ANC: Ante Natal Care; AOR: Adjusted Odds Ratio; BMI: Body Mass Index; COR: Crude Odds Ratio; EDHS: Ethiopian Demographic Heath Survey; EHNRI: Ethiopian Health and Nutrition Research Institute; FGDS: Focus Group Discussants; MUAC: Mid Upper Arm Circumference

The healthy future of society depends on the health of the children of today and their mothers, who are guardians of the future [1]. In developing countries, a woman’s lifetime risk of dying due to pregnancy and childbirth is 1 in 75, or almost 100 times higher than the 1 in 7,300 risk in developed countries. In sub-Sahara Africa, the risks are the highest in the world; a woman’s lifetime chance of dying is 1 in 22 [2].

Preventing unintended pregnancies through access to Family Planning could avert 20 to 35 per cent of maternal deaths, saving the lives of more than 100,000 mothers each year [3]. Every hour of every day, at least 30 women die from complications of pregnancy and childbirth in sub-Saharan Africa-about 270,000 deaths every year. If women had only the number of pregnancies they wanted, at the intervals they wanted, maternal mortality would drop by about one-third [2].

Spacing pregnancies at least two years apart and limiting the total number of pregnancies improves the survival chances and health outcomes of women, newborns and children [4]. Women with birth-to-pregnancy intervals of less than five months experienced a risk of maternal death that was 2.5 times higher than women with birth-to-pregnancy intervals of 18 to 23 months. In the developing world, an estimated 137 million women who want to avoid a pregnancy are not using a family planning method. Globally, an estimated 55 percent of those with unmet need for family planning have a need for spacing and 45 percent for limiting [2].

Women in developing countries over their reproductive life span conceive and nourish with their own bodies six to eight children. Because of the high energy and nutrient demands of pregnancy and lactation, women spend a large proportion of their reproductive years under possible nutritional stress [5]. Women married at an early age are exposed to frequent and early childbearing, unwanted pregnancies and abortions are more likely to report pregnancy complications, lower gestational weight gain and an increased risk of low-birthweight, pregnancy induced hypertension, pre-term labour, iron deficiency anemia and which negatively affect their nutritional status are more likely to be underweight and associated with maternal mortality [6,7].

Maternal under nutrition is a risk factor for poor maternal, newborn and child health outcomes, and interventions to improve women’s nutritional status before, during, after and between pregnancies is essential. Poor maternal nutrition contributes to at least 20% of maternal deaths, and increases the poor pregnancy outcomes, including newborn deaths [4].

In Ethiopia also, Women are the most seriously affected members of the population. Unwanted or mistimed pregnancies lead women to clandestine abortion, which results in serious health complications or even death [8]. Under nutrition is a serious problem in Ethiopia, women and children are the most affected segments of the population [9].

Investing in Modern Family Planning can result in achieving many Millennium Development Goals. By avoiding unintended pregnancy, women will gain health, education, and economic advantages because there are fewer children to educate and immunize, fewer people in need of water and sanitation services, and fewer women in need of maternal health services [2].

Most research on modern family planning utilization, maternal nutrition and health has focused on children's benefit. This study is therefore proposed to see factors affecting utilization of Modern Family planning and it’s the impact on nutritional status of women.

Study area and population

A community based 1:1 un-matched case control study complemented with qualitative method was conducted in the Tena woreda, Arsi Zone, which is located about 260 km away from Addis Ababa, the capital of Ethiopia from January to February 2013. Women in the age between 15-49 years living in randomly selected kebeles (localities) included in the study. Muslim and orthodox Christians are the two predominant religions in the district.

Inclusion criteria: Women age between 15-49 years of age who had at least one child residing in the district.

Exclusion criteria: Pregnant and two months postpartum women were excluded due to weight gain during pregnancy may mislead the result.

• Physically disabled women were excluded due to difficulty to measure the anthropometrics.

• Sick and non responsive women were also excluded.

Sample size determination: The sample size was calculated using two-sample proportion and a total of 360 women were enrolled in the study (180 cases and controls).

