Individual and community level factors associated with unmet need for contraception among married reproductive age women in Ethiopia. A multilevel analysis using 2016 Ethiopian Demographic and Health Survey

Background: There is limited evidence on unmet need to contraceptive among married reproductive age women especially in developing countries like Ethiopia. Thus, this study aimed to assess individual and community level factors associated with unmet need for contraception among married women of reproductive age in Ethiopia, EDHS 2016 dataset, 2019. Method: A secondary analysis was done on Ethiopian Demographic and Health Survey (2016) dataset by using cross sectional study design. A total of 9125 women who were married, fecund and/or sexually active were included in the analysis. Multilevel mixed-effect logistic regression analysis was done by STATA version 14.0 to identify individual and community level factors. Adjusted odds ratio with 95% confidence interval was used to show the strength and direction of association and statistical significance was declared at P value less than 0.05. Result: Factors significantly associated with unmet need were; ages between 15-19 years [AOR=2.25, 95% CI: (1.34, 3.79)], greater than or equal to three living children [AOR=1.87, 95 % CI: (1.40, 2.49)], belong to richer household [AOR=0.73, 95% CI: (0.54, 0.97)], Muslim followers [AOR=1.37, 95% CI: (1.02, 1.83)], married more than once [AOR=1.31, 95 % CI: (1.06, 1.62)]. From community level variables, belong to Somali region [AOR=0.34, 95% CI: (0.19, 0.61)] were significantly associated with unmet need. Conclusion: Both individual and community-level factors were significant determinants of unmet need. From individual level factors; ages of women, number of living children, religion, married more than once and wealth of house hold and from community level variables; region was significantly associated with unmet need for contraception. The findings suggested that health care providers should mainly focus on women nearly on menopauses, who live in the poorest household and who had many number of living children and married more than once to decrease unmet need to contraceptive.


Introduction
Unmet need for family planning (FP) is the number or percentage of married women who want to postpone their next birth for two or more years or stop child bearing but are not using a contraceptive method. Pregnant or amenorrheic women are also considered to have unmet need if their pregnancy was mistimed or [1,2]. Total unmet need is the sum of unmet need for spacing and unmet need for 3 limiting [3].
Even though FP was greatly emphasized in different strategies of maternal health, its utilization is still below what is expected and many women had unmet need to it. Globally, about 222 million couples want to stop or delay childbearing, but they are not using family planning [4]. It would range up to 84 million in Asia [5] and 200 million in developing countries [6,7]. According to Ethiopian and Demographic Heath Survey (EDHS) result, it was 25.3% and 22 % in 2011 and 2016 respectively [8,9].
World Health Organization (WHO) estimated that maternal death could be reduced to one third if the unmet need of FP was satisfied [10]. FP service reduces unsafe abortion and the number of women who need medical care as a result of unsafe abortion from 5.2 million to 1.2 million and from 2.2 million to 500,000 respectively [4,11]. Ethiopian estimate from 2005 to 2015 also showed that 24 million pregnancies were unintended. By meeting this unmet need in Ethiopia, there would be almost 6 million fewer unintended pregnancies, which lead to 2 million fewer abortions. In addition to that more than 1 million under five mortality could be averted and nearly 13, 000 maternal deaths would be decreased over ten years period [11]. Evidence from study also showed that there was elevated risk of under-five death for children born from mothers who had unmet need [12].
Unmet need for contraception were determined by socio-demographic characteristics of mothers [13][14][15][16], husband factors [17][18][19], Household factor [20] and community factor [21][22][23]. Unmet need for family planning is an important concept that is largely used for reproductive health advocacy, designing family planning policies and the monitoring/evaluation of implemented programs especially Sustainable Developmental Goals (SDGs) and Growth and Transformation Plan two (GTPІІ).
Even though unmet need for FP was addressed in previous studies, most of them were taking on individual level analysis by omitting cluster effect. In individual level analysis the independent assumption among clustered individuals may not work and the association at the individual level may not work at cluster level and vice versa. So, all of this articles are subject to atomistic or Ecological fallacy. It is clear that the factors associated with unmet need to FP are area specific which requires different approach of analysis at different level. So, this study took in account those different levels of 4 analysis and aimed to assess individual and community level factors associated with unmet need for contraception among married women of reproductive age in Ethiopia, EDHS 2016 dataset, 2019.

