Family planning is a process that usually involves a discussion between a woman, a man, and a trained family planning service provider focusing on family health and desires of the couple to either limit or enlarge their family (1). There are different family planning methods grouped into two categories. These are long-acting and permanent methods (i.e., the use of intrauterine devices, implants, and sterilization), as well as short-term methods (i.e., use of pills, condoms, spermicide, injection, other modern methods, and all traditional techniques) (2).
Providing family planning services is an important strategy for the reduction of maternal morbidity and mortality. Results of multicountry studies showed that accessing family planning can decrease mortality rates among women by 40% (3, 4) and prevent from two million newborn and child mortalities (5). Main causes of maternal mortality are hemorrhage, hypertension disorders, obstructed labor, infection, and unsafe abortion (6, 7). Family planning interventions have helped to achieve the Millennium Development Goals and are expected to help achieve the newly established Sustainable Development Goals (1).
Long-acting reversible contraceptives (LARC) is a family planning method that prevents from a higher number of pregnancies (i.e., unintended pregnancy), compared to short-acting contraceptives. The LARC include the use of the intrauterine contraceptive device (IUCD) and implants (8). The LARC prevent from unwanted pregnancies at least for 3 years (i.e., the use of implants) and for 12 years (i.e., copper IUCD). This method of contraception is immediately reversible after removal (8, 9) and the most effective modern contraceptive method for preventing unintended pregnancy. The LARC are long-acting, reliable, safe, cost-effective, and have additional non-contraceptive benefits for a broad range of women seeking enlarging or limiting methods of contraception. The LARC do not depend on users' adherence and are suitable for women with medical disorders. Specifically, in clinical trials, IUCD and implants were reported with failure rates within the ranges of 0.6-1.0% and 0.05%, respectively (10).
Although the use of contraceptives has witnessed a significant increase since the 1970s (11), the prevalence of LARC methods has remained very low, particularly in low-income countries (11, 12). Globally, the prevalence rate of LARC method is approximately 14.4% different from region to region, namely 17.8% in Asia, 11.5% in Europe, 6.1% in Africa, 6.9% in Latin America and the Caribbean, 5.6% in North America, and 3.5% in Sub-Saharan Africa (12). Results of studies revealed that the prevalence rate of LARC in different regions of Ethiopia is within the range of 13.1-38% (13-19).
A number of previous studies have attempted to identify factors associated with modern contraceptive use in different countries. These associated factors have been examined in several settings in developing countries. Recognized associated socio-demographic factors include high the level of maternal education (18, 20–23), high living standards (23) and low living standards (24), maternal age 20 (23) and ≥ 35 years (23, 25), and high level of paternal education (20).
Findings of a study conducted in Dembi revealed that LARC utilization increased among mothers who were government employees (26). In contrast, the results of a study performed in the Gambia indicated the relation between being housewives and LARC utilization (22). In other studies conducted in Arba Minch, Mekelle City, and Goba, the factors such as supportive attitude, high level of knowledge, and media exposure, were also associated with LARC utilization (13, 14, 27).
Government of Ethiopia has developed different strategies in this regard. The strategies include the training of health extension workers, counseling on the IUCD and implant insertion, organizing a health development army to discuss health issues and act accordingly, giving exemption in services for family planning, and training of health workers in LARC to increase the prevalence of LARC use. However, in Ethiopia similar to many other African countries, LARC utilization is still very low (10% in the whole country and 1.8% in the Afar region) (28).
According to the evidence, no study has been conducted up to now to recognize the prevalence of LARC use and associated factors in the Afar region in Ethiopia (i.e., a pastoral community). Therefore, this study aimed to assess the prevalence and associated factors of LARC among the family planning users in the public health facilities of the Afar region.
Materials and Methods
This facility-based cross-sectional study was carried out at public health facilities in the Afar region during December 15 to February 15 in 2018. The samples were family planning users randomly selected from the health facilities of the Afar region during the study period. The inclusion criteria were all family planning users in the health facilities of the Afar region during the study period. On the other hand, family planning users who could not communicate were excluded from the study.