Sampling procedure: Tena district was purposively selected from 25 districts from Arsi zone and 3 kebeles were selected randomly out of 13 kebeles (localities) of the woreda. A prior survey was done to identify women who utilized at least one FP method (cases) for at least one year by the data collectors. The houses of ever Family planning user (cases) women were marked using chalks. Using PPS, the required sample size was allocated to the study kebeles and subjects were selected by systematic random sampling method. Women who weren’t in the home during data collection were replaced by the next house hold members. Women who are living in the houses distantly located at hill sides were not included due to transportation difficulties. One woman was selected randomly where more than one eligible women was present in the household. Pregnant and two months postpartum, age<15 and physically disabled women were excluded from participation.

Two FGDs were conducted among randomly selected chosen two kebeles (localities), one kebele for cases and the other for controls. Each group consisted of seven discussants of women of reproductive age group (15-49) selected based on their self-expression. The FGDs were conducted to supplement the quantitative study and understand their knowledge on the benefits and factors that hinders utilization of Modern Family Planning and its effect on the nutritional status of women using family planning users and non users.

Data collection procedures

Quantitative data collection: Eleven health professionals (3 health extensions workers and 6 diploma nurses) data collectors and two degree holder nurse and public health officer supervisors those who speak the local language, were recruited for data collection and trained on the data collection instrument and also participated in the pretest process. The health extension workers didn’t involve on the actual data collections they helped the data collectors by showing the direction and the households of the study participants.

Data were collected using a pre-tested structured questionnaires developed based on literatures, to collect socio-demographic and other relevant FPM utilization and nutrition related information of the women. A team consisted of three individuals involved in the quantitative data collection.

All anthropometric measurements (weight, height, and arm circumference) were taken by the trained diploma nurses based on standard procedure outlined in the Anthropometric Indicators measurement Guidelines [10]. Two measurements were taken for each participant and in the final analysis the average of two measurements were taken.

Weight: Weight was measured using personal digital scales with precision of 0.1 kg, with the subject in light clothes, empty pockets and calibrated against known weights regularly.

Height: Height was measured using portable collapsible measuring board of 200 cms supplied by UNICEF to health extension posts, to the nearest of 0.5 cm after removing head cover (hat/shash) and shoes.

Mid-Upper Arm Circumference (MUAC): MUAC was measured with a standard MUAC tape on the upper left arm to the nearest 1 mm. After locating the mid-point for measurement between the end of the shoulder (acromion) and the tip of the elbow (olecranon) and after marking the midpoint using marker, the arm was made to hang freely and MUAC was measured at the marked mid-point.

Qualitative data collection method

The principal investigators and the two supervisors who were native speaker of the local language, Afan Oromo, were involved to undertake the FGDs. A total of two FGDs were done for each group of FP users and non users. A total of 14 discussants were recruited, seven discussants were for each FGDs. Selection of the focus group discussants was done by health extension workers based on the a ability to raise ideas. Check list and tape recorder were used. The FGDs was moderated by principal investigator and each discussion was conducted based on the prepared guideline and with scope of it. All discussants were encouraged to participate in the discussion. The discussion process was recorded using tape recorder and note was taken by assistant. The translation was made by Principal investigator.

Quality control

The data collectors were trained for two days on standardized data collection methods, particularly in the proper filling of questionnaire, and the use of the weight, height and MUAC measurement scales in order to minimize inter and intra observer errors. The questionnaires were prepared in English and translated into Afan Oromo and Amharic and retranslated back by other translator to English to compare the consistency before the actual data collection.

Questionnaire was pre tested on 5% of the sample on similar population at the nearby kebele, who are not part of the actual sample and amendment was made. One copy of Amharic version questionnaire was given to each data collectors when they face study subject who speaks Amharic language and read the questioner in Amharic and filled on the Afan Oromo version questionnaire. The data collectors were closely supervised by the principal investigators and supervisors. Each completed questionnaires were checked by supervisors to ascertain all questions were properly filled and necessary correction was made at the spot.

Data analysis

After data collection, each questionnaire was given a unique code by the principal investigator and was checked for its completeness and internal consistency. Data were then entered, cleaned, rechecked using Epi info version 3.5.1 and analyzed using SPSS software version 17. Cross tabulation was used to determine frequency distribution and to describe the data between cases and controls. T-test was used to see the mean differences of BMI, height, weight, MUAC and other continuous variables of cases and controls.

