Determinants of Modern Family Planning Methods in the Oromia, Amhara, and Somali Regions, Ethiopia: A Community-Based, Cross-Sectional Mixed Methods Study

Background: In 2019, Ethiopia had a total fertility rate of 4.2 births per woman with the rates varying signicantly across regions. The Federal Ministry of Health of Ethiopia announced “Ethiopia FP 2020” to address the high fertility rate, aiming to reduce it to 3.0 by 2020. This study aimed to identify the determinants of the use of modern family planning services in the Amhara, Oromia, and Somali regions. Methods: A community-based, cross-sectional mixed methods study was conducted, using quantitative and qualitative data. The quantitative data were subjected to binary logistic regression analyses. Participants included over 4,117 married men and women aged 15-65 years old. Results: Respondents in Oromia were 8.673 times more likely to have modern family planning methods than those in Somali. Participants in Amhara were 5.183 times more likely to have modern family planning methods than their Somali counterparts. Women, married respondents, and recipients of media messages were more likely to have family planning experience. Family planning discussions with Health Extension Workers and health professionals played a signicant role in modern family planning. Conclusion: Establishing a family planning strategy that considers the sociocultural characteristics of each region might help address regional contexts. Everyone in Somali—especially husbands and religious leaders—must be educated in family planning and funds be made available to deploy advanced measures for the same.

included Jijiga, Gode, Siti, and Kebridehar. Second, we randomly selected a rural area and an urban area in each target town. Third, for homogeneity, we randomly selected 20-40 married couples per Kebele (the smallest administrative unit) in the Amhara, Oromia, and Somali regions.
The questionnaire used in this study was adapted from the USAID Demographic and Health Survey 2016 in Ethiopia [5]. This structured questionnaire was rst developed in English by reviewing diverse studies on each region. Thereafter, the questionnaire was translated into three languages: Aaharic, Affan Oromo, and Somali by experts who uently speak both English and these local languages. The data collection was conducted through face-to-face interviews by enumerators from May 10 to May 31, 2017. We used the Open Data Kit (ODK) survey application on a tablet PC. We obtained data from 4,688 respondents living in Amhara, Oromia, and Somali regions, with a response rate of 93.9%.
Consequently, we excluded 571 respondents' answers due to missing or censored data. The nal sample for this study consisted of 1,634 people from the Amhara region, 2,383 from the Oromia region, and 100 from the Somali region.
We conducted qualitative in-depth interviews with the key informants living in the target regions. The questionnaire was developed based on the "Qualitative Study on Family Planning" by UNFPA." Religious and community leaders helped us select the target respondents from whom we randomly selected 24 (8 per region), for key informant interviews.

Variables
The dependent variable was family planning practice experience. To measure this, we asked the respondents, "Have you (or your spouse) ever used any modern family planning methods (Pills, IUCD, Injectable, Implants, Emergency contraceptives, Foam, Condom, Vasectomy) to delay or stop a pregnancy?" A response of "Yes" was coded as "1" and other responses were coded as "0." This question was taken from the Demographic and Health Survey 2016 (DHS 2016) by USAID [5].
The independent variables were socio-demographic characteristics including region, age, sex, religion, occupation, and marital status. We also selected family planning variables including a family planning discussion with partner (spouse, friend, family, health professional, HEWs, religious leader, or community leader) and exposure to family planning messages.
The qualitative interview questionnaire had 9 themes and 29 questions. We used 7 themes: 1) Fertility Intention, 2) Knowledge, Perceptions & Beliefs about Contraceptive Methods, 3) Experience of Contraceptive Use, 4) Reasons for discontinuing the use of the method, 5) Reasons for non-use of contraceptive, 6) Reasons for Unwanted Pregnancy and Seeking Induced Abortion, and 7) Future Intention on Contraceptive Use and Enabling Factors.

Data analysis
The quantitative data were subjected to binary logistic regression analysis to identify the determinants of modern family planning methods across the three regions. This analysis was performed using SPSS Statistics 24.0.
The qualitative data were recorded using a digital recorder and audio data were transcribed and then translated into English, saved as an MS Word le, and exported into Atlas-ti software for coding and categorization. Every item of the qualitative dataset was translated, and appropriate codes related to the evaluation objectives were assigned. Similar codes were grouped under the same category and a thematic content analysis was conducted. The themes were categorized into three types of reason: knowledge, interruption, and religion.

