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Multivariate analysis of Attitudes toward Family Planning and Reasons for Nonuse among Women with Unmet Need for Family Planning in Ethiopia

Multivariate analysis of Attitudes toward Family Planning and Reasons for Nonuse among Women with Unmet Need for Family Planning in Ethiopia

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The dichotomous relationship between the unmet need and met need and various predictor variables was analyzed using logistic regression. This relationship was examined for 3,885 women who had an unmet or met need for spacing (n=2,217) and an unmet need or met need for limiting (n=1,668). Recall that this analysis is restricted to fecund nonusers who express a desire to space or limit the  number of children they want and those who have a met need, that is, those who are currently using contraception. Three logistic regressions are applied for spacing, limiting, and total unmet need. The odds ratio for explanatory variables with at least one significant difference at the 95 percent confidence interval (p<0.05) with the reference category is shown in Table 8. The odds ratio is the exponent of the coefficient of the regression estimates, and takes a value between zero and infinity. The reference group always has an
odds ratio of one. All other groups are compared on the basis of the reference group. An odds ratio of less than one implies a lower probability than that for the reference group. Similarly, an odds ratio greater than one implies a higher probability than that for the reference group. The log of likelihood function measures the fit between the model and the data. The smaller this value the better the fit.

Total unmet need is significantly lower among women age 20 and over. For example, women age 20-24 are half as likely to have an unmet need than met need as women age 15-19. When total unmet need is decomposed into the need for spacing and the need for limiting, a clear difference emerges between spacers and limiters. Women age 20-49 are significantly less likely to have an unmet need for spacing as women age 15-19. However, this difference though significant for each of the five-year age groups becomes less pronounced with age. For example, while women age 20-24 are half as likely to have an unmet need for spacing as women age 15-19, women age 35 and over are only 10 percent less likely to have an unmet need for spacing as the youngest group of women. On the other, young women (15-19) are much less likely to have an unmet need for limiting than older women (25+). For example, women age 35 and over are almost five times as likely to have an unmet need for limiting as women age 15-19.

Age at marriage is not a significant determinant of the overall unmet need but emerges as significant when spacing and limiting needs are considered separately. Women married for the first time before age 15 are significantly less likely to have an unmet need for spacing, and more likely to have an unmet need for limiting, than women married for the first time between age 18 and 24.

Table 8 also shows that the number of living children a woman has is directly related to her demand for family planning services. Not surprisingly, women with living children are much more likely (about twice) to have an unmet need for family planning than women with no living children. Spacing needs are significant only with respect to women with five or more children compared to women with no children, with the former half as likely to have a need for spacing as the latter. On the other hand, women with 3-4 children and five or more children are twice as likely and nearly four times as likely, respectively, to have a need for limiting, as women with no living children.

As women’s ideal number of children increases, so does their unmet need for spacing. Women whose ideal number of children is 3-4 and 5 and over, are twice as likely and four times as likely, respectively, as women with zero ideal number to have an unmet need for spacing. Women who gave a non-numeric response are also much more likely to have an unmet need for spacing as the reference group. This pattern is in contrast to the unmet need for limiting, where women whose ideal number is 3 or more, and those who are unable to articulate a number, less likely to have an unmet need for limiting, as women who desire no children.

The magnitude of unmet need for family planning varies with socioeconomic factors. Women in rural areas are more than four times as likely as women in urban areas to have an unmet need for family planning services, with the unmet need for spacing nearly three times higher among rural than urban women. The observed discrepancy could be explained by the fact that women in rural areas are most likely to be far from health facilities, less educated, and least aware of family planning than those in urban areas. Therefore, strategies have to be devised to reach the large segment of the rural community with family planning information and services, but recognizing that rural women have a significant need to space rather than limit the number of children that they have. Surprisingly, the impact of residence is not significant in determining the unmet need for limiting.

In terms of ethnicity, the Amharas are less likely to have an unmet need than other groups. This relationship is especially significant with spacing needs, with the Oromos, Sidamos and Tigraways, about twice as likely to have an unmet need for spacing as the Amharas. On the other hand, the Sidamos and Tigraway people are half as likely as the Amharas to have an unmet need for limiting.

The educational difference between husband and wife is generally not a significant predictor of the unmet need for family planning. The only exception being women whose husbands are better educated, who are significantly less likely to have a limiting need, as women whose educational level is the same as that of their husband.

In general, nonmigrants are more likely to have an unmet need than migrants. However, the strength of this relationship diminishes when unmet need is broken down into spacing and limiting needs. Women who moved from an urban to a rural place of residence and visitors to the household are significantly less likely to have an unmet need for spacing than non-migrants. The unmet need for limiting is not significant for this variable. Women’s education exerts a powerful influence on unmet need. Educated women are significantly less likely to have an unmet need, with women who have a primary education, two thirds less likely to have an unmet need for spacing, and women with at least a secondary level schooling, one-third less likely to have an unmet need for limiting, as women with no education.

