Long-Acting and Permanent Contraception Methods (LAPCM) are Family Planning (FP) methods providing pregnancy protection for more than one year leaving the user free from any further responsibility and function for a long period of time once applied. They include the Intrauterine Contraceptive Devices (IUCD), implants, female sterilization or Tubal Ligation (TL) and male sterilization or vasectomy [1-3].

Unmet need for LAPCM remains high, for healthy timing and spacing of pregnancies and hence limiting family size; thus, a range of effective methods are needed [4-6]. Demand, access and use of the provider-dependent, LAPCM, has lagged behind, despite high effectiveness and popularity among users [7]. Hence, it is necessary to understand the factors influencing women’s contraceptive intention in Ethiopia to ensure accessibility and use of more effective contraceptives [8]. Yet no study has documented the intention of and factors associated with LAPCM in Debremarkos town. Thus, this study assessed the intention and factors associated with LAPCM in the town to tailor likely interventions.

Study area and period

The study was conducted in Debremarkos town from 15^th-20^th June 2013.

Study design

A community-based cross-sectional study was conducted to assess the intention and factors associated with the use of LAPCM. The study employed quantitative methods.

Study population

The source population was all married 15-49 years women found in Debremarkos town. The study population was married 15- 49 years women found in three randomly selected kebeles (smallest administrative units) of the town.

Sample size determination

The sample size was determined using a single population proportion formula with the following assumptions: prevalence of LAPCM by married women 15-49 years to be 12.3% [9]; therefore, (p=0.12), level of significance 5% (α=0.05), Z_α/2=1.96, 5% (d=0.05) margin of error, design effect of 2 and 10% non-response rate. Accordingly, the total sample size was 343 married 15-49 years women.

Sampling procedure

A multi-stage sampling technique was used to select the sampling units. There were 6 kebeles in the town. The sample size for each of the selected 3 kebeles was determined proportionally to the size of the household (HH). The first HH was selected using simple random sampling method. If eligible HH had two or more than two women of the specified age group, one was selected randomly. Then systematic sampling was employed to select women from subsequent HH. If the selected HH did not have at least one married woman of reproductive age group, it was skipped to the next HH.

Data collection procedures

Interviewer-administered anonymous questionnaire was developed by adapting pertinent variables and terminologies from different studies on LAPCM [10-13]. The questionnaire was designed to include socio-demographic characteristics, reproductive history, knowledge on and practice of modern contraceptives and factors affecting LAPCM utilization. Six Health Extension Workers (HEW) who had been deployed in each kebele collected the data.

Data quality management

To ensure data quality, pre-test was undertaken on 10% of the sample before the actual data collection to examine the reliability and construct the validity of the instrument. Intensive training was given for data collectors and supervisors on the objectives of the study, contents of the questionnaire and how to maintain confidentiality and privacy of the study participants. Data were entered into Epi Info software package as part of data quality management. During data cleaning, logical checking techniques were employed to identify errors.

Data processing and analysis

Epi Info 3.5.1 was used for data entry and cleaning. The cleaned data were exported to SPSS 16.0 for windows for statistical analysis. Data were explored to visualize the general feature before analysis. Univariate analysis was used to assess the uptake of LAPCM. Data were presented using tables accordingly. To determine independent factors associated with LAPCM uptake, a logistic regression model was applied. First, each variable was entered into a binary logistic regression model. Second, variables which were significant at p-value of

Study variables

Independent variables:

Socio-demographic characteristics

Reproductive History

Knowledge of modern contraceptives

Dependent variable:

Long-acting and permanent contraception methods intention.

Definitions

LAPCMs: Four contraceptive methods are classified as long-acting or permanent: IUCD, implants, female sterilization and vasectomy; IUCD and implants are long-acting methods; tubal ligation and vasectomy are permanent methods [1-3].

Intention: Desire to use long-acting and permanent contraception methods as reported by the study participant.

Ethical considerations

Ethical clearance was obtained from institutional review board of Health Sciences College of Debremarkos University. Permission was also obtained from each kebele administration. Verbal consent was obtained from the study participants as some of them were expected to be illiterate and their consent was recorded depending on their willingness to take part in the study; accordingly, the procedure of obtaining participants’ consent was approved by institutional review board of the college. On behalf of participants below 18 years, informed consent was obtained from the next of kin and/or caretakers and the procedure was also approved by the board. For beneficence, any person found sick in any HH during data collection was advised to visit the nearby health facility.

Socio-demographic and economic characteristics

A total of 342 married women of reproductive age group participated in the study yielding 99.7% response rate.

The mean age of the women was 29.75 (± 7.387 SD) years and 287 (83.9%) were Orthodox Christians. The majority, 331 (96.8%), constituted Amhara ethnic group. About four-fifth, 269 (78.7%), attended formal education; about half, 169 (49.3%), husbands were above Grade 12. The mean number of family size was 4.01 (± 1.50 SD). The majority, 131 (38.3%), of the study participants were housewives. The mean monthly income was USD 65.05 (± 64.80 SD). Most of the participants, 318 (93.0%), possessed means of communication (Table 1).

