An estimated 150 million married women in the developing world want to delay or stop childbearing and are not using contraception [1]. Currently, the world population is growing by over 80 million people every year; such a change is unprecedented [2]. According to the United Nations projections, by 2025 the world population will be over 8 billion people, of which 6.8 billion will live in developing countries [2,3].

An estimated 358,000 maternal deaths occurred worldwide in 2008, a 34% decline from the levels of 1990. Despite this decline, developing countries continued to account for 99% (355, 000) of the deaths. Sub- Saharan Africa and South Asia accounted for 87% (313,000) of global maternal deaths [4,5].

In Ethiopia, women of reproductive age (15-49) constitute 47 percent of the total female population. Demographically, the population is very young-more than 45 percent are below the age of 15-which indicates that there is considerable momentum for growth. This, together with the high level of fertility and a low level of contraceptive use, suggests that the population will continue to grow at a fast pace for at least another generation. The population is predominantly rural, with only 16 percent residing in urban areas. Most Ethiopians rely on agriculture for their livelihood; more than 95 percent of the rural populations are involved in agriculture [6].

Ethiopia demographic and health survey (EDHS) 2011 reported that the total fertility rate in the country stands at 4.8 and 4.9 in Southern Ethiopia, which is among the highest in Sub-Saharan Africa. Current use of family planning is very low and stands at 29 % in the same group of women [7].

Among women who are not currently using contraception, some indicate that they want to space births, while others indicate that they do not want to have any more children. These groups of women are classified as having an unmet need for family planning. The first group of women has unmet need for spacing, while the second has unmet need for limiting. The sum of the two groups constitutes the total unmet need among the population. The EDHS survey indicates that among currently married women, the unmet need for spacing is 16%, while the unmet need for limiting is 9%. Thus, the total unmet need is 25% [7].

The level of unmet need in a country is not static, but always fluctuates, depending on the interplays of two factors –fertility desire and contraceptive use; “Unmet need is a moving target” [8]. The Southern Nations Nationalities and Peoples Region of Ethiopia [SNNPR] is characterized by high level of fertility rate of 4.9 children per women of reproductive age which is a bit above the national average, and low level of contraceptive use 26% and high level of unmet need which is 25% among married women [7].

Therefore, this study gives clue for those who are working in areas family planning to determine the magnitude and determinants of unmet need for family planning in a given targeted by pin pointing the direction for program planners and managers to design appropriate intervention strategies to address the gap between the contraception desire and unmet need. Furthermore, the findings will be used as a reference and provide baseline information for further researchers (Figure 1).

Table 1: Frequency distributions of socio-demographic characteristics of currently married women, Misha district, Southern Ethiopia, September, 2013. (n=660).

Study area and period

The study was conducted in Misha districts of Hadiya Zone. It is located 250 km south west from the capital city of Ethiopia being one of the woreda in Hadiya zone. It is 241 km far from regional city Hawassa and 18 km from zonal city Hosanna. The district has 33 rural and 2 urban kebeles. The total population of the woreda was 155,510 and the number of females in child bearing age (15-49) is 35,767. The total number of health institution by type was 7 health centers and 35 health posts and all of these health facilities provide family planning services for the peoples. Family planning service providers in the district was health professionals (nurses, midwives and health officers and health extension workers). Study period was from September 15-25/2013.

Study design and populations

Community based cross-sectional study design was used to conduct research on currently married women of childbearing age (15-49) who were living in Misha district during the study period to identify factors related to unmet need and the existing contraceptive methods in a given targeted group. All currently married women in reproductive age group (15-49) who were living in selected kebeles for more than 6 months/permanently living included in this study. Those who were critically ill during data collection period were excluded from this study.

Sample size and sampling procedures

The sample size was calculated using single population proportion formula by considering proportion of women living with unmet need for family planning among who has more than five children was 27% in study conducted by Asefa et al. in Southern Ethiopia, margin of error 5%, a 5% level of significance (two sided) i.e. 95% confidence interval of certainty [8]. Based on the above assumptions, with an additional 10 percent contingency for non-response and multiplying by 2 for design effect; the total sample size was 664.

