A Long-Acting Reversible Contraceptive (LARC) method is a birth control method that provides effective contraception for an extended period of time without requiring user action. The most common in Africa as well as in Ethiopia are non-hormonal copper IUDs and implantable contraceptives [1,2]. There is no evidence of a delay in the return of fertility following removal or expulsion of these contraceptives [3]. These contraceptives are very safe, effective and convenient for postpartum, post abortion, non-pregnant mother, breastfeeding mother; HIV-infected; young and/or nulliparous, older women, and unable to use hormonal methods in preventing any pregnancy [4,5].

LARCs are an important and attractive method options for women and couples who wish to delay a first birth, to space births, or to limit family size once they decide that they do not want to have more children. This can improve maternal and child health. Healthy timing and spacing of births reduces the risk of maternal morbidity and mortality from complications related to pregnancy, unsafe abortion, or childbirth. When pregnancies are spaced too close, babies can be born too early and too small, making them more likely to die before the age of five years [2,4].

More than 120 million women worldwide want to prevent pregnancy. Despite a great progress in family planning service delivery over the last several decades, large proportions of women in their reproductive age are not using contraception like LARCs. Some reasons for unmet need among the very many include [6-16]. Lack of services and supplies, limited choices, partner’s opposition, worries about side effects and health concerns, misperceptions, interpretation and lack of knowledge about contraceptive.

Of the 182 million pregnancies estimated to occur annually in lowincome countries, more than one-third is unintended [11]. Such high rates of unintended pregnancy impose a heavy burden not only on the women and their families, but also on health system, the economy and the environment [12].

In sub- Saharan Africa, about 270,000 maternal deaths occur annually. Family planning, especially LARCs could prevent many of these deaths by enabling women to bear children during the time when it is safest for themselves and their babies [17-21]

The study in Sub-Saharan Africa also revealed that one in five of married women in reproductive age(MWRA)use family planning, while less than one of seven use long-acting or permanent contraception [6,14,15]. This low utilization of long-acting reversible contraceptive methods may contribute to high levels of unintended pregnancy.

For Sub-Saharan Africa regional unmet need for family planning is the highest in the world which is 48.8 million women, nearly half the married women of reproductive age want to space or limit the number of children. However, less than half (21 million women) are currently using a contraceptive methods and less than one in seven married women of reproductive age are using a modern method of contraception including LARCs [3].

Due to the above facts, Sub-Saharan Africa has the highest fertility in the world (5.4 births per woman on average)which is twice higher than that of Asia (excluding China) and more than three times higher than that of Europe. The region’s 2008 population of 809 million is projected to increase to 1.2 billion by2025. A major factor underlying high birth rates is low family planning use specially LARCs: Only 18 percent of married women in sub-Saharan Africa use modern methods of family planning. This figure, however, masks important sub-regional differences; modern contraceptive use is 58 percent in Southern Africa, 22 percent in Eastern Africa, and only 7 percent and 9 percent in Central and Western Africa, respectively [19,20].

Figure 1: Utilization of LARCs by currently married women in different SDPs, Jimma Town, May 2012

Although Ethiopia, is has an estimated current population of over 90million being the second most populous country in Africa next to Nigeria, the population is growing at a rate of 2.7 percent per year [4]. Contraceptive prevalence rate is very low in the country with only 29% of married women using any type of contraception. The most popular methods are inject able (21%), implants (3 %), IUD (2%) and less than 1 percent reported having been sterilized, using the pill, or male condoms among currently married women [12].

Overall, 25% married women at the time of the survey had unmet need for family planning (16 percent for spacing and 9 percent for limiting), which is even highest in Oromia region (30%). Reducing unmet need would significantly reduce unintended pregnancies, abortions, and maternal and child deaths. For example, current projections for Ethiopia estimate 56 million pregnancies from 2005 to 2015, of which nearly 24 million would be unintended. By addressing unmet need in Ethiopia using modern contraceptives especially LARCs, there would be almost 6 million fewer unintended pregnancies, which would lead to nearly 2 million fewer abortions, in addition, more than 1 million infant and child deaths (under age 5) would be averted, and nearly 13,000 maternal deaths would be averted over the 10-year period [11].