A binary logistic regression was run between the independent variables and dependent variable to identify the presence of significant association and to determine the crude odds ratio (COR). Then multi-variate logistic regression model was employed to control confounding effect of other variable and to determine adjusted odds ratio (AOR). The variables included in the multivariate were those significantly related or supposed to be significantly associated at least to the outcome variable at bivariate level. CI of 95% was used to see the precision of the study and the level of significance was taken at α ≤ 0.05.

In the qualitative data the entire audio taped interview was transcribed. The transcript was then translated to English. The contents translated transcript of all the focus group discussions were read thoroughly and summarized under the thematic areas emerged in the process.

Ethical clearance

The Ethical clearance and approval of the proposal was obtained from Research and Ethics committee of the school of public health, Addis Ababa University; formal letter of support was submitted to Woreda Health Office and permission was obtained from the office and Kebele (locality) administrative. Data were collected with the consent of study participants after they were informed about the objective of the study, how long it takes the interview and the measurements.

A total of 360 women of reproductive age group (180 cases (FPM user at least for one year) and 180 controls) in three kebeles (localities) of Tena district participated with a response rate of 100%.

Socio demographic characteristics of the respondents

Table 1 showed socio demographic characteristics of the respondents. The mean age for the cases and controls was 31.4 ± 6.8 and 34.3 ± 9.2 years, respectively. Over a half of (53.3%) controls and 60.0% cases attained primary educations, the rest 2.8% controls and 20.0% cases had attended secondary schooling.

Table 1: Socio demographic characteristics of the respondents by ever
FPM utilization at Tena district, Arsi Zone, Oromiya region, Ethiopia
in 2013

Concerning their spouses characteristics, 85.3% controls and 67.3% cases husbands attended primary education, 8.5% controls and 22.8% cases secondary and 0.6% controls and 5.8% cases completed higher education.

Reproductive history of the study participants

The mean age at marriage for cases was (18.05 ± 1.72) and for control was (18.63 ± 2.244). The mean age at first delivery for both groups was (20.02 ± 2.1). The mean age at first delivery for controls was 19.59 ± 1.79 while for a case was 20.47 ± 2.24 years. The median birth interval between the children was 24 for controls and 36 months for cases. The mean total pregnancy of the respondents was 4.98 ± 3.1 (6.41 ± 2.9 for controls and 3.55 ± 2.5 for cases). Women with cases 132 (73.3%) had given more pregnancy than controls 40(22.2%). About two third (61.1%) of the cases and 13.9% of control women had ANC follow-up during their recent pregnancy.

Regarding the types of ever modern contraceptive method utilization for cases, 177(98.3%) injectable was the most frequently utilized type of modern FPM, followed by 66(36.7%) pills and 9(5.0%) Norplant. The prevalence of current modern family planning utilization was 65% and injectable was the most frequently utilized type in both groups of cases and control women, followed by pills 20(8.5%) and Norplant 10(4.3%) (Table 2).

Table 2: Information on reproductive history of the study participants by ever FPM utilization at Tena district Arsi Zone, Oromiya region Jan-Feb, 2013 (N=360)

Decision making power in the household and health status of the women

Table 3 depicts the decision making power in the household and health status of the respondents by ever FPM utilization. About two fifth 43.6%) of controls and more than three quarter of cases make decision on the money their husbands earn jointly and less than one fourth of (23.9%) of cases and 32(17.8) of controls women decide to go health care facility by themselves. But women dominantly involve in buying consumable food items in both groups. More than one third (35.0%) of controls and one fifth (21.7%) of case women had illness in the past one year.

Table 3: Decision making power and health status of the respondents at Tena district, Arsi Zone, Oromiya region, Ethiopia in 2013

A qualitative finding also supports the idea that women who do not use family planning are more likely to acquire infection.

35 years old women said “When we see women who don’t use family planning they always carry children and have offensive smell because of contact of their children’s urine. They don’t have adequate time to wash the wet cloth or simply hung the cloth to dry by sun and use it again. This predisposes them to infections like common cold and other diseases. They don’t have time to keep their own sanitation and their children hygiene”.

