Implants are one of the most effective long acting reversible contraceptive methods. All age of women can utilize implants and fertility is immediate when removed, whereas the contraceptive choice of Ethiopian women is still sloped to short acting methods.

Objective: The aim of this study was to determine utilization of implants and associated factors among women who came for family planning service in Bahir Dar City public health facility, North West, Ethiopia, 2018. Institutional based cross-sectional study was conducted from April 1 to April 30, 2018. Systematic random sampling technique was used to select study participants and the sample allocates to each public health institution proportionally.

Results: A total of 359 women were interviewed giving a response rate of 90.2%. The overall utilization of implants was 16.2%. Shifting from one contraceptive method to the other (AOR=3.36, 95% CI; 1.607-6.844), media use in the house (AOR=5.4, 95% CI; 2.197-13.59) and level of education (AOR=5, 95% CI; 1.44-17.7) were the determinant factors for implant utilization.

From participants (n=300) who had heard about implants, 226(63%) of the participants had poor knowledge and 166(37.3%) had positive attitude towards implants.

Keywords: Utilization, Implants, Ethiopia

INTRODUCTION

Implants are one of the most effective long acting reversible contraceptive methods. They are hormonal releasing subdural roads which prevent pregnancy for an extended period without user’s action. All age of women can utilize implants and fertility is immediate when removed [1,2].

Contraceptive implants are sub dermal flexible plastic rods with the size of a matchstick and release a progestin hormone into the body. The commonest types are implant (single implanon rod with 60 mg of 3-keto-desogetrel (etonogestrel) with a daily release of 60ug/day), Jadelle (two rods, each containing 75 mg of levonorgestrel); and sino-implant (two rods, each containing 75 mg of levonorgestrel) [3]. The implants work by a combination of factors. The most important of these are prevention of regular egg release and thickening of the cervical mucus, making it more difficult for sperm to reach the egg [4].

Globally, there were an estimated 216 maternal deaths per 100, 000 live birth in 2016, among those 99% of maternal mortality ratio is in developing regions. Sub-Saharan Africa alone accounts for 66%. Maternal mortality ratio in developing regions was 19.9 times higher than in developed regions. Interestingly, the huge number of maternal and new born death can be prevented by ensuring that every pregnancy is planned and wanted by using effective contraceptive methods [5].

Each year globally, an estimated 80 million unintended pregnancies occur resulting in 42 million induced abortions and 34 million unintended births. Its rate is greater in developing regions than developed regions. Unintended pregnancies have negative consequences for the health and well-being of the women, particularly in low and middle-income countries [6].

According to Ethiopian Demographic and Health Survey (EDHS) 2016, total fertility rate of Ethiopia was 4.2 children per women, population growth rate was estimated to be 2.61% per year and modern contraceptive prevalence rate was 36% with long-acting reversible contraceptive utilization of 10%. The Ethiopian Ministry of Health has undertaken the initiative for measures to reduce maternal mortality through most importantly provision of LARC at all levels of the health care system The Ethiopian government also planned to achieve a total fertility rate (TFR) of 2.1 and a contraceptive prevalence rate (CPR) of 55% by 2020 with considerable effort to increase utilization of long-acting reversible contraceptive methods [7,8].

Ethiopia has made progress in increasing awareness and utilization of modern contraceptives, but most utilizers are slanted to short acting methods. As a result, the main objective of this study was to assess the implant contraception utilization and associated factors among women attending family planning health facilities in Bahir Dar city.

MATERIALS AND METHODS

Study setting and period

Institution-based cross-sectional study was conducted from April 1 to April 30, 2018 in Bahir Dar city public health facilities. Bahir Dar city is the regional capital of Amhara region, 578 km North West of Addis Ababa, capital of Ethiopia. There are two public hospitals and six health centers, four private clinics and two non-governmental organizations, all providing family planning service. A town had a total population of 221,991 of whom 108,456 were male and 113,535 were female [9].

Sample size and sampling procedure

We calculated the required sample size of 384 participants by single population proportion formula with the assumption of 95% confidence interval, margin of error 5%, 10% non-response rate and by taking proportion of women, who have income were implant utilizer (31%), from previous study in Southern Ethiopia [10].

Sampling procedure

All public, private and non-governmental organization provides family planning service. Purposively for this study only public health facilities were included in the study because of the uniformity in provision of free cost FP services, i.e., all of these public health facilities; Felege Hiwot Referral Hospital, Adis Alem Hospital, Han Health Center, Ginbot 20 Health Center, Bahir Dar Health Center, Abay Mado Health Center, Shimbit Health Center and Shum Abo Health Center [11].