The single population proportion formula was used to determine the sample size with several assumptions, including the proportion of LARC taken from a study conducted in Debremarkose as 13.1% (13), with a 95% confidence interval (CI), margin error of 3%, and 10% nonresponse rate. Finally, the sample size was obtained at 535 for the present study using the systematic sampling technique. Firstly, all hospitals and seven health centers were randomly selected. By considering the average number of family planning users who performed family planning programs daily during the data collection period, estimated based on a previous day, the client flow to the units was obtained by referring to the family planning registration centers for 6 months prior to data collection.
Probability to proportional size allocation technique was utilized for determining the number of respondents in each health facility. The first subject from each health center was randomly selected. Then, the subsequent respondents were chosen from every eight clients until the final sample size was obtained. Eleven respondents were refused to participate in this study among whom the response rate was 98%.
Data collection was carried out using a pretested structured interviewer-administered questionnaire. The research instrument was developed based on the instruments applied in other related studies (13-22). The questionnaire was structured into five parts, namely sociodemographics, reproductive history, source of information, as well as knowledge and attitude toward LARC use.
Knowledge level of the participants was measured regarding the benefits and contraindications of using LARC for mothers through six items. Content validity was used for evaluating the validity of the questionnaire. The reliability test was conducted in terms of the knowledge and attitude items, and after performing the pretest, the Cronbach’s alpha coefficients were obtained at 0.86 and 0.78, respectively. In addition, ten nurses with diplomas and two with a bachelor’s degree were hired for the data collection and supervision.
To ensure the quality of data gathered from the study subjects, the questionnaire was firstly translated to the local language and then translated back to English by experts to check its consistency. The questionnaire was pretested on 5% of the calculated sample size before the actual data collection period in comparable settings. Moreover, data collectors and supervisors were trained in this regard. Furthermore, the supervisors and the principal investigators checked the filled questionnaires at the end of data collection every day for completeness. The data were carefully entered and cleaned before the beginning of the analysis.
The data were entered into EpiData software (version 3.1) and analyzed using SPPS software (version 21.0). Descriptive statistics, frequency, and proportions were computed to summarize the data. Logistic regression analyses were conducted to identify the factors associated with the outcome variable. Initially, bivariate logistic regression analysis was performed on all the independent variables. Multivariable logistic regression was then carried out on the variables with a P-value less than 0.25 in bivariate logistic regression analysis. Degree of association between the independent and dependent variables was assessed using odds ratio with 95% CI. In conclusion, P-value less than 0.05 was considered statistically significant in the multivariable model.
Long-acting reversible contraceptives utilization: Use of LARC among the mothers who were using either IUCD or implants during data collection period and dichotomized considered a binary outcome variable (i.e., used) or absent (i.e., not used). Knowledge toward LARCwas measured using six items, with a minimum score of 0 and maximum score of 6. The knowledge toward LARC was estimated based on the percentage of the knowledge scores of respondents. A score was considered “high” if a woman answered 80% of the knowledge questions and above correctly, “moderate” if a woman answered 60-79% of the knowledge questions, and “low” if a woman answered less than 60% of the knowledge questions correctly (13, 18). Attitudes toward LARC were measured using a 3-point Likert scale. There were six items assessing the attitudes of women. Order of scoring for positive statements included agree: 3, neutral: 2, disagree: 1, and vice versa for negative statements. The total mean score was obtained and computed to be categorized into positive and negative attitudes. A score ≥ mean value was considered a positive attitude; however, a score mean value was regarded a negative attitude (14).
The ethical clearance letter was obtained from the Vice-chancellor of Research and Community Services in Samara University in Samara, Ethiopia (RERC 0145/2018 (10.06.2018). Moreover, the permission/cooperation letter was obtained from the afar regional Health Bureau and Health Office of each district. Finally, verbal informed consent was obtained from each participant, included in the study during the data collection time, after explaining the objectives of the study to them. The subjects were informed about the purposes, procedures, potential risks, and benefits of the study. Furthermore, confidentiality terms were maintained through not asking personal identifiers, such as name and address.
Approximately, 50% of the women were aged between 25-34 years, and the age range was between 17-40 years with a mean (±SD) score of 26.71(±5.4) years. Majority (n=364; 69.3%) of the participants were housewives. In addition, 213 (40.6%) women had Afar ethnics, and 308 (58.9%) subjects were Muslims. Regarding their educational level, 56 (10.7%) cases were reported with higher educational levels, and 87 (16.6%) respondents' husbands attained higher educational levels (Table 1).