Media exposure is significant only with respect to the unmet need for spacing, where women who have been exposed to the media 80 percent less likely to have an unmet need for spacing as women with no exposure. Contact and discussion of family planning exerts a positive influence in meeting women’s unmet need. Women who discussed family planning with a fieldworker are significantly less likely to have an unmet need, and especially an unmet need for limiting. At the same time, women who visited a health facility and who discussed family planning with a health worker are significantly less likely to have an unmet need, both for spacing and limiting than women who did not visit a health facility in the 12 months prior to the survey.

Spousal communication is important in influencing family planning use among Ethiopian women. Women who discuss family planning with their partner are about 40 percent less likely to have an unmet need for family planning services than women who have never discussed family planning with their partner. This pattern is consistent for both the unmet need for spacing and limiting. This finding is consistent with similar studies done elsewhere (Omrana et al., 2001;Toure, 1996).

The analysis also confirms that women who approve of family planning, and women who believe that their husband approves of family planning, are less likely to have a need for family planning services than women who disapprove, or women who believe that their husband disapproves of family planning use. However, this relationship is significant only in relation to the unmet need for spacing.

Summary and Conclusion
This study has focused on an examination of a variety of factors associated with unmet need for family planning in Ethiopia. Attempts have also been made to assess major reasons for nonuse of contraceptives among women with unmet need. This analysis has shown that unmet need is significantly higher among young women age 15-19, women who have at least one living child, women who reside in rural areas of the country, women who belong to the Oromo ethnic group, nonmigrants, uneducated women, women who have never discussed family planning with a health worker either at a health facility or at their home, women who have never discussed family planning with their husband, women who disapprove of family planning and women who believe that their husband disapproves of family planning.

At the same time, the analysis underscores the importance of recognizing that demographic, socioeconomic and attitudinal factors impact women’s unmet need for spacing and limiting differently. Very young women have a greater need to space than limit, whereas older women have a greater need to limit than space. Women who marry young have a greater need to limit than space, than women who married for the first time between age 18 and 24. The unmet need for limiting increases with the number of living children, while the unmet need for spacing increases with ideal number of children. Rural residence is an important determinant of the unmet need for spacing but not limiting. The Amhara women are less likely to have an unmet need for spacing than all other women, but a greater need to limit than Sidamo and Tigraway women. The migrant status is an important predictor of the unmet need for spacing among urban-rural migrants and visitors, but unimportant in influencing the unmet need for limiting.

Although educated women are less likely to have an unmet need for family planning, primary education impacts spacing needs more significantly whereas secondary education impacts limiting needs more significantly. Exposure to media impacts spacing but not limiting needs. Contact with a family planning fieldworker decreases the unmet need for limiting alone but contact at a health facility exerts a positive influence in addressing the unmet need for both spacing and limiting. Discussing family planning with one’s spouse has a significant positive impact in reducing both spacing and limiting needs. Finally, spacing rather than limiting needs are more likely to be met when women approve of family planning or believe that their husband approves of family planning.

Some overall strategies to address the unmet need for family planning are recommended, based on the findings of this study. Education contributes significantly to the quality of women’s lives. Improving women’s access to education and encouraging continuous and constant exposure would significantly increase use of family planning and reduce unmet need. Community-based family planning services need to be expanded and strengthened in rural Ethiopia so as to disseminate information, education, and counseling on family planning and provide services to the needy, especially to the unreached and underserved populations. Community-based family planning services introduced in many parts of Africa and Asia have played a paramount role in increasing access to and supply of contraceptives by having a network of suppliers (community based distribution agents) who live in the community. By bringing family planning services closer to users, it is possible to improve accessibility and availability of contraceptives.

Various performance assessment studies that have been carried out in Ethiopia have shown a substantial increase in the prevalence of contraceptive use in rural areas where there were interventions from community-based family planning services (Korra, 1997; Mengistu et al., 1999; Walie and Mengistu, 2001). Missed opportunities could be minimized with increased effort on the part of service providers at the institutional level. Service providers have to be encouraged and provided with the necessary training and motivation to effectively promote family planning services in health facilities on a regular basis. A study carried out in Pakistan has shown the importance of increasing access to basic family planning services for meeting much of the substantial unmet demand for family planning (Shelton et al., 1999). In a traditional society like Ethiopia, where men are dominant in decision-making, encouraging spousal communication and involving men in family planning decision-making is important in bridging the gap between met and unmet need.

Nevertheless, programs designed to meet women’s need for family planning in Ethiopia should also devise strategies to address spacing and limiting needs differently, and target women accordingly. An overall strategy, although easier to implement, would be less effective than a need specific approach. The various program options to meet the unmet need for family planning in Ethiopia are discussed in greater detail in a companion analysis to this publication (Ahmed and Mengistu, 2002).

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