The other women, 45 years women declared as follow, “In the home where FPM is there the diet is served in quality and lonely by service (plate) to each individual (child). The serving material being washed properly before and after diet everything is kept in quality. But in the home where family planning is utilized the food is eaten in order to relief from hunger or not be dead all children together on single large service dish (a large plate (tree)) some without washing their hands. While eating together some may have cough or TB, not washing the hand and bleeding nails while cutting it during this time disease can be transmitted from one child to another. Serving material (plate) not being washed before and after diet everything is neglected. The magnitude of the problem is like the area of the serving dish”.

Nutritional status of the women as determined by anthropometry

As displayed in Table 4, the proportion of respondents with height below, weight below 45 kg, BMI below 18.5 kg/m² and MUAC below 21 cm was higher in controls than cases. The overall prevalence of underweight (BMI<18.5 kg/m²) among women was 26.7%. The prevalence underweight was higher among control 70(38.9%) group than cases 26(14.4%). Only 4.4% of women were overweight (7.2% of cases vs 1.7% controls). The FGDs were asked whether utilization of Modern Family Planning improves the nutritional status of the women or not, and almost all of the women of FGDs in both controls and cases exaggerated the effect of modern family planning utilization on their nutritional status between modern Family Planning Method users and non users as the distance between the sky and earth. They were also added that, having few children helps to get nutritious diet in quality and quantity on timely. FGDs women understood that modern family Planning utilization improves the nutritional status of both the woman and her children.

Table 4: Anthropometric measurements of women of respondents by ever FPM utilizations at Tena district, Arsi Zone, Oromiya region, Ethiopia, 2013

In the qualitative finding, a 30 year NFPM user woman told as, “Yes there is a great difference like sky and earth. In Large family the food items not served for individuals in quality. For example to share a 2 birr cabbage for large family is difficult for that reason they always consume the diluted stemming pea (Yetebetebete shiro). But in small family it is possible to share, they will get balanced diet. Since mother is part of the family she also get balanced diet when the family is small in number.

They are overloaded with work, they prepare meal for others, and on the other hand they have no time to breastfeed their young child. Really they are much harmed (suppressed) and ignore themselves. But those who use FPM even they gave birth they look nulliparous and they have small number of children. They serve food for elders on timely and breastfeed the young child timely. They keep their own and their children sanitation well. Really the difference is like sky and earth.”

The other 40 years old FPM user women also stated the following, In the home where FPM utilization is there the diet is served in quality and on separate dish. The serving material being washed properly before and after diet everything is kept in quality. But in the home where FPM is not utilized, the family member is large and usually the food is served on a single serving material, they share in order to relief from hunger or to survive (nefis endatiwuta bicha).

While eating together some may have cough or TB, not washing the hand and bleeding nails while cutting it, during this time disease can be transmitted from one child to another. Serving plate not being washed before and after meal”.

Determinants of modern family planning utilization

In the Multivariate logistic regression analysis ANC, gravidity, history of abortion and decision to go heath care facility remained significant determinant of women’s underweight by adjusting other variables. Women who had currently less than five children were more likely to use modern family planning than those who had more than 5 children (AOR=3.94; 95% CI=2.06 to 7.57).

Women who had no history of abortion were more likely to utilize contraceptive than those who had no abortion (AOR=9.38; 95% CI =4.99 to 17.60). Women who had ANC follow up were 7 times to utilize contraceptive than women who ever had ANC follow up during pregnancy (AOR=7.16; 95% CI=3.64-14.09). Contraceptive utilization is very low for women decision was made to go health care facility by their husbands only (AOR=0.17; 95% CI=0.07 to 0.40) than by women themselves or jointly (Table 5).

Table 5: Association of Modern Family planning utilization with selected characteristics of the respondents at Tena woreda ArsiZone, Oromiya Region, Ethiopia in 2013

The issue of husbands dominancy in the household was also raised in the FGDs. Discriminatory activities by husband against women are one of the factors mentioned that hinder women to participate in household decision making power which hinders not to perform activities that improve their healthy lifestyle, including modern family planning utilization.