Despite widespread availability, safety, effectiveness and advantages, there is low use of contraceptives especially LARCs. Due to this, unintended pregnancy remains an alarming global public health problem and a personal and socioeconomic challenge for individuals, families and society. It remains a relatively small, and sometimes missing, component of many national reproductive health and family planning programs.

Although use of long acting reversible contraceptives is low in Ethiopia, there is no study that documented use of long acting reversible contraceptive and its predictors in the study area. This study was carried out to fill this gap in information about the practice of longacting contraceptives use in Jimma Town.

Study subjects and setting

A cross-sectional study was carried out from February to March 2012among married women visiting public health facilities in Jimma Town; Southwest Ethiopia. Jimma Town is 357 kms in the southwest of Addis Ababa. The town had 26,000 households and a total projected population of 128,330 in 2007. The town is divided in to 3 districts and 13 Keble’s (the smallest administrative unit).

The sample size was determined using a formula for estimation of single population proportion with the following assumptions: a prevalence of modern contraceptives among currently married women in urban Ethiopia of 49.5 %[ 12], a 5% desired precision and 95% confidence level. Adding 10% for non-response on the calculated sample size of 384, a final sample size of 422 was estimated.

All family planning service delivery points in Jimma town were taken. The total sample size (was allocated to the respective service delivery points proportionately based on their average client flow of the previous six months. Then, a systematic sampling method was used to select subjects who used family planning services during data collection time. The sampling fraction (is five (2280/422 = 5), every 5th women at each health facility until the allocated sample size for that health facility is obtained were included in the study. Based on the patients’ card number a starting patient was determined by using lottery method from the 1st 5 clients.

Measurements

A structured Amharic and Afan Oromo version questionnaires which was first drafted in English and then translated in to Amharic and Afan Oromo and back translated in to English by another person was used to collect data. The instrument was adapted from different literatures developed for similar purpose by different authors and tools designed by various organizations [12,13].

Before the actual data collection, the questionnaire was pre-tested on 5% of the total samples that is on 16 married women getting Family planning service in Serbo Health Center and appropriate corrections were made before using it for the main study. The questionnaire was intended to collect information on demographic and socioeconomic characteristics of women; family planning characteristics of LARC contraception as well as services characteristics.

In-depth interview was carried out by Bsc nurses on health care providers who agreed to be interviewed. A semi structured interview guide was used to facilitate the interview process. The interview was audio taped and field notes were also taken. Client exit interview was done by five trained nurses.

Data analysis

The quantitative data were checked for completeness cleaned and analyzed using analyzed by using SPSS for windows version 16. Frequencies and graphs were used to describe some variables. Binary logistic regression was used to examine association between dependent and independent variables. To isolate the adjusted effects of each independent variable on the outcome variables a multivariable logistic regression analyses was carried out. The results were presented using odds Ratios and 95% confidence intervals and P<0.05 was considered to be statistically significant.

Data obtained from the 9 in-depth interviews of health care providers were transcribed verbatim into English by the principal investigator. Then, transcript was carefully read, categorized into thematic frame works, color coded and analyzed. The findings were presented in narratives using direct quotes as illustrations.

Ethical considerations

Ethical clearance was obtained from Jimma University Ethical Review Board. Official letter of cooperation from the above organization was written to respective health institutions and verbal consent was obtained from individual participants. All the participants were told that their participation would be on voluntary basis and their information will be kept confidential. Moreover, the purpose, procedures of the study, advantages and disadvantages were told to the participants.

Out of 422 women in the reproductive age group targeted from urban area 418 were interviewed giving a response rate of 99.1%. The age of interviewees ranged from 15 - 49 years. The mean age was 26.7(±5.4) years. Majority of the women 205(49.0%) were Muslim and followed by Orthodox 133(31.8%), protestant which accounts (17.0%) and the rest 9 (2.2%) were others. One hundred forty nine (35.6%) of the respondents attended primary education (grade1-8) which is similar with their husbands` educational status where 143 34.2% attended primary education. Most of the respondents 173(41.4%) were housewives, followed by employers 82(19.6%).Half (50.2%) were Oromo by ethnicity (Table 1).

