Reproductive health in its broader sense should be a concern for all but it is not for just that of women. Until today most researchers focused on women as the target group and paid little attention to the role that men might have with respect to reproductive health decision-making and behavior [1].

In order to curb the harmful effects of population growth, many developing countries are imparting different Information, Education and Communication (IEC) about family planning programs and for services provision [2].

One of the most important choices a woman or couple can make is the decision to use contraception. Even if a couple wants a child as soon as possible after marriage, the use of contraception thereafter: for child "spacing" is a sensible decision. For couples, use of contraception also contributes to a more satisfying sexual relationship by reducing the fear of unwanted pregnancy [3,4].

Ethiopia is the second most populous country in Africa, with a total population of almost 77.2 million and an annual population growth rate of 2.7 percent. In fact, the total fertility rate declined from 1990 to 2000 with substantial variations among regions; rural-urban discrepancy remains unanswered (i.e. 6 to 1.4 children on average). Overall, fertility is highest in Ethiopia’s rural regions and least-educated families [1,5,6].

Family planning services in Ethiopia was started in 1966 by the family guidance association of Ethiopia. In 1975, the Ethiopian government started integrating family planning with maternal and child health services. Despite the efforts to implement family planning by the Ethiopian government, the results obtained and the goal desired remain unachieved as evidenced by very low contraceptive usage (8%) [3,4].

The new report, "Benefits of Meeting the Contraceptive Needs of Ethiopian Women," released today by the Guttmacher Institute and the Ethiopian Society of Obstetricians and Gynecologists (ESOG), documents the considerable financial and health benefits that would accrue from increased investment in contraceptive services. The gap between wanted and actual fertility is particularly large among poor women, who have especially limited access to contraceptive services [7].

However, there is no study conducted so far to assess husband-wife communication about contraceptive use in this particular woreda. Therefore, the study intends to pinpoint any possibilities of husband-wife communications in the study area for at least three reasons:

1) For the theoretical understanding of whether wife only or her husband affects her fertility decision.

2) Furthermore, the findings of this study will enable for local planners, policy-makers and any other concerned bodies will go through promoting deliberate decision making by couples regarding when and how long to use contraception.

Study setting and period

Angecha woreda is found in Kembata Tembaro zone, South Ethiopia. The woreda has a total population of about 88,060 and the total house hold of 20,147 (2007) and almost all are engaged in agriculture. It is located 132 km far away from regional city Hawassa and 256 km far away from central city Addis Ababa. The woreda comprises a total of 19 kebeles, 17 rural and 2 urban kebeles.

Study design and population

Community based cross sectional study was conducted using both quantitative and qualitative data collection methods. The source populations were all the couples residing in the woreda. The study populations were sample of couples taken from the source population.

Sample size and sampling procedure

The required sample size was determined using single population proportion formula by considering 77.5% proportion of spouses who approve contraception use (both the male and female method), margin of error 5%, a 5% level of significance (two sided) i.e. 95% confidence interval of certainty by considering the design effect of the sampling technique and 10% non-response rate. Based on the above assumptions, the final sample size are approximately 590 couples living in the study area. A stratified multistage sampling technique was used to select the households, as shown below (Figure 1). For qualitative data in-depth interviews were conducted by employing purposive sampling method from 13 key-informants (8 HEWs from each selected kebeles, community leaders (1), and religious leaders (4) (1 from Orthodox, 1 from Muslim, 1 from Catholic and 1 from Protestants).

Figure 1: The sampling procedure on husband-wife communication and practice of contraceptives in Angecha Woreda, Kembata Tembaro Zone, South Ethiopia, March 2012.

Measurement and variable

As independent variables:Socio-economic and cultural factors such as- educational status, religion, ethnicity, place of residence, occupational status, spousal knowledge of contraception, spousal attitude towards contraception. Demographic factors such as- age, age at marriage, duration of marriage, spousal need to have more children, marital union and spousal communication, family structure and spousal communication, number of living children, husband-wife communication about contraceptive use, Information, Education and Communication (IEC).