Ethical approval
Ethical approval was obtained from the Research Ethics Committee of the School of Public Health and the Institutional Review Board of the College of Health Science, Addis Ababa University (No. 032/17/SHP). Moreover, we obtained a support letter from the Federal Ministry of Health, regional health bureaus, and the study districts' health o cers.
We obtained written informed consent from all participants for both the quantitative and qualitative surveys. We especially emphasized the respondents' right to refuse the interview. Couples were interviewed at the same time in separate places to avoid contaminating the data due to sensitive information being passed between spouses during the interviews.
Married respondents were 2.277 times more likely to use modern family planning methods than respondents who lived with a partner but were not married (AOR=2.277, 95% CI: [1.593-3.255, p<.001]. Household monthly income was not a signi cant factor in modern family planning methods. Respondents who discussed family planning with their spouse were 2.426 times more likely to use modern family planning methods than those who did not. Family planning discussions with HEWs (2.430 times) or a health professional (1.806 times) were signi cant factors in modern family planning methods.
Respondents who received family planning messages through the media were 1.210 times more likely to use modern family planning methods than those who did not (AOR=1.210, 95% CI: [1.043-1.404], p<.05).
( Table 2 Here) Qualitative analysis A total of 24 key informants participated in the study. Religious leaders, community leaders, HEWs, FP service providers, and heads of health centers assisted with the qualitative interviews of this study.
Some of the points that emerged from the qualitative interview respondents belonging to different religions are listed below. The results showed that family planning practices could be divided into three focal points: knowledge, interruption, and religion.
Knowledge Some informants reported that they were aware of the importance of family planning for the health of both the mother and the newborn child. However, they said that opposition from their husband, spouse, or family stopped them from putting family planning strategies into practice.
"Child-spacing bene ts both the mother's and child's health, but often husbands don't like their wives when they have few children, and as a result they often marry a second wife to get many children. But I believe that child-spacing is good; for example, children who are born spaced are physically stronger than those who are born in succession"[Somali, female, non-user] On the other hand, many respondents did not use family planning because of incomplete or incorrect knowledge. Some respondents reported that family planning practices would cause a physical disease (such as skin disease, back pain, etc.), illness, or decreased sexual feeling.
"… I am male, but I hear people saying once a woman uses this family planning, she will never give birth again as her reproductive organ will be closed. In cases where she lacks adequate food, the pills cause damage to her belly, skin discoloration ("madiat") on her face, etc. These are some of the doubts or fears in our community." [Oromia, male, nonuser] "… The drug results in weight gain and has a sensation of burning. It also makes the women aggressive and results in quarrels between husband and wife. It decreases love by reducing the sexual feelings of females; they also complain about pain during intercourse. I know many people who divorced because of this problem…"[Amhara, male, Orthodox religious leader] Interval in childbearing Some respondents stopped using family planning services because they faced problems like pain, disease, headaches, etc. The following quote is from an interview with a 30-year-old woman who used family planning for 7 years after the birth of her second child: "…After the second child, she again used an injectable for some time but stopped using it because she thought that it caused aggression, headaches, an internal burning sensation, and her menses did not ow…" [Amhara, female, orthodox] There were no answers from the Oromia and Somali regions on this topic.

Religion
Most respondents who did not practice family planning for religious reasons were Muslims. This is because the Muslim community considers family planning practices such as condoms, implants, UIDs, etc., as taboo under Sharia law. Therefore, Muslims have a low rate of practicing family planning. The following interviews were conducted with Muslims in the Amhara, Oromo, and Somali regions: "She aspires to have at least 10 children because she believes that having more children is more prestigious in the community and she will be respected more by her husband and his relatives. On the other hand, she believes that modern family planning methods are forbidden by Sharia and she has a plan to space her children using the calendar method and breast feeding, which are acceptable in Islam."[Somali, female, Muslim] "….God said multiply and replenish the earth…children are gifts from God…when every child is born, he/she comes with his/her own fate/luck…" [Amhara, female, Orthodox] "I believe that the only one who makes every decision of the household including family size and family planning use [is the man] since he is entitled under Sharia law." [Oromia, male, Muslim]