Table 1: Socio demographic characteristics of family planning clients interviewed in six services delivery points, Jimma town.

The table indicated that 34% of currently married women were in the age group 15-24, and 54% of currently married women were in the age group of 25-34.As presented in Table 2, 67% of women were married before the age of 20.The mean age of womenwasa18.72 years with the standard deviation of 2.8 and the mean number of living children (was 2.1(± 1.5) years.

Table 2: Reproductive characteristics of study participants in six services delivery points, Jimma Town.

Of the total participants of the survey, only 361(86.4%) of currently married women knew about LARCs. Among these, around 195(54%) knew both implant and IUCDs, 142(39.5%) knew implant only and 24 (6.5%) knew IUCD only. With regard to source of information about contraceptive, 39.5% heard from health worker and followed by radio and TV which accounts for 32.5%.Concerning attitude towards the LARCs use, half of currently married women reported that they will never to use LARCs in the future. From the total client intention to use LARCs, 82.1% preferred to use implant while 17.9% of them preferred IUCD..Regarding the discussion of LARCs among client and provider, 61.2% discussed about implant while 40.7% discussed about IUCDs during facilities visit. As shown in Table 3, 72.2% of currently married women discussed about long –acting reversible contraceptives with their partner. Of study participants who discussed with their husbands, 35.4% encountered opposition from their husbands.

Table 3: Percentage distribution of currently married women who have utilized LARCs, by family planning characteristics, Jimma Town.

Of clients who chose contraceptives, 56% percent of married women got information on the side effect of the method they chose and 53% discussed about what to do if any problem is encountered during use of contraceptives.

Results from the counseling observation also showed that among currently married women who received a contraceptive methods, 38.8% were told the available methods by the provider), 36.7% were assisted to choose the method and s advantages and disadvantages of the selected method, was explained for 28.6%.

As presented in Table 3, the overall prevalence use of long acting reversible contraceptive methods use was 16%. Out of those who used LARCs(n=67), the majority of women used implants 51(76.1%) followed by IUCD 16(23.9%).The most popular LARCs method of currently married women was implant which is about 12.2% and IUCDs accounts 3.8% all contraceptives used. From short acting contraceptives the most popular method was injectable (71.1%).Of all modern contraceptives users, 79.2% of currently married women were used for the purpose of birth spacing and 20.3%were for limiting birth. One of the providers stated, “…most of the married women used injectable, this due to familiarity of clients with the contraceptives and negative attitudes towards LARCs”.

A total of 23(6.5%) currently married women had ever used LARCs. The reasons for stopping LARCs were fear of the side effect 69.6%), and partner’s disapproval (17.4%). Half (50.0%) of currently married women who were not using long acting reversible contraceptive at the time of the survey do not want to use LARCs in the future, while 39.8% had intention to use long acting reversible contraceptives in the future Non-users of contraceptives were asked to list down of the reasons that hindered them from using LARC methods. They stated the main reasons to be: fear of side effects (36.8%), fear of infertility (20.5%), rumor (48.1%), husband’s opposition (47.6%) and lack of information (16.8%). Here, the health care providers were also asked why their clients do not choose LARCs as follows; “…it was because of the rumors they heard about the methods, lack of adequate information and religious prohibition that they refrain from using LARCs. For example most Muslim followers say, LARCs are foreign materials we don’t want to put in our bodies. Husband’s opposition and side effects were some of the reasons for not using.”

Of currently married women asked about their husband’s feeling towards LARCs, 216 (51.7%) support utilization of LARCs while around 174(41.6%) were oppose it.

The majority (86.1%) of the married women gets the service from public institution. Eighty six point four percent of the married women got contraceptives free and the average waiting time to get service was 19.5(± 12.5) minutes. 371 (Eighty eight point eight percent) the clients were satisfied/reasonable with length of waiting time and the rest 47(11.2% were dissatisfied or too long with the waiting time.

