Family planning has been identified by the World Health Organization (WHO) as one of the six essential health interventions needed to achieve safe motherhood by reducing maternal and child mortality [1-3]. World Health Organization defines as family planning implies the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births [4].The growing use of modern contraception around the world has given couples the ability to choose the number and spacing of their children and have saved the lives and protected the health of millions of women and children [3,5].

Globally, the use of modern contraceptive methods has increased dramatically over the past 30 years from less than 10% in the 1960's to 55% present day leading to a fall in fertility rates in developing world from six to less than three [5,6]. Despite this great achievement, the world's poorest countries have made low progress in modern contraceptive use and there are still significant levels of demand for family planning that are yet unmet. Sub-Saharan African countries have the lowest contraceptive prevalence and highest unmet need for modern family planning, where 24% of married woman have an unmet need and only 17% of women of child bearing age use modern contraceptive methods [3,5].

The reproductive health needs and rights including modern family planning of forcibly displaced people including refugees and internally displaced persons (IDPs) were neglected till the year 1994 despite they are significant in number. Globally, there were 43.3 million forcibly displaced peoples at the end of 2009 of which 15.2 million were refugees fell under United Nations High Commissioner for Refugees (UNHCR’s) and United Nations Relief and Working Agency's (UNRWA) responsibility [7]. It was in 1994 in the International Conference for Population and Development (ICPD) held in Cairo stated that the needs of modern family planning to these disadvantaged populations must be given an attention [8]. However, in refugee camps and conflict affected areas, the prevalence of modern contraceptive use is very low and high unmet need is more likely because of their social breakdown such as their traditional information sources, assistance, protection, income reducing the refugee’s ability to make free choices [9,10]. In addition to this, there are paucity of literatures studying the practice of modern contraceptive use and its factors among refugee women in Ethiopia.

Study setting and period

The study was conducted in Sheder refugee camp, found in Somali region, 688 km away from Addis Ababa. The camp comprising of three zones with 1580 households and a total population of 10,397 are residing in the camp. Out of this, 20% of the total population are females between reproductive age group of which 1,350 of them are currently married. In Sheder there is one clinic which gives service to the local community which is under the Somali Regional Health Bureau and one health center near the camp which serve for the refugees administrated by Administration of Refugee-Returnee Affairs (ARRA). There are also other non-governmental organizations working for the refugee community in different areas giving support on public health care activities in emergency situation in collaboration with Federal Ministry of Health, Ethiopia [11].

Study design and sampling

A Community based cross-sectional study design using quantitative and qualitative method mix was employed. There are three zones in the camp. The number of study subjects from each zone was determined by probability proportional to size allocation for each zone. Enumeration was conducted to identify households with currently married women between reproductive age group. The source populations were currently married women of reproductive age group (15-49 years) living of which respondents were randomly sampled using simple random sampling techniques. In addition, key informants interviews and focus group discussion with currently married women their husbands, family planning service providers, head of the health facility of the study area and religious leaders living in the camp were employed for further data triangulation of the findings. The sample size was calculated by using a single population proportion formula considering the following assumptions. Proportion of women 15-49 years married women who used modern family planning among refugee women living in the camp - 50%, margin of sampling error tolerated- 5% (0.05), and critical value at 95% confidence interval of certainty (1.96) making the initial sample size of 384. Since sampling was from a finite population of size less than 10,000 (N=1350), the final sample size, was recalculated by using finite population correction formula by adding a 10% non-response rate making the finals sample size as 329 married women in the refugee camp. For the qualitative data 4 Focus group discussions (2 FGDs for married women and 2 FGDs for married men) which contained 7 discussants in each group were employed among purposely selected married women and men. Also in-depth interviews of 5 key informants were employed for religious leaders (2), family planning service providers (2) and head of the health facility of the study area (1).

Measurements

Interviewer administered questionnaires were used to collect the data. The questionnaire contains women’s socio-demographic status, socio-economic and cultural factors, reproductive history, knowledge and attitudes of women and their partner towards modern FP use and practice of modern FP are adopted from the Ethiopian Demographic and Health Survey, 2005 and questions related to attitudes of women regarding modern FP use are adopted from similar studies conducted in Guinea and Gaza [12-14]. The questionnaire was prepared in English and it is translated to Somali language by an individual who have good ability of both languages and again translated back to English to check for consistency. Ten female 12th grade complete data collectors and two supervisors were recruited for the data collection and two days training on the study instrument, interview techniques and data collection procedure. Operationally, Current contraceptive user was defined as a woman using any one of the modern methods at the time of data collection. It takes into account all use of contraception, whether the concern of the user is permanent cessation of childbearing or a desire to space births, Knowledge of modern contraceptive methods was defined as those who knew at least one modern method were labeled as having knowledge of modern contraceptive methods. Modern contraceptive methods are defined as methods which includes condoms (both male and female), spermicidal, hormonal contraceptives (oral contraceptive pills), Copper IUDs (intrauterine devices), hormonal implants, injectables, surgical contraception (both male vasectomy and female sterilization), Standard day's method, Lactation Amenorrhea Method (LAM).