Discussion
In this study, the respondents' experience rate of modern family planning methods was 68.9% on average, with 75.7% in Amhara, followed by 65.0% in Oromia and 33.0% in Somali. The respondents discussed family planning with their spouses the most (87.5%), followed by friends (29.9%), health professionals (19.6%), HEWs (8.5%), religious leaders (2.4%), family (0.7%), and community leaders (0.7%). This concurs with the extant DHS data which found that people discussed family planning mostly with their spouses (72.8%) [5]. On the basis of region, family planning was discussed with spouses at the rate of 87.5% in Amhara, 88.9% in Oromia, and 54.0% in Somali region. According to DHS 2016, the rate in Amhara was 75.8%, 11.7% lower than in this study, and the rate in Oromia was 72.8%, or 16.1% lower than in this study. However, in Somali region (62.6%), the rate was 8.6% higher than in this study.
The quantitative analysis showed that the rate of usage of modern family planning methods was signi cantly different for each region in Ethiopia. The use of modern family planning methods in Oromia was 8.673 times higher compared to the Somali region (AOR=8.673, 95% CI: [5.160-14.583], p<.001) and Amhara was 5.183 times higher compared to the Somali region (AOR=5.183, 95% CI: [3.147-8.538], p<.001). These results were associated with Somali's total fertility rate of 7.2, twice that of Amhara (3.7) and more than 1.5 times that of Oromia (5.4) [11]. According to the quantitative and qualitative analyses, because 98.7% of the local residents in the Somali region followed Islam, and family planning (contraception) is prohibited under Sharia law, it is rarely used there. In particular, the use of condoms, implants, pills, and IUDs for family planning is prohibited, while only the calendar method and breastfeeding is permitted. In fact, the Quran clearly states, "Bring a lot of children for the prosperity of Islam" in the Quran, so there are limitations in implementing family planning policies for Muslims [12,13].
According to a study by Tigabu (2018) on religious views on contraception in western Ethiopia, there is a belief that if a female Ethiopian Muslim dies with an implant, a female contraceptive device, in her body, her soul cannot go to heaven.
On the other hand, there were some opinions that ran contrary to our qualitative ndings and the ndings of previous studies. One Muslim woman responded that family planning was necessary because she perceived that her children were born healthy because of family planning, which controlled the age gap of her children. This demonstrates that, even though women themselves recognize the need for family planning, they fail to implement it for religious reasons. There is a 3.4% level of use of family planning in Somali region, where 98.7% of the population is Muslim, while 79.0% of women are aware of the importance of family planning [5]. There are, thus, many women who cannot practice family planning (contraception) for religious and doctrinal reasons, despite their wishes. Traditionally, Muslim husbands have all the decision-making power. A previous study on the use of condoms in Ethiopia found that, because family planning in Muslim families was decided by the husband, women faced many limitations in using/practicing modern family planning methods on their own [15,16].
In this study, the proportion of women that decided on family planning after consultation with their husband was 54.0% in the Somali region, lower than in Amhara (87.5%) and Oromia (88.9%). Therefore, in the Somali region, it is important to educate religious leaders and heads of the family (e.g., husbands) about the importance of family planning (contraception) to increase the rate of family planning practice, thereby lowering the total fertility rate. In fact, after conducting educational sessions on family planning with Muslim religious leaders and men in three groups, it was found that their perceptions changed, which lowered the fertility rate and gestational disease rates [17,18].
In Ethiopia, family planning projects such as education for health professionals, HEWs, and religious leaders, media education, and the distribution of brochures are carried out by various organizations including international organizations and NGOs, research institutes, and civic groups [8, [19][20][21]. Among them, the Small, Happy, and Prosperous family in Ethiopia, conducted by the Korea International Cooperation Agency, was identi ed as the most effective intervention for delivering family planning educational messages through the media [22,23]. However, the Somali region has the lowest message exposure (radio: 4.8%, TV: 6.6%), so there are limitations in delivering family planning education content through the media [5]. Therefore, family planning education in the Somali region should involve 1) supplying equipment to send messages (to improve message exposure), and 2) providing direct education to religious leaders, husbands, and medical professionals. The details are as follows: First, providing equipment (radios, TVs) to listen to messages will help improve message exposure in the Somali region and increase the effectiveness of education delivered through the media. In this study, the number of people with experiences of receiving family planning messages through the media (exposure experience) was 1.12 times higher (AOR=1.120, 95% CI: [1.043-1.404], p<.05) than the number of people with no experience of using family planning services. In particular, the transmission of messages has proved to be an effective and widely used intervention in previous studies [23,24].
Second, education to increase awareness of family planning is necessary for family decision-makers and certain in uential groups such as husbands, health professionals, and HEWs. In this study, the use of modern family planning methods depended on with whom these discussions were held. Those that discussed whether to use modern family planning methods with HEWs, which had the highest in uence, were 2.430 times (AOR=2.430, 95% CI: [1.698-3.476], p<.001) more likely to use the services compared to those that did not, and this result was statistically signi cant. This is because Ethiopian females were worried about getting scolded by their husbands. They therefore relied on, and consulted the most with, HEWs who were of the same gender and not a family member [25]. The second most in uential group to discuss using modern family planning methods were spouses; the use of modern family planning methods after a discussion with a spouse increased by 2.426 times (AOR=2.426, 95% CI: [1.968-2.990], p<.0001) as compared to the absence of a discussion. The third most in uential group was health professionals, where the use of family planning services was 1.448 times higher (AOR=1.488, 95% CI: [1.185-1.869], p<.001) after a discussion with them.
On the other hand, discussions with friends, religious leaders, and community leaders were not signi cantly related to the use of modern family planning methods. Usage of these services increased when consulting with a decision-maker or in uential health professional, but in some cases, false information prevented people from using them. According to the interviews in the qualitative survey, a male respondent heard from his neighbors that using modern family planning methods would block the female reproductive system and prevent his wife from future childbirth and he cited this as the reason for not using it. This shows that incorrect knowledge among major decision-makers such as husbands can act as a barrier to family planning.
One limitation of this study were the discrepancies in the responses to the qualitative and quantitative surveys. The respondents of the qualitative survey were interviewed regardless of whether they had participated in the quantitative survey. To minimize errors in the quantitative and qualitative analytical results, there needs to be consistency in the respondents [26]. However, since we could not conduct corresponding qualitative surveys for all 4,117 respondents of the quantitative survey, the qualitative respondents were selected via conditional extraction. Moreover, the Somali region sample had only 98 respondents, because Muslim women avoided talking with outsiders and did not want to participate in the survey as it was about family planning. In future studies, it is necessary to minimize the errors in the analysis by equalizing the respondents in the qualitative and quantitative surveys.
Moreover, this study was conducted in three out of nine regions of Ethiopia: Amhara, Oromia, and Somali. In future studies, it is necessary to minimize errors by conducting surveys in all nine regions.