A multi-stage stratified sampling technique was employed for the selection of the study units. In the study area, there are 2 urban and 33 rural kebeles. Considering urban and rural kebeles, for the purpose of logistic feasibility and improving representativeness, 1 kebele from urban and 7 kebeles from rural were randomly selected. The sample size was proportionally allocated to each kebele depending on their number of households. Finally, systematic random sampling method with 13^th interval was applied to select the households and spinning the pen at the center of the kebele and going counter clock wise direction until the sample size was filled. If the selected house hold is ineligible the next house hold was selected. If there were two, one was selected by lottery method. Local guiders were used to show the area for data collectors to avoid confusion on k^th interval. The respondents were wives and when they were not present at home or closed home, 3 visits were made and after 3 visits, they were recorded as non-response.

Dependent variable

Unmet need for family planning

Independent variables

Socio-demographic variables: age, religion, ethnicity, occupation, education of women, and monthly income of the family.

Reproductive factors: parity, sex composition of children, alive children, desired number of children, history of child death and induced abortion.

Family planning factors: knowledge, attitude and practice towards family planning, and spousal and HEWs discussion towards to FP, service availability and distance to the source of FP.

Women with unmet need:- these group of women includes (i) those women who are neither pregnant nor amenorrheic but fecund women and who want to space or limit their fertility but are not using contraceptive methods, (ii) those pregnant women whose pregnancy was mistimed or unwanted at the time when they became pregnant and (iii) all amenorrheic women whose last birth was mistimed or unwanted [9].

Met need for contraception: refers to those currently married women who want to space births or limit the number of children and are using contraceptive methods to avoid unwanted or mistimed pregnancies [9].

Infecund women: women who are considered infecund if they are married 5+ years ago, had no child in the past 5 years and never used contraception; or said “can’t get pregnant” on wanting of future children; or said “menopause/hysterectomy” on reason for not using contraception; or response time since last period is ≥ 6 months or “never menstruated; or response to time since last period is “last period was before last birth” and last birth 5+ years ago [9].

Fecund women: refers to women who have reported as capable to reproduce or who has no above infecundity criteria [9].

Postpartum amenorrhea: refers to the interval between child birth and resumption of menstruation up to 0-23 months, a period during which a woman is temporarily infecund [9].

Knowledge of contraception: awareness for at least one method of contraception (mention at least the name of one modern contraception methods).

Favorable attitude: A woman who has cumulative sum value for 11 attitudinal statements response was lower than summed mean score value of all women.

Unfavorable attitude: A woman who has cumulative sum value for 11 attitudinal statements response was greater than or equal to the summed mean score value of all women.

Housewife: women whose main occupation is caring for her family and running the household, who does not have regular paid work outside home.

Data sources, data collection instruments and procedure

Experienced 16 data collectors were recruited for data collection. The current study is entirely based on primary data. The structured interviewer administered questionnaires were used to collect data from currently married women of reproductive age (15-49 yrs). Questionnaires were adapted from other similar study on prevalence and associated factor for unmet need for family planning among currently married women and modified based on filter questions of measure EDHS revised definition of unmet need [9,10].

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 two days for data collectors and supervisors; and pre-test was done on 5% of the study subjects on similar population out of study area. The necessary modifications and correction was made to standardize and ensure its validity in and care was given not to be heard for those who already planned to be participated in the main study. Supervisors and principal investigator performed immediate supervision on a daily basis. The collected data were entered in Epidata 3.2.1 and exported to SPSS 16.0 version for analysis. Descriptive statistics was used to describe the percentages and number of distributions of the respondents by socio-demographic characteristics, reproductive factors, and family planning factors. Furthermore, bivariate and multivariable logistic regression analyses were used to identify the influencing factors using backward variable selection techniques. All explanatory variables that were associated with outcome variable in bivariate analysis with p-value of 0.25 or less were included in the initial logistic models to increase the candidate variables for final model prediction. The crude and adjusted odds ratios together with their corresponding 95% confidence intervals were computed and interpreted accordingly. A P-value<0.05 was considered to declare a result as statistically significant in this study.