When wives keep their hygiene or participate in public activities like a meeting husbands don’t like it and feel suspicious. The above women, “Today you went meeting what did you bring (hear)? Today you washed (had bath) where do you want to go? But when we become smart (keep ourselves neat) they assume that we want to go to search for other person.”

A 40 year FPM users said as follow, “We produce (work) but we have no right to decide. Our capacity to work (produce) is more than males but when we come to the decision, our role is neglected. For example I had education even I had two diplomas in different fields and I am generating income in different ways weather in agriculture or in trade but truly I say I have no chance to the decision even when I was sick to go to health care facility.”

Table 6 below displays the association of the socio demographic and anthropometric variables with the modern family planning utilizations of the respondents.

Table 6: Association of Modern Family planning utilization with selected characteristics of the respondents at Tena woreda Arsi Zone, Oromiya Region, Ethiopia, 2013 (N=360)

In bivariate analysis family planning utilization of women was associated with Age, religion; women’s and their spouse’s educational status, radio possession, weight and MUAC.

After controlling other socio demographic characteristics in multi-variety analysis, religion, women’s and husband educational status and MUAC were significantly associated with women nutritional status. The probability of ever modern family planning utilization among Christian was more than 3 times higher than Muslims (AOR=3.64; 95% CI=2.05 to 6.47).

The influence of religion and culture utilization of modern family planning was raised by FGDs. One of 40 years FGDs stated as the follow, “Once I have been participated as data collector for population census, I encountered a home with many children. At least there were 12 children in the home, no difference observed between the children regarding their size. The woman was young. I asked her by saying “why did you have many children?’’ she responded, my husband is a popular respected religious leader. In this community taking pills is forbidden. I also asked, ok if he isn’t voluntary why don’t you consult health professionals and take it (contraceptive)? OOH! No, if he (husband) knows he might kill me.”

Those women who were attended secondary and above schooling were more likely to be ever modern family planning users than illiterate (AOR=7.44; 95% CI=2.04, 31.16). Women whose husbands attended primary schooling were nearly 3 times to utilize modern family planning than illiterates (AOR=2.73; 95% CI=1.35 to 5.50) and schooling secondary and above increases the odds of modern family planning uptake by more than 3 times(AOR=3.43; 95% CI=1.22 to 9.63 those at. Access to radio as means of media communication increases the odds of ever modern family planning utilization among women by more than 2 times (AOR=2.00; 95% CI=1.14 to 3.52) Women whose MUAC measurement <21 cm were more likely 4 times to utilize modern family planning than >21 cm measurements (AOR=3.90; 95% CI=1.82, 8.36).

This study tried to determine factors affecting ever modern family planning utilization and its effect on the nutritional status of women of reproductive age group.

The median birth interval was 24 months (24 months for controls and 36 months for cases), which was lower than the study in Nigeria 2011 and Ethiopia 2011 which was 33 months [11,12]. The mean total pregnancy of the respondents was 4.98 ± 3.1 (6.41 ± 2.9 controls and 3.55 ± 2.5 cases). Women with controls had given more pregnancy than cases. More than three quarters (77.8%) of control and 59(32%) cases women had at least one abortion. Unintended pregnancy with short birth interval is high if a woman is not using modern family planning, during this time she may plan to give unwanted birth or abort.

The prevalence of current modern family planning utilization was 65%. The prevalence higher than the study done in 2010 Nepal 40% [13], in Ethiopia 2011, 38.3% [14]. Injectable was the most frequently utilized type in both groups of cases and control women, followed by pills 20(8.5%) and Norplant 10(4.3%). Regarding the types of ever modern contraceptive method utilization for cases, 177(98.3%) injectable was the most frequently utilized type of modern FPM, followed by 66(36.7%) pills and 9(5.0%) Norplant. Injectables and oral contraceptives respectively in magnitude were the most utilized contraceptives in the study done Ghana and Ethiopia [14-19].

