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Women's Autonomy Decision Making Power on Postpartum Modern Contraceptive Use and Associated Factors in North West Ethiopia.

1. Introduction

Postpartum Family Planning (PPFP) refers to the use of contraceptives within the first six weeks after giving birth to protect women from unplanned pregnancies [1]. A Short inter-pregnancy interval put endanger new baby, mother and previous child [2, 3]. Globally, six million children were died in 2016 before reaching their fifth birthday and approximately 35 women dying every hour due to the complications of pregnancy and childbirth [1, 4, 5].

Despite, 30% of maternal deaths and 10% of child death could be avoided by extending pregnancy above two years [6], 41% of women in Sub-Saharan Africa who intended to use modern contraceptives in the first year postpartum, were not using it [2]. Another report identified 95% of women who were 0-12 months postpartum want to avoid a pregnancy in the next 24 months, however, 70% of them were not using modern contraceptives [7]. As a result, 20% of birth in low-income countries were before 24 months of the previous birth [8, 9]. According to Ethiopian demographic and health survey (EDHS) 2016, while the proportion of women who want to have another child within the first 24 months sharply decreased, using modern contraceptive remain low [10].

On key strategy for ensuring the optimal birth interval is modern contraceptives (MC) use during the postpartum period(PPP) [8]. However, the post-partum period is a period when women usually have a high unmet need for FP due to reasons related to lack of knowledge about contraceptive methods, opposition from partners or families, or limited autonomy [2, 11]. Women's autonomy decision making power in the household is the most important factor in using modern contraceptives during the postpartum period [6]. Women's decision making power in the household on PPFP has paramount importance, however, however, the postpartum period is usually given less emphasis on family planning (FP) users. In relation to this, little is known about factors affecting women's autonomy decision making power on postpartum modern contraceptive use in the study area. Therefore, this study was aimed to assess women's decision-making power on postpartum modern contraceptives use and its associated factors in sekota Town and its surroundings.

2. Methods

2.1. Study Area and Period. This study was conducted in Sekota town and its Surroundings from May 5 to June 15, 2017. Sekota is the capital town of Waghmra zone located at 720 Kms from Addis Ababa to the North Ethiopia. According to the 2007 Ethiopian population and housing census population projection made, an estimated of 10,980 women delivered in 2016/17. There are eight governmental health centers, 39 health posts and one general hospital in Sekota town and its surroundings, which provide health services to the community [12].

2.2. Study Design. Facility-based cross-sectional study design was employed.

2.3. Sample Size. The minimum sample size was determined by using a single population proportion formula by considering the following assumption: margin of error 5%, confidence level 95% (Z[alpha]/2 = 1.96), the proportion of women's decision making power on modern contraceptive use from South Ethiopia, 53.8% [13], and adding 10% non-response rate the minimum sample size calculated was 421.

2.4. Study Population. All women who gave birth before six months prior to the survey and attended immunization service for their children at the public health facility were included.

2.5. Sampling Technique and Process. In this study, a systematic sampling technique was employed to recruit 421 women who attended their children's immunization service.

All the health facilities in the study area (that is one hospital, 8 health centers, and 34 health posts) that provide vaccination service either in static or outreach approaches were included in the study. The calculated sample size was, then, proportionally allocated to health facility based on the number of vaccination. Next, systematic random sampling technique was applied to select the study participants until the allocated sample size was obtained. Accordingly, interview was made for every other women.

2.6. Operational Definition, Definition of Terms and Measurement

2.6.1. Women's Autonomy Decision Making Power on Modern Contraceptive Use. A woman was considered as having "autonomous decision making power on postpartum family planning use" if she decided independently or together with husband/partner on contraceptive use, number of children, choice of contraceptive methods and when to give birth in conditions where their idea did not coincide, the women's decision accepted.

2.6.2. Modern Contraceptive Use. A woman was considered as "modern contraceptive user" if she was used tuba-ligation (female sterilization), intrauterine device (IUD), Injectable, oral contraceptive (pills), and a condom.