Ethical considerations

The study was got ethical approval from Institute of Jimma University research ethical committee and prior to data collection, a formal letter was given to Zonal health department, District health office and kebele administration and got permission for the study from each hierarchy. All study participants were informed about the purpose of the study verbally. All participants’ right to self-determination and autonomy were respected. Participation was voluntary and participants can withdraw from the study at any time.

Socio-demographic characteristics of the respondents

Six hundred sixty respondents were participated in the study giving response rate of 99.3%. Accordingly, 93.9% (620/660), of the respondents were from rural areas. The mean age of the respondents is 24.9 ± 1.7. (Table 1)

Table 1: Frequency distributions of socio-demographic characteristics of currently married women, Misha district, Southern Ethiopia, September, 2013. (n=660).

Reproductive characteristics

The women’s age at first marriage and pregnancy was less than 18 years were 92(13.9%) and 76(12.1%) respectively (Table 2).

Table 2: Frequency and percentage distribution of reproductive characteristics among currently married women, Misha district, Southern Ethiopia, September, 2013. (N=660).

Knowledge and attitude towards FP

In this study, the majority 648 (98.2%) of the mothers heard of modern contraceptive methods and more known methods were Pills 615(93.2%) and Injectable 629(95.3%) (Table 3).

Table 3: Frequency and percentage distribution of knowledge and attitude towards to contraceptive methods among currently married women, Misha district, Southern Ethiopia, September, 2013. (n=660).

Discussion with partner and HEW

Of the total women, nearly half, 315(47.9%) of mothers discussed about contraceptive methods with Health Extension Workers and 328(49.7%) discussed with their partner six month prior to the survey (Table 4).

Table 4: Frequency and percentage distribution of discussion with HEWs and their partner six month per month prior to the survey of currently married women, Misha district, Southern Ethiopia, 2013. (N=660).

Practice of family planning and service avalilbilty factors

About 62 percent of women ever used modern family planning method in their life time. Total demand for family planning was 385(58.3%), and from this demand 210(31.8%) was met and 175(26.5%) was unmet need for family planning among currently married women for study area (Figures 2-6).

Figure 2: Demand versus met need for spacing and limiting, and total for FP of currently married women, Misha district, Southern Ethiopia, 2013.

Figure 3: Unmet need for spacing and limiting, and total unmet need for FP of currently married women, Misha district, Southern Ethiopia, 2013.

Figure 4: Percentage of reason for not using family planning methods among currently married women, Misha district, Southern Ethiopia, September, 2013.

Figure 5: Algorithm of unmet need for modern contraception of married women Misha district, September, 2013 (Bradley and F. West off et.al ) 2012.

Figure 6: Diagrammatic sampling procedure of the study area.

In multivaraite logistic regression, education of mothers, discussion with health extension and partner, parity and knowledge of at least one method of contraceptive were become significantly associated with unmet need for contraceptive use among currently married women. For instance, those respondents whose educational status primary school have higher odds of unmet need for contraceptive use with odds ratio(4.01, 95% CI: 2.43-6.60), meaning, having total unmet need for contraceptive is 4 times higher for mothers of secondary or higher class compared with mothers of no education (Table 5).

Table 5: The variables associated with unmet need for family planning among married women in Misha District, Southern Ethiopia, September, 2013. (n=660).

This study revealed that, 31.2% of currently married women of reproductive age were using modern contraceptive FP during the survey and of which 23.3% were met need for spacing and 8.5% were met needs for limiting. Among the women who want to space or limit their birth, 26.5% had unmet need for family planning. This is a bit higher than national and regional unmet need 25%, and higher than Nigeria and Niger [7,11]. But, much lower than the study conducted in Butajira where unmet need 52% [12]. The possible explanation for the difference could be due to increased awareness of family planning by health extension workers and community health workers in the study area. The other possible explanation might be government concern of reducing maternal mortality by allocating line item budget for family planning and also time variation with Butajira, Nigeria and Niger study where all are before 2005.

Level of awareness about contraceptive method is nearly universal like national report of 2011 and in line with other similar studies [6,13,14]. The reason may be due to urban health extensions are vigorously working in increasing awareness of contraceptive methods. The other is improvement was also observed with different levels based on the type of intervention increased accessibility to information.