Data Processing & Analysis

After data collection, each questionnaire was checked for completeness and code was given. Data were entered, cleaned and explored for outliers, missing values and analyzed using SPSS version 20 software. Descriptive statistics like frequency tables, graphs were used to describe the study variables. Bivariate binary logistic regression analysis was used to see the existence of association between dependent and independent variables. 95% CI and p- value less than 0.05 were used as cut of point to see their level of statistical significance. To control the effect of confounding variables and to identify determinants of modern family planning use, stepwise multiple logistic regression analysis was used. Ethical clearance was obtained from Jimma University, College of Public Health and Medical Sciences. Permission paper was also obtained from Administration of Refugee-Returnee Affairs (ARRA) country Head Office, Addis Ababa, ARRA head office Somali region, Jigjjiga and from head of Sheder refugee camp. Similarly after explaining the purpose of the study, verbal informed consent was also obtained from each study participants while the study subjects right to refuse was respected. Anonymity was kept to ensure the confidentiality of the information obtained.

Socio-demographic characteristics of respondents

A total of 309 study subjects were participated in the study making the response rate 93.9%. The mean age of the respondents in this study was 29.7(SD ± 8.5) years and the median duration of time since marriage is 9.7 years. Two Hundred fifty seven (83.2%) were coming from urban origin and most of the respondents, 304(98.4%) were Muslims by the religion. Majority, 225(72.8%) of the study participants had no formal education and 230(74.4%) of them were housewives (Table 1).

Table 1: Socio-demographic characteristics of respondents in Sheder refugee camp Ethiopian Somali regional State, eastern Ethiopia, May 2014.

Awareness about modern contraceptive methods

Most of the study participants, 292(94.5%) have heard of at least one modern contraceptive method. Oral contraceptive Pills and injectables were the most mentioned methods of modern contraceptives by respondents accounts 275 (89%) and 266 (86.1%) respectively (Figure 1).

Figure 1: Distribution of modern contraceptive methods known by married women aged 15-49 years, Sheder refugee camp, Ethiopian Somali regional state, eastern Ethiopia, May 2014.

Practice of modern contraceptive methods

The total proportion of women currently using modern contraceptive methods is 55(17.8%), out of this 43(78.2%) and 12(21.8%) used for the purpose of child spacing and for limiting respectively. Out of those women currently using, the most used modern methods were pills which accounts 26(47.3%).The rest 22(40%) uses injectable and 7(12.7%) of them use Norplant. Proportion of current users was found 51(19.8%) among refugees coming from urban women and 4(7.7%) among rural women also proportion of mothers who used modern contraceptives were found higher among mothers with age 20-29 years which is 29(26.1%) and among mothers in the age group 30-39 years accounts 25 (29.1%) compared to age groups less than 20 years (2%) (Figure 2).

Figure 2: Distribution of current modern contraceptive use among married women disaggregated by age, Sheder refugee camp, Ethiopian Somali regional state, eastern Ethiopia, May 2014.

Non contraceptive current users were asked the reason why they do not practice modern contraceptives. Thus, majority 158(60.5%) mentioned desire to have more children, followed by religious reason 108(41.4%), cultural reason 41(15.7%), lack of information about modern contraceptives 40(15.3%) and partners disapproval 20(7.7%) (Figure 3). During the focus group discussion one FGD discussant (25 years, female) said “I don’t want to use contraceptives because I want to have more children”. Again, one of FGD discussant (35 years, Female) also said “…Yes it is a sin for me to practice contraceptive methods, because it is all about denial against Allah’s gift to me so that I don’t want to become against the power and gift of Allah”. Another FGD discussant (32 years) also stated“….we are here as a refugees, we are completely dependent on aid, we want to practice modern family planning to limit our number of children but our husband opposed us to use it.” This issue was also raised during the main discussion made with married men that most of the discussants reported they opposed their wives to use modern contraceptives methods because of their culture and religion. One FGD discussant (40 years, Male) said“….I myself don’t want to encourage my wife to use modern contraceptive methods, because I need more children, it is our God’s (ALLAH) will to have children, it is beyond our control”. Proportions of current users were found increasing across educational levels of women. Prevalence of current users increases from 13(5.3%) in women with no education to 12(36.1%) among mothers with primary education and to 30(62.5%) among women with secondary or higher education (Figure 4). Similarly, proportion of current users among women whose husband’s with primary education and secondary or higher education was found by 19.3% and by 33.5% higher respectively compared with no education Proportion of current users among women who work outside their home was found 39(49.4%) and 16(4.7%) among women who work at their home or housewives. By their partner’s occupation, proportion of current users among women whose husbands employed was found to be higher compared with among women whose husbands have no employment (28.6% vs 17.5%). Proportion of current users was found higher or increasing from 9 (7.7%) among mothers with live children of 0-2 to 26 (31.7%) among women with 3 to 4 live children.