Furthermore, among 524 study participants, 429 (81.9%) women were multigravida among whom 99 (18.9%) women were grand multiparous, and 101 subjects (14.5%) had more than four living children. In this study, one-seventh (13.5%) of the participants experienced abortion. Moreover, the majority of women (n=442; 84.4%) had a functional radio. In addition, 497 (94.8) women heard about LARC, and 16(3.1%) cases used modern contraceptives. A total of 350 (66.7%) subjects reported discussing LARC with their husbands.
With regard to the utilization duration of contraceptives, 182 (35%) women had used it for more than 3 years.In this study, the overall prevalence rate of LARC use was observed to be 33.4% (Table 2).
Regarding misconceptions toward LARC, 258 (49%) women believed that family planning methods cause cancer, and 224 (42.7%) subjects believed that they were forbidden to use contraceptives according to religion. In addition, three-fourth of the family planning method users believed that the decision should be made by their husbands to use LARC.
Knowledge of respondents about long-acting reversible contraceptives
Regarding the knowledge of respondents about LARC, 33.3% of the participants indicated IUCD is not appropriate for females at high risk of getting sexually transmitted infections. Furthermore, 81.9% of the subjects expressed that the use of implant prevents from pregnancy up to 5 years, and 65.1% of the participants stated the IUCD has no interference with sexual intercourse or desire.
In addition, 65.8% of the participants said that LARC is immediately reversible (they become pregnant soon after the removal), and 72.7% of the women told that IUCD can prevent from pregnancies for more than 10 years. In this study, 51.7% of the subjects stated that the insertion and removal of implants need minor surgical procedures. Considering the knowledge level of the participants, 29.4% and 40.6% of the women had high and low levels of knowledge toward LARC, respectively (Table 3).
Attitudes of women toward long-acting reversible contraceptives
Concerning the attitude of the women toward LARC, 33.3% of the participants agreed that LARC use restricts normal daily activities, and 36.6% of them agreed that the insertion of IUCD is shameful and their privacy will not be preserved. Moreover, 32.4% of the subjects approved that using implants or IUCD store blood in abdomen and causes cancer, and 48.5% of them agreed that good nutrition is required for the utilization of LARC. Furthermore, 51.5% of the participants accepted that using implants causes heavy irregular monthly hemorrhage, and 42.6% of them agreed that the insertion and removal of IUCD are highly painful. According to the results of the present study, 46% of the studied women had a negative attitude toward LARC use (Table 4).
Associated factors with long-acting reversible contraceptives utilization
In multiple logistic regression analysis, maternal age (≥35), level of knowledge and attitude toward LARC utilization, and discussion about LARC with husbands were observed to be the contributing factors toward the adoption of LARC use. The subjects aged were 70% less likely to opt for LARC in comparison to women within the age range of 20-34 years (AOR=0.3; 95% CI: 0.2-0.7). Similarly, cases who discussed LARC with their husbands were twice or more likely to utilize LARC than their counterparts (AOR=2.4; 95% CI: 1.5-3.8). Moreover, the likelihood of utilizing LARC increased in mothers whose knowledge scores were higher. In this regard, women whose levels of knowledge were nearly three times higher were observed to be more likely to utilize LARC, compared to those with a lower knowledge score (AOR=2.7; 95% Cl: 1.7-4.4). In addition, the participants with a positive attitude were nearly twice more likely to utilize LARC, compared to their equivalents (AOR=1.8; 95% CI: 1.2-2.3) (Table 5).
The present study was carried out to assess the prevalence and associated factors that contribute to LARC use among women as an extended-term contraceptive method. In this study, the prevalence rate of LARC was observed to be 33.4%. Prevalence of LARC utilization in the present study is relatively similar to that reported in facilities-based studies conducted in Addis Ababa and Gondor, Ethiopia, as 34% and 33.7%, respectively (16, 28). However, a higher prevalence of LARC utilization was observed in the present this study, compared to those of other studies in Arba Minch town, Mekelle Town, Deberbrhan, and Bati, Ethiopia, as 13.1%, 16.6%, 19.5%, and 29%, respectively (13-15, 17).