Conclusion
This study aimed to identify the determinants of the use of modern family planning methods in Ethiopia, and a mixed method approach using both quantitative and qualitative surveys was designed. This study was conducted in the three largest regions of Ethiopia: Amhara, Oromia, and Somali regions.
Compared to the Somali region, the use of modern family planning methods was signi cantly higher in the Amhara region (5.183 times higher) and the Oromia region (8.673 times higher). The reason, con rmed through the qualitative research, was that 98.7% of those in the Somali region were Muslims and there were limits in using modern family planning methods due to the absolute right of husbands to decide on family planning, the prevailing religious doctrine, and a lack of knowledge. In particular, although the results showed that people were aware of the importance of family planning, for religious reasons it was not possible to use it.
In addition, the use of modern family planning methods differed signi cantly depending on the person consulted. When participants consulted with their husband on whether to use modern family planning methods, usage increased by 2.426 times (a signi cant difference) compared to those that did not. When they consulted with a religious leader, usage increased by 1.806 times (not statistically signi cant). In addition, those that listened to a family planning message through the media had an increased usage of modern family planning methods by 1.210 times (a signi cant difference).
Thus, it is necessary for Ethiopia to establish a family strategy in consideration of the cultural and social characteristics of each region. In particular, the Somali region needs to educate husbands and religious leaders about the importance of family planning. Since there exists a shortage of media equipment, supplying media equipment or organizing a common radio/TV spot is necessary to enable their access to family planning messages.