Partner discussion was found to be strongly and positively associated with currently married women`s utilization of LARCs. Women who have discussed about LARCs with their partner were 15.5 times more likely to use long acting reversible contraceptives than those who have never discussed about LARCs (AOR15.483, 95% CI: 1.759- 136.304).

Women whose husbands’ support utilization of LARCs were 25 times more likely to use LARCs than those who oppose utilization of long acting reversible contraceptives (AOR 24.851, 95% CI: 4.602- 134.187).

Discussion with health workers about long acting reversible contraception was found to be strongly associated with married women of LARCs use. In Table 4, it was indicated that married women who discussed with health workers about long acting reversible contraception were 13 times more likely to utilize LARCs than those who have never discussed (AOR 13.45, 95% CI: 2.42- 74.70)

Table 4: Multivariable logistic regression predicting utilization of long acting reversible contraceptives.

Observation of counseling session also indicated that, out of the total clients observed, the provider discussed on number of living children with only 11 (10.7%) of clients, related to desire for more children with 14 (13.6%) and on timing of next child with 14 (13.6%) women were counseled. With 7 (6.8%) clients, Partner’s attitude about FP (approval/disapproval) was also discussed during the observation.

Regarding the attitudes of currently married women about LARCs , clients who did not hear myths and beliefs( misconception ) about long acting reversible contraceptives were ,2.5 times more likely to use of LARCs than those who heard (AOR 2.449, 95% CI:1.025-5.852).

When the providers were asked about rumors they heard from their clients, they reported “…hearing stories about IUDs inserted moving to other parts of the body like the brain, the heart, or the stomach was common reasons for not using them. Fear of insertion (which includes a mild surgery), or the fear of an infection or bad side effects from the IUD and can cause cancer. Men’s ideas about the IUD, or their complaints of feeling the string during sex were reported by providers to be deterrents for some women. Implant providers reported that their clients were afraid that implant would go missing or would travel to other parts of the body and they were concerned about the absence of their menses, pain during removal, or worrying about side effects of causing sterility and weight loss. Some women reported that they were worried about the implant limiting the range of motion in their arms, which would affect their ability to perform an activity.”

The counseling observation also indicated that doubts or a misconception about the methods was clarified by provider for 16 (15.5%) of currently married women. one of the reason women to have myths and misconception about the method was due to low value clarification by providers during counseling.

Clients who did not perceived religious against utilization of long acting reversible contraceptives were about 9 times more likely to utilize LARCs than currently married women who perceived (AOR: 8.654,95% CI:1.780-42.084).

This is supported by qualitative result: one provider reported“… married women who were Muslim follower said that because these LARCs are foreign materials, we don’t want to put in our body because if I die with it, Allah will not give eternal life”. “Kesugarsiqeber Allah jenatayasgebanyim,”

In this study, the utilization of LARCs contraceptive methods was totally dominated by short term family planning methods.

The overall prevalence use of long acting reversible contraceptive methods use was 16%. Of this majority (76.1%) of women used implants followed by IUCD (23.9%). On the other hand the overall prevalence of implant and IUCD were 12.7% and 3.8%, respectively. This is better when compared with the EDHS 2011 which was 3.4% on implant and 2.2% on IUCD in Oromia Region and in Mekele Town [10,13] also the IUCD and implant users were about 1.5% and 10.6%, respectively. The discrepancy may be due to the sample size, resident of the study participants and access to information on family planning.

As illustrated earlier, 6.6% of married women had ever used long acting reversible contraceptive. The main reason for discontinuation of LARCs fear of side effect (69.6%) and partner opposition which accounts 17.4% were the most common.

In this study it was found that general knowledge (awareness with at least one LARCs was considered by this study) was 361(86.4 percent). This is better than 58.3% and 77% showed in the study done by Maries topes international Ethiopian Batu Town [19]. This could be due better accesses clients to information than the rural counterpart. This is also similar with the study conducted by Hairon, N.[19] which showed that while most participants were aware of long-acting methods; but had limited knowledge of individual methods, and relied on ‘negative, second-hand stories’ from friends and other sources.