Study area and data source
The study was conducted in Ethiopia, which is located in the North Eastern part of Africa, also known as the horn of Africa, lies between 3 0 and 15 0 North latitude and 33 0 and 48 0 East longitudes. This study used the EDHS 2016 dataset which were conducted by Central Statistical Agency (CSA) in collaboration with the Federal Ministry of Health (FMoH) and the Ethiopian Public Health Institute (EPHI). Data were accessed from their URL: www.dhsprogram.com by contacting them through personal account after justifying the reason for requesting it. Then reviewing the account permission was given via the email. A cross-sectional study design using secondary data from 2016 EDHS was conducted. All reproductive age women who were married, fecund and or sexually active were included in the study and those women who were sexually active 30 days prior to the survey were excluded.

Sample size determination and sampling procedure
A total of 9,125 weighted reproductive age women who were married, fecund and/or sexually active were included (Figure1).
The 2016 EDHS sample was stratified and selected in two stages. In the first stage, stratification was conducted by region and then in each region stratified as urban and rural, yielding 21 sampling strata. A total of 645 EAs (Enumeration Areas) (202 in urban areas and 443 in rural areas) were selected with probability proportional to EA size in each sampling stratum. In the second stage, a fixed number of 28 households per cluster were selected with an equal probability systematic selection from the newly created household listing.

Variable measurement
The outcome variable for this study is dichotomized as unmet need (yes/no) which was generated from a constructed EDHS variable. It is the sum of unmet need for spacing and limiting and reproductive age women who were married, fecund and/or sexually active have unmet need if they don't want any more children or want to delay their next birth for at least two years but not using contraception. Pregnant or amenorrheic women with unwanted or mistimed pregnancies or births were also considered to have unmet if they were not using contraception at the time they conceived [15,17,24].

Data processing and analysis
Data cleaning was conducted to check for consistency and missing value. Recoding, labeling and exploratory analysis was performed by using Stata/SE version 14.0. Descriptive statistics was used to present frequencies, with percentages in tables, graphs and using texts. Sample weight was used in order to compensate for the unequal probability of selection between the strata that were geographically defined, as well as for non-responses.
Multilevel analysis was conducted after checking that the data was eligible for multilevel analysis that means Intra-cluster Correlation Coefficient (ICC) greater than 10% (ICC=12.74%). Since DHS data are hierarchical, i.e. individuals (level 1) were nested with in communities (level 2), two-level mixedeffects logistic regression model was fitted to estimate both independent (fixed) effects of the explanatory variables and community-level random effects on unmet need for family planning. The log of the probability of unmet need for family planning was modeled using two-level multilevel model as follows: Where, i and j are the level 1 (individual) and level 2 (community) units, respectively; X and Z refer to individual and community-level variables, respectively; πij is the probability of unmet need for family planning for the i th women in the j th community; the β's indicates the fixed coefficients. Whereas, β0 is the intercept-the effect on the probability of unmet need for family planning in the absence of influence of predictors; and uj showed the random effect (effect of the community on unmet need for family planning for the j th community and eij showed random errors at the individual levels. By assuming each community had different intercept (β0) and fixed coefficient (β), the clustered data nature and the within and between community variations will be taken in to account. 6 During analysis first bivariable multilevel logistic regression was fitted and variables with p-value less than 0.2 were selected to build the 3 models (model1-3).Then the analysis was performed in four

Socio-demographic characteristics of respondents
The total numbers of married and/or sexually active fecund women included for the analysis were 8710 when it is weighted 9125. Out of which, 4684 (51.33%) women were age less than 30 years.
Five thousand three hundred sixty four 5364(58.80) women were not educated at all. Coming to place of residence, 7614(83.43) women were rural dwellers and 3,782(41.44) women were Orthodox followers (Table1).