Knowledge of at least one method of contraceptive became positively associated with unmet need for contraceptive. This finding is similar with South Ethiopia by Asefa et.al where both unmet need for spacing and limiting found to be higher compared with those who don’t knew at least one method [15].

This study indicated that, mother education as a one of the predictor for unmet need. This finding also supported by DR Congo and Eritrea which was as women education increase unmet need for contraceptives also increase [16,17]. But different from study conduct in SNNPR and national report; mothers of primary education with slight increment and secondary and above had lower unmet need for contraceptive [7,15]. This difference may be due to the increased demand for family planning by more educated mothers because of different exposure for family planning messages through various media.

In this study, spousal communication was found to be strongly associated with women unmet need. Women who made discussion about family planning had lesser unmet need for contraception. This is due to the fact that husband-wife communications on family planning provides an enabling environment for women to implement their fertility desires and contraceptive needs. This is in line with previous studies conducted in Butajira, Amhara, Uganda and Misha woreda report [12,18-20].

Discussion of FP issues with in women and health extension workers was also found to be statistically significant factors in changing patterns of contraceptive use. Discussion about family planning issues enhances the utilization of family planning services. This finding is also similar with other similar study conducted in Amhara region [19]. But poles apart from Kenya where contact with health services provider increases unmet need for spacing, limiting as well as for total unmet need [20]. The possible explanation for the difference may be due to the service providers in the Kenya were not community health worker as like HEWs that may not provide the service in their community set up.

Another factor that directly associated with unmet need for contraceptive was parity. When number of parity increase unmet need for FP also increase. This study finding is comparable with other study conducted elsewhere [13,15,16]. This may be due to the fact that women who may face high labour experience and pregnancy related problems. The other possible explanation might be women who have many children may have life experience on the consequences of having many children both on the economy and the health of mother.

Moreover, other factors like age at first marriage, attitude of husband and mother’s attitude were not significant in this study but become significant in different literatures. So, they are also may be considered as possible explanation factors of unmet need for family planning. But, the limitations are: first, age data were exposed to recall bias since the women didn’t know exact date of birth and even date of marriage; Secondly, knowledge of family planning issues was measured by a single variable but was not comprehensive knowledge of family planning. The other possible limitation, since it is cross sectional study it might not show cause and effect relationship of dependent and associated factors.

In conclusions, in this study, despite availability of contraceptive methods and high proportion of respondents were knowledge about it, there is still high proportion of currently married women living with unmet need for family planning. The direction of the result indicated the need to increase discussion with their partner’s and with the HEWs of the unmet need is vital. And the finding indicated that for those more educated, more knowledgeable and having more children have shown high unmet need compared to their counterpart. On top of these, the possible obstacles that may hinders mothers from using family planning were fear of side effect, health concern and husband disapproval which in turn can leads high unmet need for family planning among women.

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 should focus on Strength, Weakness, Opportunity and Threat (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.

? Zonal health department and district health office should directly go to the grass-root level and assess any inconveniences and gap identified by the study among the family service eligible.

? District health office should undergo continuous orientation and refreshments for the community family health workers. The office should also fix time to evaluate the effectiveness of Information, Education and Communication (IEC) on family planning services.

? Health extension workers promote the minimal risk or side effects associated with contraceptive methods compared to health problems and maternal health incurred by unwanted pregnancies. Focus on men as well as women.

? Health extension workers encouraging communication between couples and involving men more in family planning are the keys to improve unmet need.

? Health extension workers should promote appropriate and active IEC programs that address provision of accurate information about availability of the services and various contraceptive options, and reducing perceived barriers to service use (such as rumors and misconceptions).

? Woreda health office strengthening the communication and discussion with the health extension workers (HEWs) are the possible factor to decrease unmet need for family planning.

? Health extension workers should focus on expansion of long acting and permanent family planning methods closer to the community level to increase the options for women and to avoid unmet need due to lack of preferred methods by providing women with full access to family planning services.

? Researchers should focus further research to identify the extent of unmet need of different population groups, including unmarried women and couples together.