Figure 3: Reasons reported by non-contraceptive current users, Sheder refugee camp, Ethiopian Somali regional state, eastern Ethiopia, May 2014.

Figure 4: Distribution of current contraceptive users by their educational status, Sheder refugee camp, Ethiopian Somali region regional state, eastern Ethiopia, May 2014.

Concerning decision making role of women on family planning, 143 (46.6%) of the participants reported that either they themselves decides or decides jointly with their partners. Among the total study participants (women), 121 (39.2%) of them were found in favor of family planning use or approved the use of modern family planning while more than half of them 165 (53.4%) disapproved modern family planning use.

Determinants of modern contraceptive method use

The multivariate logistic regression analysis showed women who attended formal education were 6.7 times more likely [AOR=6.7 (95% CI: 2.1, 11.5)], to use modern contraceptives than women who did not. Women who worked outside their home were 5.4 times more likely (AOR 95% CI [1.68, 17.8]) to use modern contraceptives than those housewives. The odds of being exposed to discussions with their partners were 2.9 times [AOR=2.9(95% CI: 1.6, 5.8)],) to use modern methods than those who didn’t discuss. Similarly women who reported that they were involved in decision making on FP use were more likely [AO =2.9% CI : (1.57, 6.8) to use modern methods than women who were not involved. Additionally, women whose husband’s approved FP use were more likely [AOR=3.7 95% CI (1.8, 9.3)] to use modern methods than women whose husbands disapprove modern FP use (Table 2).

Table 2: Determinants of modern contraceptive use of respondents in Sheder refugee camp, Ethiopian Somali regional state, eastern Ethiopia, May 2014.

Ninety four percent of study subjects in this study area knew at least one modern contraceptive method However, high awareness of women about modern contraceptive methods didn’t correspond with the magnitude of contraceptive use in this study which is low (17.8%). This implies knowledge does not necessarily lead to practice. This finding is almost similar with finding obtained from study conducted in Uganda, Kyaka refugee camp [15] in which the contraceptive prevalence was 18.2% but it was low compared to studies conducted on Somalia married refugee women 27% [16] and among Sierra Leonean and Liberian refugees living in Guinea, 26% [12], but much higher compared to findings obtained from studies conducted in Angola, 2.5% [17]. This difference in contraceptive between this study and the other studies might be due to socio cultural difference and service related factors like access to mix of choices influencing on modern contraceptive use. The possible explanation why the practice is low might also be explained by the influence of their culture and religion on family planning practice.

Pertaining to practice of modern contraceptives of women by educational status, our finding showed that, women with formal education were more likely to use contraceptives than mothers who had no education. Possible explanation for the high rate of using modern family planning methods by women with formal education in this study might have been a result of the women’s economic independence, less likely to be influenced with social value judgments, such as being independent on their husbands for decision-making, the effects of religion and women’s value for many children may be changed when attend higher education. This finding of is consistent with many previous studies conducted in refugee camp settings and local community in which their findings indicated that proportion of users were found significantly higher among women with primary and secondary or higher education [13,18].

In this study, though women who were not employed but working outside their home were included, it was found that, women who work outside their home were more likely to use modern contraceptives than those who are housewives. Similarly, a study conducted in Iran in 2010 revealed that women who were employed were found significantly higher in modern contraceptive use. This difference in contraceptive use between women who works outside their home and house might be due to their economic freedom to decide or its indirect effect on women’s approval and knowledge of modern methods [19].