(Fixed Effects)
After adjusting for individual and community level factors (model 3) age of women, number of living children, wealth of house hold, religion, married more than once and region were found to have a statistically significant association with unmet need for contraception.
Those women whose ages between 45-49 years were 2.3 times more likely to have unmet need for contraception than those ages between 15

Random effect (measure of variation)
The results of multilevel logistic regression for random effects showed that, there was a significant variation in the utilization of PNC across the clusters (Table3). The Intra-cluster correlation coefficients showed that 12.74% of the variation in unmet need for contraceptive was related to community-level factors. The full model also showed that, there is statistically significant variation in unmet need to contraceptive across communities or clusters. About 33.33% of unmet need to contraceptive in clusters was explained in the full model. In addition, the MOR confirmed that unmet need to contraceptive was attributed to community level factors. The MOR for unmet need for contraceptive 8 1.79 in the empty model: These indicates that there was variation between communities (clustering) since MOR was 1.79 times higher than the reference (MOR = 1). The unexplained community variation in unmet need for contraceptive decreased to MOR of 1.46 when all factors were added to the model. This shows that when all factors are considered, the effects of clustering are still statistically significant in the full models.

Discussion
As described in model 3 ages of women, number of living children, wealth of house hold, religion, married more than once and region were statistically significant with unmet need (Table2). In this study age between 45-49 years was positively associated with unmet need for contraceptive. The finding of this study is in line with previous studies conducted in Enemay district and Southern nations, nationality and peoples Region, Ethiopia [14,24,25]. It is also consistent with a study conducted in Kenya, Nigeria and Saudi Arabia [15,26,27]. The possible reason for this association may be due to that women near to menopause may perceive as low risk to pregnancy.
But, unmet need for contraception was negatively associated with living number of children. This finding is similar with previous studies conducted Oromia and Southern nations, nationality and peoples Region, Ethiopia [14,23]. It is also similar with different studies conducted in African countries [15,[28][29][30]. Again it is in line with a study conducted in India [17,21]. The possible reason for this may be due to that, as the number of living children increase their interest to have further children decrease.
Similarly wealth also has negative relationship with unmet need for contraception. The finding is in line with a study conducted in Ethiopia [24]. This is consistent with Nigeria, Kenya [20, 31, 32] Bengal, Iran and Indonesia [13,33,34].This may be due to wealth may increase their health seeking behavior and may increase exposure too. Women who were Muslim are more likely to have unmet need to contraceptive than orthodox followers. But, the finding of this study is contrary to the finding of a study conducted in Nigeria which says Muslims had less likely to have unmet need [27]. This difference might be due to that the context of Ethiopia and Nigeria is totally different.
The other findings tell us as they undergone marriage more than once; they would have high 9 probability of unmet need to contraceptive. The finding is in line with a study conducted in Burkina Faso [29]. This might be due to that if they are married more than once, their husband may not understand them and the women may not have decision to control fertility. The only significant community level variable is region. This is also similar with previous studies conducted in Ghana and Nigeria [27,31,35,36]. Since this study takes secondary data, small numbers of community level variables were included in the analysis that could be potential determinant factors for unmet need for contraception.

Ethical approval and consent to participate
Ethical approval was obtained from the Ethical Review Committee of Wollo University, College of Medicine and Health Sciences with approval and supporting letter. Authorization letter of permission for downloading 2016 EDHS dataset was obtained from CSA of Ethiopia, by requesting with the website www.measuredhs.com. The data was used only for purpose of this study. It was not passed to other researchers without consent of DHS. All data was treated as confidential and no need to identify any household or individual respondent interviewed in the survey.

Consent for publication: Not applicable.
Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests:
The authors declare that they have no competing interests.  Others*= who didn't know and it was also recorded as others in EDHS dataset, Others**= Catholic and traditional. *=significant at 5%, SNNP= Southern nation, nationalities and peoples, Others*= who didn't know and it was also recorded as others in EDHS dataset and Others**= Catholic and traditional  Figure 1 Total number of reproductive age women who were married, fecund and/or sexually active (sample size) included for analysis in 2016 EDHS, 2019.