2.6.3. Knowledge about Family Planning. A woman was considered as "knowledgeable about family planning" if she heard about family planning and list at least one of the modern contraceptive methods [14].

2.7. Data Collection. The data were collected through face-to-face interviews using a pre-tested structured questionnaire. The tool was prepared in English and translated to local languages, Amharic and Himitana. Nine female diploma midwives and three bachelor degree holder nurses were deployed as data collectors and supervisors, respectively after receiving a one day intensive training.

2.8. Data Analysis. The collected data were entered into Epi Info V7 and exported to SPSS Version 23 for analysis. Both descriptive and inferential statistics were done. In the analytical study, first bivariable logistic regression analysis used to identify the independent effect of each on women's autonomous decision making power. Variables having P-value [less than or equal to] 0.20 in the bivariable analysis were remained in the multivariable analysis to control the effect of confounders. The Hosmer-Lemeshow goodness-of-fit statistic was used to assess the fitness of the model. Odds ratios (AOR) with their 95% CI were calculated to measure the strength of association, and P-value [less than or equal to] 0.05 was considered as statistically significant.

3. Results

3.1. Socio-Demographic Characteristics of the Respondents. Four hundred and twenty-one (421) mothers were invited for an interview, however, the response rate was 98.6% (415). The mean age of mothers was 28.1 years (Standard devision [+ or -] 6). Out of the total mothers, 401 (96.6%) were Orthodox and the rest were Muslim (3.4%). The majority of mothers were rural residents 318 (76.6%) and did not attend formal education 278 (67.0%) (Table 1).

3.2. Obstetric History. About 24.4% and 4.1% of mothers had a history of abortion and still birth respectively during their last life. Almost two-third (65.8%) and one-fourth (25.0%) of mothers respectively had at least one antenatal and postnatal care visits during the last pregnancy. About 111 (27%) of mothers reported that their index births were unplanned, of which 32 (28.8%) were unwanted (Table 2).

3.3. Contraceptive Knowledge. About 396 (95.4%) mothers had mentioned at least one type of modern contraceptives. Most frequently mentioned modern contraceptives method was injectable (Depo-Provera) (89.4%) followed by pills (74.5%). Health extension workers (HEW), the lowest health professionals at kebele level were the major source of family planning information (69.8%). The majority of mothers (78.1%) knew that pregnancy could happen during the postpartum period (within 6 weeks after birth) (Table 3).

3.4. Modern Contraceptive Use during Postpartum Period. From the total mothers about 30% of mothers were using a modern contraceptive during the postpartum period, of which 62.9% of them were using for spacing purpose. Many of them were using implants (52.4%), followed by pills (20.2%) (Table 4).

3.5. Information on Breastfeeding. All mothers were breast feeding the index child, of which 366 (88.2%) mothers feed their children at least eight times per day. Nevertheless, breast feeding initiation within one hour during the index birth was practiced by 57.6% of the respondents.

3.6. Women's Autonomy Decision Making Power on Postpartum Contraceptive Use. Of the respondents who attended immunization service for their children, the overall proportion of women with decision making power on PP modern contraceptive use was 77.3% (p = 77.3, 95% CI: 73.0, 81.2), of which 45% of mothers could make decision together with husbands. Yet, significant proportion, 22.7%, of mothers need partners' approval.

3.7. Factors Associated with Women Decision Making Power to Use FP On bivariable analysis, women's educational status, age, ANC, place of delivery, ethnicity, knowledge about PPFP, discussion with husband, time gap between the previous and index births, knowledge on likelihood of pregnancy during PP period, and counseling about PPFP were associated with women's autonomy decision making power on PPMC use. On multivariable analysis, however, discussion with husband about PPMC, time gap between previous and index birth, know that pregnancy could happen during PP period and counseling about PPFP remain significantly associated with women's autonomy decision making power on PPMC use.