As dependent variables:Husband-wife communication about contraceptive use and practice of contraceptives. Practice of contraceptives- refers to the current contraceptive behavior of couples so that they were using the method of their choice (modern or traditional, male and female methods) at the time of the survey/study. Husband-wife communication about practice of contraceptives- refers to the discussion between husband and wife on different contraceptive methods (both male and female methods, whether modern or traditional methods) to use at least six months before the survey/ in the previous year. Age of husband and wife at marriage- refers to the age at which the husband and wife were married to each other at the time of the survey. Duration of marriage- refers to the number of months or years both a husband and a wife have been sustained with their current marriage at the time of the survey. Family structure of husband and wife- staying in an extended family or a nuclear family i.e. households having at least two adults (husband and wife) is taken as a nuclear family whereas households with three or more than three adults is taken as extended family at the time of the survey. Marital union of husband and wife- this refers to the type of marital union practiced by the couples, which may be either monogamous or polygamous at the time of the survey. Couple’s need to have more children- refers to differences in spousal need for an additional number of children they want to have at the time of the study. Number of living children- refers to the number of children living with parents and lives elsewhere at the time of interview/survey. Knowledge about contraceptive methods- refers to couple’s knowledge of different contraceptive methods, which is based on compulsory knowledge question. Couple’s attitude towards contraceptive use- refers to couple’s agreement/disagreement with the use of contraceptives and based on a ten-item Likert-type scale, respondent’s answers was computed to obtain total scores and means was calculated. The means scores was used to categorize respondents into three groups, those with positive attitude (respondents who scored => 75%), neutral attitude (respondents who scored 50-74%) and negative attitude (respondents who scored below 50%) towards contraceptive use. Information, Education and Communication (IEC) - refers to various media sources through which husband and wife (couples) had exposed to contraceptives information in the previous year (Figure 2).

Figure 2: Conceptual frame work on husband-wife communication about practice of contraceptives in Angecha Woreda, Kembata Tembaro Zone, South Ethiopia, March 2012.

Data collection instrument and procedure

Quantitative data were collected using structured interviewer administered questionnaires by guidance of experienced data collector. The questionnaire was adapted from literature in English to increase the comparability of the finding. Qualitative data were collected by principal investigators using in-depth interview from key informants. The guideline which inquiries about the reason why they are using contraceptives , respondents logical decisions in accepting or not accepting contraceptive use, perceived difference of users and non-users, and delivering style with some probing questions were prepared for each categories of key informants separately. Respective responses of informants were recorded by using tape recorder and written notes, and were analyzed by Atlas software.

Data quality management, processing, and analysis

Questionnaires were translated to local language and then back translated to English to maintain its consistency. Training was given for data collectors and pretest was made on 5% of the study subjects which was similar population before the actual data collection. The supervisors and principal investigators performed immediate supervision on a daily basis. Each and every completed questionnaire was checked for completeness. In qualitative study, the recorded voice was transcribed first in Amharic and translated to English to keep consistency of the original meaning. The collected data were entered in EPI data version 3.1 computer programs. Prior to the analysis, the whole data were cleaned and the double entry verification was done to minimize data entry error. Then, data were exported to Statistical Package for Social Sciences (SPSS) 16.0 version for analysis. Data were analyzed using SPSS version 16.0 and descriptive analysis was used to describe the percentages and number of distributions of the respondents by socio-demographic characteristics, husband wife communication factors, past behaviours, so on. Furthermore, bivariate and multivariable logistic regression analyses were used to identify factors that affect husband wife communication using forward variable selection techniques. All explanatory variables that were associated with the outcome variable (response) in bivariate analysis with p-value of 0.25 or less were included in the initial logistic models. The crude and adjusted odds ratios together with their corresponding 95% confidence intervals were computed. A P-value <0.05 was considered to declare a result as statistically significant in this study. To support the quantitative findings, qualitative data response were transcribed in Amharic and translated to English and the main response was reported using narrative and mentioned in direct quotation.

Ethical consideration

Prior to data collection, appropriate ethical clearance was obtained from the ethical clearance committee of Jimma University. Formal letter of permission was produced from administrative bodies of the zone to the woreda and then to the respective kebeles. Moreover, confidentiality was assured for the information provided since the name of the information provider was not stated on the questionnaire rather coding system was applied. Finally, before the interview, the respondents were requested for their verbal consent after adequate explanation on the objectives, benefits and harm of participating in the study.

Socio-economic and demographic characteristics of the respondents

The study was conducted in a total of 588 samples with 99.6% response rate. Out of a sample of 588 households, 434 (73.8%) households had above 3 members and the remaining 154 (26.2%) households had 2-3 members. The mean age of wife at marriage was 20.6 + 2.28 and the mean age of husband at marriage was 26.4 + 4.30 (Table 1).

Table 1: Shows socio-economic and demographic characteristics of the respondents in Angecha woreda, Kembata Tembaro zone, South, Ethiopia, March 2012.

According to the study, the minimum age of wife at marriage was 18 years and the maximum age was 27 years. The minimum age for husband at marriage was 18 years and the maximum 42 years. On the other hand the average number of years couples lived together was 9.54 (SD 6.06). And the minimum and maximum year couples lived together after the current marriage was 1 year and 27 years, respectively. The minimum number of living children of a household was 0, and the maximum number of children of a household was 14.