Result obtained from study conducted in Mali showed that approval of family planning by women was found strongly associated with modern contraceptive use [20]. In this study, proportion of current users among women who approved family planning use by couples was found to be higher compared to women who disapproved family planning use by couples. It similar with findings obtained from studies conducted in Guinea and Gaza that insignificant difference was observed in contraceptive use between those who approved and disapproved modern contraceptive use [12,13]. This difference might be due to religious and cultural differences between these studies which may contribute to higher resistance to use modern methods despite women’s approval of family planning use. Or it might also be due to because proportion of women in favour of family planning was higher in the study in Mali in which 61% of women were infamous of family planning.

In the study conducted in Gaza, it was found that women whose husbands approved or infamous of family planning were found significantly more likely in using modern methods than those women whose husbands disapprove family planning [13]. Similarly, this finding revealed that mothers whose husbands approve family planning were found higher in using modern methods than those whose husbands disapprove. This implies the risk of not using contraceptives is more likely higher among mothers whose husbands are against family planning which indicate that husband’s opposition is one of the barriers for women’s contraceptive practice in this study area.

Women’s discussion with their partners on family planning was found among the determinants of modern contraceptive use of women in many previous studies [20,21]. A study conducted among Afghan women in Kabul, 2004, it was found that, the odds of using contraceptive methods was found significantly higher among women who reported that they were involved in decision making on family planning with their partners compared to those who did not involve in decision making [18]. Results of this study also indicated that, women who have had recent discussions with their partners were significantly more likely to practice modern contraceptives than those who reported they were not discussed.

In this study, women’s desire for no more child/children was not found to be associated with modern family planning use .This implies, women’s desire to limit child birth does not necessarily make women to practice modern methods. This finding is inconsistent with finding obtained from study conducted in Kabul in which women’s desire for no more children was found strongly associated with contraceptive use [18]. This difference might be due to socio cultural influences or differences influencing their practice of FP despite they want to limit their children. The other possible explanation for this difference might be due to; more than half of those women in our study who reported desire no more children were found in the age group 40-49 years then may influence their approval of FP use. The adequacy of sample size and respondents characteristics will also justify its inconsistencies [22].

There are limitations of the study such as due to cross sectional nature of the study, temporal relationships of the outcome variable and the predictor variables cannot be established. In addition, service related factors like quality of family planning service and participants attitude towards family planning providers that may contribute to difference in contraceptive use were not included in this study. There are also unusual large Odd Ratios and wide confidence interval observed in this study. In addition there are also some variables that were not significantly associated with the outcome of interest which might affect the precision. This might be due the sample is not adequate to justify the relationships between the explanatory variables and outcome of interest and the observed counts also so small in some of the variables making the Odd Ratios so large and so wide. Therefore any interpretation of this finding shall take into account the degree of precision.

In conclusion most of women in this study area knew at least one modern family planning method that women or men use to delay or limit unwanted pregnancy and at least one source of these modern family planning methods. Large proportion of study participants were found not practicing modern family planning or disapproved the practice of modern family planning which indicate a major challenge in increasing the prevalence of modern family planning use. Desire for more children, husband’s opposition, religious opposition and lack of information on modern contraceptives were the main reasons reported by study participants. In addition women’s formal education, women’s involvement in decisions on family planning issues, women’s recent discussion with their partners, husband’s approval of modern family planning use, work status of women (work outside her home) were found strongly associated with modern contraceptive use in this particular study area. Therefore, the following recommendations will be sought including involvement of religious and community leaders and other influential members of the refugee community in mobilizing the community for family planning utilization, involvement of partners is also crucial so that FP service providers, community health agents should encourage partners’ discussion on modern FP by giving awareness creation activities. In addition, Non-Governmental Organizations working for refugees both at local, regional and international level should have to consider women employment or other means of income generating activities for women’s economic empowerment so that improving the decision making role of women. Male partner involvements are also crucial for further promoting the use of modern contraceptive methods. At the last further analytic research design incorporating to assess factors associated with the role of men on modern contraceptive use and accessibility of modern FP including quality family planning provision and other variables which were not included in this study is recommended.

We acknowledge the Jimma University for financial assistance. Our thanks also extend to ARRA Head Office, Addis Ababa, Jigjiga and Sheder Office for their unreserved help throughout data collection. At last but not the least, we would to express my heartfelt thanks to the health providers of Sheder health center and study participants for their commitment and genuine responses in providing the required information.

KT conceived and designed the study, performed analysis and interpretation of data and developed the first draft of the manuscript. WS critically reviewed and revised the subsequent drafts of the manuscript. All authors read and approved the final manuscript for publication.

We authors declare that we have no competing interests regarding the publication of this paper.