The Odds of women's autonomy decision making power on PPMC use among mothers who had discussed with their husbands/partners about post-partum contraceptive use were 14.6 times higher compared to their counterparts (AOR = 14.62, 95% CI: 6.52, 32.75). The Odds of having autonomy on PPMC use among mothers who counseled about PPFP were almost two folds higher compared with those who did not get counseling (AOR = 2.29, 95% CI: 1.27, 5.71) (Table 5).

4. Discussion

According to this study, 77.3% of mothers had autonomous decision making power on PPMC use (p = 77.3%, 95% CI: 73%, 81.2%). The finding was consistent with the study done in Wolaita Soddo Town, South Ethiopia (77.5%) [15]. However, this finding was lower compared to the studies done in Southeast Ethiopia (91.7%), and Hosanna town (90%) [16, 17]. The reason for this variation might be due to the educational status of women. The majority of women in southeast Ethiopia and Hosanna town were literate when compared to our participants. Women's education, contribute to women understand their rights and responsibilities on the reproductive and sexual issues. Secondly, women with better educational levels have better access to health care information from different sources, like school, leaflet, newspaper media and internet pregnancy [18-22]. Conversely, it was higher compared to the study done in Mizan Aman southern Ethiopia (67.2%) [23], South Ethiopia (53.8%) [13]), and EDHS 2011 (25%) [3]. The reason might be due to religious, marital status, and cultural differences of women. Unmarried women were the most likely to have autonomous decision-making power on modern contraceptives use [24]. In addition, the Muslim tradition, beliefs, and cultural norms put husband as a decision-maker for all household matters [20, 25]. The current women's autonomous decision making power on PP modern contraceptive use also higher compared to the studies done out of Ethiopia in Malawi (28.5%) [26], India (68%) [27], Pakistan (28%) [28].

In this study the proportion of joint decision making power with their husbands/partners was 45.1% (95% CI: 40.2-50.1%), lower compared to studies done in Southeast Ethiopia (83.4%), Hosanna town (81%), Wolaita Soddo town (71.4%), and Tigray region (78%) [15-17, 29]. However, it was higher compared to Performance Monitoring and Accountability 2020 (PMA2020) Project report from different part of Ethiopia such as in south nation and nationality people region (30.7%), Gambella region (12%) and Somali region (2%) [30]. The possible reason might be due to religious difference of study participants. Almost all women in Somlai region are Muslim religion followers.

In this study women who discussed with their husbands/ partners about PPMC were more likely to have autonomous decision making power on PPMC use compared to those women who didn't discuss the issue. This finding was in line with previous studies done in the different parts of Ethiopia [15, 17, 23]. The reason might be the number of children would have been decided by both (wife and husband), and this could in turn enabled them to discuss the means to do so.

The birth interval was found to be associated with women's autonomy decision making power on PPMC use. Women who had the index child within one year after a previous birth were more likely to have autonomy decision making power on PPMC use compared to women had the index child after three years of previous birth. This finding was in line with a study done in Ghana [31]. The reason might be women know that pregnancy could happen during the postpartum period and this could in turn enabled them to discuss with partners and health care providers.

Women who had counseled about PP family planning were more likely to have autonomous decision-making power on PPMC use compared to don't receive counseling. The finding was in line with previous studies [32, 33]. The reason might be women received more information about family planning and unplanned pregnancy during the discussion. The other finding in this study is that women who knew that pregnancy could happen during PP period were more likely to have autonomy decision making power on PPMC use compared to women who didn't know that pregnancy could happen during PP period. This finding was in line with the study done in South Africa [34]. The reason might be women who had information about the pregnancy can happen during the postpartum period, might have a better educational level. On the other hand, they might be among women who had the index baby within one year after a previous birth.