Women who were not using long acting reversible contraceptive were asked their reason for not using. The most important reasons mentioned by women were rumor (48.1%), husbands’ opposition (47.6%), fear of side effects (36.8%), religious prohibition (34.8%), fear of infertility (20.5%) and Lack of information which accounts (16.8%), which is consistent with the findings of previous studies conducted in Great Britain and Mekele Town [5,12]. Therefore, more than half of married women did not want to use long acting reversible contraceptive in the study area.

This study also revealed that, large proportion of married women use contraception for child spacing (79.2%) and 20.8% for limiting birth which was similar with study conducted by Mussie in Mekele Town [12]. This may be due to the fact that 75% the women in the study area want to have a child in the future and 51% of the women did not want to use LARCs during the study periods. The majority (86.1%) of married women had the service from public institutions. This finding is consistent with the study conducted in EDHS 2011and Mekele [10,12].

Most of the problems related to provision of LARCs in Ethiopia are shortage of supply. The present study also revealed that shortage of trained man power on LARCs and unavailability of some methods specially implant type like Jadelle and Implanon were among the main problems reported by the health providers in health centers and hospital, but Jimma FGAE and MIE had a range of modern contraceptive choices. Therefore, this study was consistent with the finding of Mekelle Town [13].

Most of the respondents (82.1 percent) preferred to use implant while 17.9% of preferred to use IUCD. This might be due to the fact that implants were more discussed by providers than IUCDs in the study area and husbands’ opposition on the method. This is better when compared to the report of EDHS 2005 [17], which indicated 1.7% of currently married women preferred to use implant while 0.3% preferred IUCD. These variations may be due to access to information about the methods and the study population.

Those married women who have discussed about LARCs with their partner had higher than those who did not. Twenty one point two percent of married women reported that they discussed about LARCs with their partners, while those who did not discuss did not use. The result was almost similar with the study conducted in Enderta District, Tigray Region 2006 which was 82% [13]. This is due to the fact that husband-wife communication on matters pertaining to family planning and reproductive health provides an enabling environment for couples to implement their fertility desires and contraceptive needs. In this study, the most commonly discussed modern contraceptives with health care providers were injectable (96.7%) and pills (62%) which were followed by implant (60.8%) and IUCDs (40.0%) which is similar with the study conducted in Mekele and Batu Town [12,22]. The results of multivariable logistic regression showed that respondents who underwent discussion with provider were 13 times more utilizing long acting reversible contraceptives than those who did not which is consistent with the findings of other studies [22,13,17].

Similar to the study conducted in Eastern Turkey [18], a husband’s view on long acting reversible contraceptive is one of the significant factors that influenced use of LARCs. Our study also showed that28% of the women who used LARCs were supported by their husbands, while 97% those whose husband’s opposed did not use long acting reversible contraceptives.

A total of 11.9% of the women heard myths and belief / misconceptions/ about the methods a about LARCs. This finding was similar with the study in Ethiopia [19,20]. The result from the observation also revealed that, out of the 103observed, clarification of any doubts or misconceptions about the methods was provided to only 15.5%. This shows that satisfactory clarification about the methods was not given by the providers.

Regarding the attitude of married women toward utilization of LARCs, 30% believed that their religion is against the use of LARCs. Muslims practiced less on long acting reversible contraceptives than Christians ‘which was 9.4% and 21.6% respectively. This is similar with the study done in Bangladesh [21].

The results showed that the level of LARCs use was much lower than that of short acting, which is 16% as compared to 84%, respectively. The most common reasons that hinder women from using LARCs were rumor, husband opposition, fear of the side effect, religious prohibition, fear of infertility and lack of information.

Partner’s influence or partners feeling towards use of LARCs and discussion among couples about LARCs issues is one of the most significant factors that influence utilization of long acting reversible contraceptives.

The results have implications for family planning program especially on long acting reversible contraceptives implicating the need for examining ways to increase contraceptive use seriously. Family planning information, education and communication (IEC) strategies should be strengthened by FMOH and regional health bureaus to encourage husbands and wives to discuss LARCs issues, which is aimed at changing husband’s attitude and increasing their active involvement in the use of LARCs contraception.

Authors would like to acknowledge Jimma University Department of nursing and Midwifery for the support it rendered for conducting this study.