critical in designing programs that could improve the quality of the service. In the current study, the majority of women reported ‘not having sex’ is a major factor for not using contraceptives. Similarly in a report by Guttmacher Institute, significant proportions of married women with an unmet need gave exposure-related reasons for nonuse. They believed they were not at risk of getting pregnant, most often either because they were breastfeeding or not having sex frequently. They reported among women who were never married, infrequent sexual activity was by far the most common reason for not using contraceptives (18). On the contrary, other scholars reported that never given birth, religious influence, fear of side effects, and desire to have a child were the main reasons why women are not using contraceptives (15).
Women who had 1-3 children were less likely to use contraceptives. These women might not have reached the maximum birth limit or desire to have another child. This could be for the reason that women who reached the maximum birth limit are more likely to practice sex infrequently or not at all. This finding is in line with unpublished data by Sita S, 2003 who reported women with an ideal family size to have a lower need for FP services. Nonetheless, the finding is inconsistent with the report in North Shoa (15).
Considering age to assess contraceptive utilization, the majority (58%) were in the age group of 23-33. This is in line with the report by Ashford LS et al. (19), who showed that contraceptive use was higher among women 20-34 years of age. The association of contraceptive utilization and age was insignificant in the multivariant analysis. The majority of women were told about where they can get modern contraceptives during their treatment follow up. Almost all of these were informed about where they can get the service. This shows that the integration of contraceptive services, such as counseling of patients on FP at TB clinics, is a good approach for FP service delivery although a significant difference was not observed. On a study of contraception for high-risk patients, regular counseling might be needed for the women on treatment as they may wish to discontinue methods due to actual or perceived side effects that may be associated with their chronic medical condition, or due to their co-morbidity (3). The closeness of FP service providing places to home was also an important factor for contraceptive utilization. Almost all of the contraceptive user women reported FP outlets were close to their homes. Similarly, the report by Ashford LS et al. showed that contraceptive utilization was higher among women, living within walking distance from a health facility (19).
Worldwide in 2015, 12% of married or in-union women are estimated to have had an unmet need for family planning. The level was much higher, 22% in the least developed countries. Many of the latter countries are in sub-Saharan Africa, which is also the region where the unmet need was highest (24%), double the world average in 2015 (13). In Ethiopia, the unmet need for the general population was 22% (12). In the current study, the prevalence of unmet need was found to be 18.9% among married and sexually active single women on TB treatment, this is lower than the general population due difference in the repeated health facility visits among the two groups. In countries such as Kenya, Madagascar, Malawi, and Zambia, a decline in unmet need has corresponded with an increase in FP for the general population (13). In this study too, a high contraceptive utilization (41.9%) corresponds to a lower unmet need finding.
Nationally unmet need for FP declined from 34% in 2005 to 25% in 2011 and 22% in 2016 (12). According to the 2011 EDHS report, there is variation in unmet need prevalence by region, ranging from a low of 10.6% in Addis Ababa to 29.9% in Oromia (20). Our result’s discrepancy with the report from Addis Ababa could be attributed to the study’s participants were residing in combinations of urban and rural areas (referrals). In Tigray, the unmet need for FP among married reproductive age women was 21.4% (21), this is higher than our finding as study subjects enrolled were more rural residents and of a married group. However, the current finding is comparable to the UN report among married or in-union women in Africa 22% and East Africa 24 % (13). Similarly, it was in line with the report from the Amhara region (17.4 %) (22) and Cameron (20.4%) (23). TB treatment centers can consider their services to identify and address those in need of FP service. This can be upscaled to the different HCs providing TB treatment to address high-risk patients by asking them about their FP preferences at their commencement of treatment benchmarking from HIV patients during their initiation of ART services. Although women on TB treatment were informed about FP services at the TB clinic, there is no formal integration of the two services for follow-up of outcome. However, a women’s visit to obtain TB treatment could be a good contact point to inform and provide FP services to providing the best available care and also recording outcomes. Further work needs to focus on filling the data gap on women taking TB medication and their contraceptive needs with regards to providing the right counseling. Drug impacts on the fetus at different points of pregnancy to help the mother informed descision on delaying pregnancy should be explored. The stress and psychological impacts of the pregnancy occurring with TB should be investigated to help protect the mother from pressure.