5. Conclusions

The proportion of women's autonomy decision making power on PPMC use was low. Women who discussed with husbands/ partners on PPFP, counseled about PPFP, knew that pregnancy could happen in the postpartum period, and the index child within one year after previous birth were more likely to autonomous decision making power on PPMC use. Health professionals including Health extension workers, strengthening women to discuss with their husbands about postpartum family planning may improve women's autonomy decision making power on PPMC use. Furthermore, counseling and educating women on postpartum family planning should be strengthened. Moreover, the concerned bodies should promote interventions targeting the predisposing and reinforcing behavioral factors affecting women's autonomous decision making power on PPMC use.

Received 27 February 2019; Revised 4 August 2019; Accepted 4 September 2019; Published 8 December 2019

Academic Editor: Giuseppe La Torre

Data Availability

The data used to support the finding of this study are available from the corresponding author upon the request.

Ethical Approval

Ethical clearance was obtained from Bahir Dar University's ethical review committee. Permission written letter was also obtained from Amhara Regional Health Bureau, Waghmra Health Department. Informed consent was obtained from each health facility and respondent. Each study participant was informed about the purpose and anticipated benefits of the research project. They were also informed on their full right to refuse, withdraw and partially reject part or all of their part in the study.

Conflicts of Interest

The authors declare that they have no conflicts of interests.


We would like to express our gratitude for the Waghmra Zonal Health Office, health facilities study participants, data collectors, supervisor, Health care providers, and Bahir Dar University College of Medicine and Health Science for their contributions to do this work.

Supplementary Materials

The file attached at supplementary material was questionnaire. (Supplementary Materials)


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Samrawit Yonas Tadesse, Amanu Aragaw Emiru [ID], Tadese Ejigu Tafere [ID], and Melash Belachew Asresie [ID]

Department of Reproductive Health and Population Studies, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Correspondence should be addressed to Melash Belachew Asresie;
Table 1: Socio-demographic characteristics of mothers in Sekota
town and its surroundings, Northwest, Ethiopia 2017 (n = 415).

Variables         Categories        Frequency n (%)   Variables

                     15-24            122 (29.4)
Age                  25-34            218 (52.5)
                     35-44             75 (18.1)
                    Married           382 (92.0)
Marital            Unmarried           33 (8.0)       Occupation
  status      No formal education     278 (67.0)
Educational         Primary            59 (14.2)
  status           Secondary           43 (10.4)
                Secondary plus         35 (8.4)        Religion
                     <700             120 (28.9)
Monthly             701-900           101 (24.3)
  family           901-1500           100 (24.1)      Ethnicity
  income             >1500             94 (227)

Variables          Categories         Frequency n (%)

                    Housewife           219 (52.8)
Age                 Students             17 (4.1)
                   Daily labor            9 (2.2)
                    Merchant             44 (10.6)
Marital       Governmental employee      32 (7.7)
  status        Private employee          8(1.9)
Educational          Farmer              80 (19.3)
  status           Unemployed             6 (1.4)
                    Orthodox            401 (96.6)
                     Muslim              14 (3.4)
Monthly              Himtana            329 (79.3)
  family             Other*              86 (20.7)

Key: Other* = Amhara and Tigire.

Table 2: Obstetric history of mothers, in Sekota town and its
surroundings, Northwest, Ethiopia, 2017 (n = 415).

Variables         Categories       Frequency n (%)     Variables

Gravidity       [less than or        189 (45.5)      Unplanned for
                  equal to] 2                          (n = 111)
                      3-4            126 (30.4)          used
               [greater than or      100 (24.1)      contraceptive
                  equal to] 5                          (n = 111)
                [less than or        210 (50.6)
                  equal to] 2
No of parity          3-4            131 (31.6)
               [greater than or       74 (17.8)
                  equal to] 5
                [less than or        211 (50.8)
                  equal to] 2
No of living          3-4            131 (31.6)        Why did
  children     [greater than or       73 (17.6)        not used
                  equal to] 5                          (n = 106)
Index child    Health facilities     340 (81.9)
  place of           home             75 (18.1)
Time gap b/n    [less than or         71 (23.0)         Future
  previous     equal to] 1 year                        fertility
  and index        1-2 years         162 (53.0)         desire
  birth        [greater than or       76 (24.0)
  n = 309      equal to] 3 years
Present               Yes            304 (73.3)
  birth               No             111 (26.7)