Source of information for family planning and contraceptive use

Regarding source of information, 207 (35.2%) wives and 382 (65.0%) husbands heard about contraceptive methods from radio in the last year. From a total sample, 377 (64.1%) households used radio as a source of information at a household level. The remaining 189 (32.1%) households did not have any source of information. Knowing the existence of contraceptive was assessed using different items and almost known by less majority of respondents (30.1% of wives and 29.8% husbands.

The study revealed that 179 (30.4%) wives were currently using contraceptives and 47 (8.0%) wives ever used contraceptives. On the other hand, 94 (16.0%) husbands were currently using contraceptives, 442 (75.2%) husbands didn’t any methods of contraceptives till the day of the study. To get reason for this idea, in qualitative, both couples stated reasons for not using contraceptive as to have more children, religious prohibition, cultural prohibition, family/relative opposed, health problem, and fear of side effects. Less commonly, a few participants didn’t know even the existence of contraceptives. On the other hand the reason for using contraceptive was mentioned as limiting birth, birth spacing, birth spacing and to control unwanted pregnancy.

Out of 588 sample households, 306 (52.0%) discussed about contraceptive use in the last year. On the other hand, 282 (48.0%) haven’t discussed about contraceptive use. The common contraceptive methods practiced by respondents are pills, injectables, implant/nor plant, female condom and periodic abstinence and withdrawal methods.

Predictors of husband-wife communication about contraceptives use

Socio-demographic factors, knowledge of contraceptive methods and source of information of a household showed significant association with the dependent variable (husband-wife communication) during bivariate analysis were entered in to multivariable logistic regression. Therefore, the following table (Tables 2 and 3) shows some predictors on husband-wife communications about practice of contraceptive.

Table 2: Adjusted effects of categorical predictor variables on husband-wife communication about practice of contraceptives obtained from the logistic regressions, Kembata Tembaro zone, Angecha woreda, South Ethiopia, March 1-7/2012.

Table 3: Adjusted effects of categorical predictor variables on practices of contraceptives by wife and husband obtained from logistic regressions, Kembata Tembaro zone, Angecha woreda, South Ethiopia, March 1-7/2012

In this study, husbands and wives were asked whether they approve or disapprove the use of contraceptives by couples, about 49.3% of husbands and about 46.1% of wives approved the use of contraceptive methods by couples for any reason. Which was very less when compared with a study conducted in Sodo town of Wolaita [1]. This finding is supported with the following qualitative finding:

A 45 years old community leader said that “…few years before our community was somewhat less likely to think reproductive issues are business of both couples. Most of us were only interested in having many children. There was no time to think of contraceptives. And no one approves the use of contraceptives. Because if it so, it was considered as one is creating trouble in his own marriage. But, now, thanks to the health extension program and health extension workers, we are working together and change is now coming……..”.

In this study husband-wife communication about practice of contraceptives is about 52%, which is better than 24% reported by the study conducted in the northern part of the country in 1995 [8]. But the result of this study is slightly less than a study done in Sodo town of Wolaita and Hosanna town on married men discussed the issue of family planning, respectively [1,9].

The difference among the three studies might be explained by cultural difference among the communities. And also, this idea is supported by a 23 years old health extension worker that: ”.....it was too difficult even to think of husband-wife communication about contraceptive use before. This was mainly because of the strong local cultures and female’s fear of rejection and lack of support from their husbands. But know, we are working on those cultures and encouraging females to talk on reproductive health issues with their husbands...........”.

The tendency to discuss family planning was higher among women with husbands from non-agricultural sectors. This means service and business sectors were favorable to spousal discussion about family planning. Almost similar finding was found that the rate of discussion for husbands from other occupational status (such as for self-employed and daily laborers) was higher when compared to the rate of discussion of wives with similar occupational status.

In this study, there was no significant association was found between education and husband-wife communication and practice of contraceptives. However, the study conducted in Pakistan revealed that the differential of contraceptive practice rate is greater between women who have no education [10].

This is finding is also supported by the following qualitative finding:

A 22 years old health extension worker said that “…….at the beginning things were difficult for us to work with these people. Because, most of them have no education and were resistant to our program. Even some of them had a false feeling that ‘contraceptives are the strategies for infertility’. But know we are so much happy that our people are having a better understanding of what we are doing regardless of their educational level……..”.

From this study, we can see that the odds of couple’s discussion about practice of contraceptives is higher among couples who do not want to have any more children when compared to couples who want to have more children .The following qualitative finding from each religion also supports the above finding and was summarized as follows:

“……..it’s God’s/Alaha’s will and order for each generation to keep its perpetuity. But he wants everyone to have a plan for his/her life. Therefore, we should stop the old saying that ‘let a child be born and enjoy a fate of life, because, children are wealth’. But now, most household is adjusting its family size with the economic standard. Otherwise we should talk on and encourage others to talk on the number of children to have……..”.