The above-mentioned finding might also be due to the study time, study setting, and study design of the present study. In contrast, in the present study, a lower prevalence of LARC was observed, compared to that in a study performed in Harar, Ethiopia, which was 38% (29). This difference may be explained by the variations in study setting and due to various interventions performed between these study areas.
According to the results of the present study, the rate of LARC utilization was lower, compared to those in other countries, such as Nigeria, Gambia, Chad, and Democratic of Congo, reported as 44.7%, 38%, 89%, and 74%, respectively (22, 29, 30). This finding might be due to social, economic, and cultural differences. In addition, in case of Chad and the Democratic Republic of Congo, the project called Supporting Access to Family Planning and Postabortion Care was conducted during 2012 to 2015 with the main strategies of providing competency-based training with follow-up clinical assessment and coaching. Performing this project ensured a continuous supply and facility supervision on a regular basis in partnership with district and zonal health management staff.
As revealed by the results of the present study, the women who had high level of knowledge about LARC were reported with a high odds ratio of LARC use. This finding is again supported in studies conducted in Arba Minch, Mekelle, Goba and Uganda revealing that those women who had high levels of knowledge about LARC were more likely to utilize LARC than those with low levels of knowledge in this regard (13, 14, 27, 31). This might be due to the fact that the more the mother identifies the side effects and benefits of the methods the more they use the methods.
In addition, women who have good knowledge about LARC are more likely to face the risks and benefits of using LARC and make sound decisions. The present study also identified positive attitudes toward LARC as a factor effective in LARC utilization. This finding is comparable with the results of studies conducted in Mekelle, Uganda, and Goba reporting a similar positive association between positive attitude toward LARC and LARC utilization (14, 25, 27). This finding was almost observed to be a universal fact indicating that as the supportive attitude increases the use of LARC increases.
Finding of the present study revealed that those women who had good discussion with their husbands about contraceptive methods were more likely to utilize LARC method, compared to the mothers who had no discussion with their husbands. This finding is parallel to those of studies conducted in Butajira (32) and in Debre Markos (20) indicating that those women who had no discussion about LARC with their husbands or partners or discussed it once or twice had less demand for it than those who discussed it more thoroughly.
In this study, the women aged were 70% less probable to utilize LARC in comparison to those within the age range of 20-34 years. Findings of the present study are similar to those of studies conducted in Zimbabwe, Uganda, and Northern Nigeria (23, 25, 29). This result may be related to those mothers who had already attained their plan of family size and wanted to use LARC up to reaching menopause. Therefore, it is not unexpected that women desiring to have more children were less likely to use LARC. Results of the present study will help policy-makers, program designers, and nongovernmental organizations to support the study area. Furthermore, the findings of the present study can also help as secondary data to carry out further studies in a similar area of inquiry.
Study participants were selected using the probability sampling method to ensure the representativeness of the study, and different approaches were used to maintain the quality of data.Limitation of this study included a health facility in scope that might not represent mothers who did not come to health facilities. Moreover, this study was not supported using a qualitative method; therefore, it was not possible to demonstrate detailed reasons from different perspectives for not utilizing LARC. In addition, classification bias may be introduced when changing attitude scales from a 5- to 3-point Likert scale.
Prevalence of LARC utilization was low in the study area. The obtained findings indicated that the knowledge and attitude of the women, discussion with their husbands about planning, and maternal age were the factors associated with the use of LARC. In general, the similarity of the results to those of previous studies may show the ineffectiveness of surviving national programs in improving the prevalence of LARC. Factors of LARC utilization suggested that strengthening maternal knowledge, creating positive attitude, and encouraging discussion with husbands about LARC are important in increasing the use of LARC. Findings of this study indicated all concerning bodies to focus attention on raising the prevalence of LARC use and collaboration of regional health bureau with different stakeholders, such as Samara University and non- governmental organization.
The authors extend their gratitude to Samara University, health facility authorities, supervisors, data collectors, and respondents who participated in this study.
Conflicts of interest
Authors declared no conflicts of interest.