Variables              Categories            Frequency n (%)

Gravidity                Spacing                79 (71.2)
                        Limiting                32 (28.8)
                           Yes                   5 (4.5)
                           No                  106 (94.5)
No of parity       Fear of side effect          10 (9.4)
                   Spousal disapproval          23 (21.7)
                    On breastfeeding            17 (16.0)
No of living          Amenorrhearic             26 (24.5)
  children          Lack of FP method            5 (4.7)
Index child     Absent of choice methods         5 (4.7)
  place of          Religious reason            20 (18.9)
Time gap b/n          Want another              16 (3.9)
  previous            before 2 years
  and index    Want another after 2 years      190 (45.8)
  birth          Do not want more child         63 (15.2)
  n = 309
Present                Not decide              146 (35.2)

Table 3: Contraceptive knowledge of mothers, in Sekota town and
its Surroundings, Northwest, Ethiopia 2017 (n = 415).

Variables     Categories     Frequency (%)       Variables

Heard             Yes          415(100)
  about FP        No            0 (0.0)

List at           Yes         396 (95.4)         Source of
  least           No           19 (4.6)         information
  one MC
Which MC        Condom        134 (32.3)       Discuses with
  method         Pills        309 (74.5)       husband on use
  did         Injectable      371 (89.4)     of PPMC (n = 382)
  hear           IUCD          28 (6.7)       Knew pregnancy
               Implants       143 (34.5)        could happen
             tuba ligation      7(1.7)       in the PP period
               Vasectomy        5 (1.2)
Counseled         yes             273        Perceived idea of
  about           no              142           a husband on
  PPFP                                            MC use

Variables      Categories     Frequency (%)

Heard          Mass media       60 (14.5)
  about FP       Health        165 (39.8)
List at           HEW          290 (69.8)
  least         Friends        175 (42.2)
  one MC
Which MC        Families        55 (13.3)
  method          Yes          244 (58.8)
  did              No          138 (33.3)
  hear            Yes          256 (61.7)
                   No          159 (38.3)
              He approves      157 (42.2)
             He disapproved     64 (17.2)
Counseled    He has no idea     88 (23.7)
  about        Don't know       63 (16.9)

Table 4: Modern contraceptive use during PPP among mothers, in
Sekota town and its Surroundings, Northwest, Ethiopia 2017 (n = 415).

Variables            Categories      Frequency (%)     Variables

used modern             Yes           124 (29.9)     The reason not
contraceptive            No           291 (70.1)        used MC
  methods                                              during the
during PPP                                             PP period
                                                       (n = 291)
Which method           Condom          18 (14.5)
  used                 Pills
 (n = 124)           Injection         25 (20.2)
                      Implant           2 (1.6)
                        IUCD           65 (52.4)
                   Tuba ligation        9 (7.3)
                        Self            5 (4.0)
Who decided           Jointly          68 (54.8)
  to use the          Husband
  method                               37 (29.8)
  (n = 124)                            19 (15.3)
Where did          Public health      119 (96.0)        When did
  you usex          institution                        you start
  you use          Private health       5 (4.0)       after birth
  (n = 124)          institution                       (n = 124)
                      To space         78 (62.9)        Used MC
                                                       after PPP
Reason using          To limit         37 (39.8)       (n = 291)
  contraceptive   Partner pressure      9(7.3)        Intended to
  (n = 124)                                            use MC in
                                                       (n = 204)