Table 1: Socio-demographic and economic characteristics of married 15-45 years women in Debremarkos town, northwest Ethiopia, June 2013

Reproductive history

The mean age at marriage was 20.16 (± 3.61 SD) years. More than four-fifth, 278 (81.3), of the women had ever given birth and the mean age at first birth was 22.36 (± 3.65) years. The majority, 126 (45.3), had 2-3 ever born children. The mean number of alive and more wanted children in life was 2.25 (± 1.22 SD) and 3.56 (± 1.09 SD) respectively. Most, 310 (90.6), women discussed about FP with their husbands and the number of children was decided both by the mother and father in more than three-quarters (77.5%) of the families (Table 2).

Table 2: Reproductive history of married 15-49 years women in Debremarkos town, Northwest Ethiopia, June 2013.

Knowledge of long-acting and permanent family planning methods

About three-quarters, 189 (74.7%), of the women reported that implants act for a long period and 76 (30.0) did not know the advantage of the methods. Acting for a long period was also reported for IUCD by 152 (44.4) and 114 (45.0) did not know its advantage. More than twothird and about half women did not know the advantages of vasectomy and tubal ligation respectively (Table 3).

Table 3: Knowledge of long-acting and permanent FP methods of married 15-49 years women in Debremarkos town, Northwest Ethiopia, June 2013 (* Multiple responses were possible.)

Long-acting and permanent family planning methods intention

Almost one in five157 (45.9%) women intended to use long-acting and permanent family planning either to space or limit birth. More than seven in ten 113 (71.9%) women indented to use LAPM in the future 12 months. Implants were the most likely long-acting family planning methods intended by the study participants 98 (86.7%) followed by IUCD 32 (28.3%). Having ‘no choice’ and ‘to give birth of many children’ were mentioned as reasons not to intend to use LAPM (Table 4).

Table 4: Long-acting and permanent family planning methods intention of married 15-49 years women in Debremarkos town, Northwest Ethiopia, June 2013

As shown in Table 5, age, educational status of both the women and their husbands and occupation were found to be statistical significantly associated socio-demographic characteristics for intending to use LAPM. However, only age and educational status of the husband was significant predictors of LAPM intention. Moreover, reproductive health histories including number of children ever born, number of children wanted in live, discussion of FP methods with husband, knowledge of LAPM, ever use of modern FP method and its duration, method shift and current use of the modern methods were significant on bivariate analysis. Furthermore, number of children wanted in live, discussion about FP methods with husband, duration of FP use (in years), method shift and current use of the methods were statistical significant on multivariable analysis. Women near to their menopause were 94% more likely intend to use LAPM (AOR=0.06, 95% CI: 0.01- 0.51) (Table 5).

Table 5: Bivariate and multivariable analysis of LAPM intention and selected variables of married 15-49 years women in Debremarkos town, Northwest Ethiopia, June 2013 (*significant variables on multivariable analysis)

The data for this particular issue were generated from study done on uptake of LAPM in Debremarkos town in 2013. About one-quarter (25.4%) married women were using LAPM and more than one in ten (45.9%) intend to use in the future making 71.3% total demand for LAPM. This finding is less than as compared to a study in northern Ethiopia that revealed LAPM intention among reproductive age group women to be 48.4% [14]. This result revealed significant increase in demand for LAPM in Ethiopia alerting stakeholders to improve method mix the methods [15]. Implants were long-acting methods intended to be used by most women followed by IUCD and tubal ligation; this in line with other study where 69% women prefer to use norplant [16]. Having no choice for the methods attributed for not intending to use LAPM among 21% women followed by tending to have many children (20.5%) allowing a room for increasing method mix and health promotion activities by stakeholders. Fear of the procedures and method permanence were also coined as significant reasons for the women’s future intention [11,17]. The intention of using LAPM increases as age increases; this might be due to achievement of the desired number of children. Discussion on FP methods with husbands showed positive association with LAPM intention as more information regarding the methods would be more disclosed enhancing the desire towards these methods. Moreover, longer duration of using any FP method, ever shift of the methods and current use of any of the methods were positively associated with intention of LAPM attributing for overall exposure to more effective methods.

Generally, LAPM intention was found to be high among married women either to space or limit their pregnancy. Age and education were significantly related socio-demographic factors affecting women’s intention. Moreover, exposure to any of the modern family planning methods positively affected LAPM intention. However, having less access for method mix, interest in giving more birth and fear of side effects were among the reasons not to intend LAPM.

Health promotion activities on the benefits of long-acting and permanent family planning must be undertaken to increase women’s awareness. Long-acting and permanent family planning methods mix should be scaled up to enhance the desire to use and increase more effective methods uptake.

The finding would be used as baseline evidence for family planning commodity planners, managers and relevant stakeholders to be able to secure family planning commodities in line with the need of the catchment population.