In this study, couple’s practice of contraceptives could be determined by husband-wife need whether to have or not to have more children. Similarly, husbands who don’t want to have more or additional children were more likely to practice contraceptives than their counterparts. This finding is in line with a study conducted in Hossana. It was found that men who want to have more children were less likely to practice modern contraception when compared to those who wanted no more children.

Urban settings are unique in that the development of social services, such as job opportunities, school participation, broadcasting facilities and other services are more accessible than rural counterpart. I think that’s why this and other studies also revealed that couples living in urban were more likely to discuss and practice contraceptives than the rural counter parts. Wives living in urban were more likely to discuss with their husbands and more likely to practice contraceptives than wives living in the rural counter parts. Similarly, husbands living in urban areas were more likely to discuss with their wives and more likely to use contraceptives than their rural counterparts. This finding is in line with the study conducted in Tanzania, Bangladesh and Nepal [2,10,11].

From this study it was also found that husbands in a middle age group (33-47years) were more likely to discuss with their wives when compared to those husbands in a young age group (18-32 years). On the other hand, wives in a middle age group (28-37 years) had better discussion with their husbands about practice of contraceptives when compared to wives in a young age group (18-27 years). This finding is in line with the study conducted in Nepal that found that husband-wife communication about family planning varied with age of husband and wife [12].

Moreover, the study revealed that wives who discuss with their husbands about the practice of contraceptives were more likely to practice contraceptives. And husbands who discuss with their wives about practice of contraceptives were more likely to practice contraceptives than their counterparts. One study conducted in Hosanna and Sodo town of Wolaita zone also found that men with inter-spousal communication were 17.27 and 4.09 times more to practice family planning method than men who had no discussion [1,9]. As strength of the study the study incorporates both the quantitative and qualitative methods of the study. The study tried to address the knowledge, attitude and practice of contraceptives of both the husband and wife; but the study has limitations of being a cross sectional study, this study may have the limitation that causal relation might not be inferred clearly. This is to mean that, spousal communication about fertility desire and contraceptive use could occur either before or after adoption of contraception, “chicken-egg dilemma”.

In conclusion this study found that despite massive resources and intensified interventions desired achievement for contraceptive use is not achieved evidenced by 61.6% of wives and 75.2% of husbands did not use any methods of contraceptive methods till the day of the study. This was mainly because of the influence of the desire for more children and cultural factors. Better knowledge and attitude is not linked with better practice. Husband-wife communications about practice of contraceptive use found to be a strong picture to work on it. Finally, age, occupation, residence, need for more children, and knowledge of couples to different contraceptive methods were independent predictors of husband-wife communication about contraceptives use. On the other hand, husband-wife communication is an independent predictor of practice of contraceptives by couples.

To Regional Health Bureau, Zonal Health Department, District Health Office, Health Extension Workers, Researchers and any organizations working in the area of family planning should follow the following recommendations.

Regional health bureau – the regional health bureau should focus on SWOT analysis and use various family planning studies in order to plan short and long term family planning services to fill the gap and address most disadvantaged areas and groups. Moreover, the bureau should focus on practical and technical aspects of the service so that service providers will be well equipped in order to fill the gap in family planning consumers.

Zonal health department and woreda health office – this body should directly go to the grass-root level and assess any inconveniences and gap identified by the study among the family service eligible. In addition to this, health department and woreda office should undergo continuous orientation and refreshments for the community family health workers. Health department and woreda office should also fix time to evaluate the effectiveness of IEC on family planning services.

Health service providers – health service providers including health extension workers should consider the above identified gaps and act up on it. That means they should use culturally acceptable and environmentally accountable technologies and strategies to promote positive contraceptive attitude and practice of couples/family planning eligible.

Other relevant bodies and NGOs – these bodies should consider the above gap if they are interested to work in this particular local area on family planning services. Moreover, the study might be used as a preliminary source of information for them to conduct further studies. Another guidance of this study for such bodies is that it helps them start their planning from attitude and practice gap so that they could design appropriate intervention.

The authors declared that they have no competing interests.

Degefa Helamo wrote the proposal, participated in data collection, analyzed the data and drafted the paper. Fasil Tessema approved the proposal with some revisions, participated in analysis, commented on the analysis and improved the first draft. All the authors and Feleke Doyore revised subsequent drafts of the paper. Feleke Doyore prepared this manuscript for publication.

Our earnest gratitude goes to college of Public Health and Medical Sciences, Jimma University for proper review and approval of this paper. We would also like to extend our gratitude to data collectors for their patience to bring this meaningful information. Our special thanks also extended to Jimma University for financial support for this study.