Variables             Categories        Frequency (%)

used modern        Menses not resume      97 (33.3)
contraceptive      Religious reason       49 (16.8)
during PPP
Which method       Not start sexual       56 (19.2)
  used                intercourse
 (n = 124)           Breastfeeding        51 (10.7)
                   Husband disproval      20 (6.9)
                  Fear of side effect     28 (9.6)
                     Lack of time          8 (2.7)
                     Need to have         17 (5.8)
                     another child
Who decided         Previous health       12 (4.1)
  to use the             problem
  method             Other reasons         3 (1.0)
  (n = 124)          [less than or         6 (4.8)
                    equal to] 2 weeks
Where did              3-4 weeks          39 (31.5)
  you usex
  you use              5-6 weeks          79 (63.7)
  (n = 124)
                          yes             87 (29.9)

Reason using              no             204 (70.1)
  contraceptive         Yes No           142 (69.6)
  (n = 124)                               62 (30.4)

Table 5: Factors associated with women's autonomy decision making
power on PPMC use, in Sekota town and its surroundings, Northwest,
Ethiopia 2017.

Variables                    Women's autonomy decision
                             making power on PPMC use

                             Yes   No
15-24                        88    34
25-34                        178   40
35-44                        55    20
Educational status
No formal education          206   72
Primary education (1-8)      44    15
Secondary education (9-12)   39    4
Tertiary & above             32    3
Time gap b/n previous
  & index birth
<1 year                      64    7
1-3 years                    129   33
>3years                      48    28
Index birth planned
Yes                          230   74
No                           91    20
Yes                          288   68
No                           33    26
Counseled about PPFP
Yes                          231   42
No                           90    52
Place of delivery
Health facility              282   58
Home                         39    36
Discussed on PPMC with
Yes                          224   20
No                           66    72
Himtana                      246   83
Other*                       75    11
Had knowledge on PPFP
Yes                          311   85
No                           10    9
Knew pregnancy could
  happen within PPP
Yes                          225   31
No                           96    63


                                    COR                   AOR
15-24                                1                     1
25-34                         1.72 (1.02-2-90)     1.72 (0.59-5.01)
35-44                         1.06 (056-2.03)      2.18 (0.65-7.41)
Educational status
No formal education                  1                     1
Primary education (1-8)       1.02 (0.53-1.95)     1.06 (0.29-3.86)
Secondary education (9-12)    3.41 (1.18-9.90)     3.74 (0.28-49.68)
Tertiary & above             3.73 (1.11-12.55)     0.83 (0.14-5.08)
Time gap b/n previous
  & index birth
<1 year                      5.33 (2.15-13.24)    7.98 (2.50-25.52)*
1-3 years                     2.28 (1.25-4.17)     2.11 (0.95-4.70)
>3years                              1                     1
Index birth planned
Yes                                  1                     1
No                            1.46 (0.84-2.54)     0.54 (0.22-1.31)
Yes                           3.33 (1.87-5.95)     1.97 (0.74-5.30)
No                                   1                     1
Counseled about PPFP
Yes                           3.19 (1.98-5.15)     2.29 (1.27-5.71)*
No                                   1                     1
Place of delivery
Health facility               4.49 (2.63-7.65)     2.14 (0.93-04.93)
Home                                 1
Discussed on PPMC with
Yes                          12.22 (6.94-21.53)   14.62 (6.52-32.75)*
No                                   1                     1
Himtana                              1                     1
Other*                        2.30 (1.17-4.54)     1.10 (0.31-3.86)
Had knowledge on PPFP
Yes                           3.29 (1.30-8.36)     1.00 (0.13-7.03)
No                                   1                     1
Knew pregnancy could
  happen within PPP
Yes                           4.76 (2.91-7.80)     6.53 (3.2-14.12)*
No                                   1                     1

*= Statistically significant at p [less than or equal to] 0.05.
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Title Annotation:Research Article
Author:Tadesse, Samrawit Yonas; Emiru, Amanu Aragaw; Tafere, Tadese Ejigu; Asresie, Melash Belachew
Publication:Advances in Public Health
Geographic Code:6ETHI
Date:Dec 31, 2019
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