Contraceptive utilization is very low for women decision was made to go health care facility by their husbands only than by women themselves or jointly. The FGDs also revealed lack of decision making power on the income generated by women has some implications on modern family planning users as mostly women have no chance to the decision even when sick to go to health care facility. The finding is consistent with study done in Ethiopia [20] and in Nigeria where women were rated in society lower than men [21]. Discriminator activities by men, community, culture and religion against women impeding them to participate in different issues that will improve their way of life in most developing countries, including Ethiopia needs attention of all stakeholders and policy makers for some improvement.

Education is an important factor for different behavioral change in both men and women can contribute to the economic, cultural and social development of the country. Husband education has an effect on utilization of modern contraceptive. Those women who were attended secondary and above schooling were 7.44 more likely to be ever modern family planning users than illiterate. This finding is in line with the study done in Sudan 2007, Uganda 2011, Ethiopia 2006 and 2013 [16,22-24]. This is likely to be ascribed because education may enable women to make independent decisions for different activities in the home, to be accepted by other household members, and having better knowledge help to have greater access to household resources that are important modern family planning utilization. They freely discuss about reproductive issues with their spouses or partner or their families they do not feel ashamed and go to health care facilities. Higher educational status of the husbands increases the odds of modern family planning utilization among women.

Access to radio as means of media communication increases the odds of ever modern family planning utilization among women by more than 2 times. A study conducted in Nepal 2011 access to media exposure like radio and TV factors affecting contraceptive utilization [25]. Exposure to mass media communication may help the women to have adequate health related information including Modern Family Planning.

The odds of ever modern family planning utilizations was higher among slims (weight<45 kg and MUAC<21 cm) women. This could be the probability that most fat women fear to utilize modern family planning due to the side effect of gaining weight from some contraceptives, especially from Depo-Provera. From my experience, I have heard these rumors from many women even from my family and relatives.

The cultural and religious background of a given community has powerful effect on health seeking behavior in general, and contraceptive use in particular in different parts of the world. The probability of ever modern family planning utilization among Christian was more than 3 times higher than Muslims. The influence of religion was also mentioned in the qualitative findings. The effect of religion on modern family planning was reported on studies done in other parts of sub-Saharan Africa countries [26-29].

The mean weight was higher than Bangladesh study [30], in Ethiopia [31,32]. The differences noted could be explained by seasonal variation, i.e. the study was conducted after the major crops had been collected, and meaning that the women were food secured and work was less.

The prevalence of underweight (BMI<18.5 kg/m²) among the women in this study was 26.7%, is almost similar to the EDHS 2005 and 2010 data (27%) [15,33], Northern part of Ethiopia (25%) [32]. But higher than the prevalence in Pakistan [34] and lower than study in Ethiopia by EHNRI 2010 (29%) [35], in South- western Ethiopia (35%) [31]. The mean MUAC of the study participants was comparable with previously done study done in Northern part of Ethiopia [32]. When woman is not using modern family planning method, she is more likely to have frequent deliveries, heavy blood loss, may experience abortions and will have large family size. Frequent conception predispose the woman for an overlap of pregnancy and lactation, which results sharing of nutrients among three lives; the mother, the born child and the fetus; other than these the longtime lactation because of that she will have little recovery time to regain body fat and nutrients lost due to reproductive stress, especially, if she doesn’t get adequate dietary intake during lactation, since the energy, protein, and other nutrients in breast milk come from her own body stores can reduce her energy and nutrient reserves, this is more likely in low resource setting countries like Ethiopia. The FGDs also stressed the difference of nutritional status between family planning users and non-users.

•Lack of assessing knowledge and Attitude of women toward modern Family planning Methods

•Sample of the study population may be not enough

•Social desirability bias might be introduced

•The prevalence of current modern family planning utilization was 65% and injectable was the most utilized type in both cases and control women, followed by pills and Norplant

•Religion, women and their husband educational status, Radio possession, number of children, ANC follow up, and Decision making to go health facility were factors that affect utilization of modern family planning methods.

•The effect of family planning on the nutritional status (as measured by BMI) of women using Modern Family Planning Methods was better than the non users.

•Utilization of modern family planning is important in improving the overall health status of the women.

We thank all the women who participated in our study as well as the district health office of Tena woreda; data collectors and supervisor for their unreserved cooperation. The study was funded by the UNFPA through the School of Public Health, Addis Ababa University.