The calculated sample size was proportionally allocated to each health facility based on the average monthly client flow in the last similar month with our data collection period, was 1988 obtained from Bahir Dar city administrative health Beuro. The study participants were selected by using systematic random sampling method and the sampling fraction (K^th) value was determined by dividing the total number of women that used family planning in the last similar month prior to data collection 1988/359=6 and the first respondent was selected by lottery method.

Data collection procedure

Data was collected through face to face interview by using a structured questionnaire. Eight data collectors and two supervisors were assigned during data collection period and each data collector was assigned to each family planning delivery service unit. Exit interview was conducted after participants took contraceptive method at the service delivery unit.

Data quality assurance

Date collection tool was first prepared by English, translated to local language, Amharic and translated back to English by a professional expert to check for consistency. Pretest was done on 5% of respondents on other health centers which was not included in the study prior to data collection and appropriate correction was made. Training was given for data collectors and supervisors on ways of approaching a study participant, keeping their confidentiality, method of extracting information through interviewing and recording collected data. Supervisors made spot checking and reviewing the completed questionnaires on daily basis to ensure completeness and consistency of the data.

Data processing and analysis

Data was cleaned for completeness and consistency, coded entered into Epi info version 7 and exported to SPSS version 23 for analysis. The result was organized, summarized and presented using appropriate descriptive measures such as text, graph, table, frequency and percentage. Association between outcome variable and independent variable were assessed by using odds ration with 95% CI, bi-variable logistic regression was used to identify factors significantly associated with the outcome variable with p-value less than or equal to 0.05. These variables were entered into multi-variable regression models to assess the independent predictor of implant utilization. Finally variables which were significant at p-value less than 0.05 with 95% CI were considered as a determinant factor for implant utilization.

RESULTS

Socio-demographic characteristics

A total of 359 reproductive age women respond to the questionnaire and analyzed making the response rate 90.2%. The mean age of the study participants were 26.4 years (26.4 ± 5.626 SD) and the median age was 25 years. Regarding to educational status 41 (11.4%) cannot write and read, 55 (15.2%) completed elementary school, 125(34.6%) completed secondary school and 83 (23%) had completed college or university degree.

Majority of the respondents were in the age group of 21-25 years, 26-30 years, 31-35 years, 15-20 years, 36-40 years, >40 years were 151941 (8%), 89 (24.7%), 79 (21.9%), 21 (5.8%), 11 (3%) and 8 (2.8%), respectively.

Regarding the ethnicity of respondents were Amhara 307 (85%), Tigray 29 (7.8%) and Oromo 23 (6.4%). Most of the respondents 162(45.1%) were housewives, followed by employers 73 (20.3%) (Table 1).

Reproductive history of the study participants

Among the study participants, 220 (61.3%) gave birth and among them, 180 (87.8%) gave birth after the age of 20. Regarding the live number of children 113 (31.2%) women had 0-2 children, 91 (25.5%) had 3-4 number of children and 16 (4.8%) had 4 and more children.

Information and utilization of implants among study participants

Three hundred thirty of the study participants (91.9%) had information about modern contraceptives, among those 300 (83.6%) were heard of implants. The most common source of information was health professionals 140 (46.66%). Regarding the current use of implant contraceptive 16.2% of women were utilizing implants.

Among women who were not implants utilizer, the main reason for not utilizing implants was desire of more children, hearing implant affects daily activity, husband disapproval and fear of side effects (Figure 1).

Out of the study participants who ever heard about implants, 162 (45.1%) participants know that implant cannot prevent sexually transmitted disease, 156 (43.5%) know that implant prevents pregnancy for 3-5 years and 164 (45.7%) know that implants reverse pregnancy quickly when removed.

Among those who participated who ever heard about implants only 106 (29.5%) agreed that using an implant does not restrict from performing daily activities, whereas 161 (44.8%) were not sure about using implant does not restrict from performing daily activities. Regarding pain during insertion and removal, 141 (39.3%) agreed that insertion and removal of the implant are not highly painful and 104 (29%) agreed that implants does not cause infertility, 154 (42.9%) were not sure if implants cause infertility (Table 2).

Factors associated with the utilization of implants

Utilization of implants was 16.2%. Multiple logistic regression model revealed that shifting from one contraceptive method to the other, media use in the house and level of education were the determinant factors.

Women who shift contraceptive methods were 3 times (AOR=3.36, 95% CI; 1.607-6.844) more likely to utilize implants than their counterparts.

As to this study, women who use media in the house were 5 times (AOR=5.4, 95% CI; 2.197-13.59) more likely to utilize implants than women who had not to use media in the house. Additionally, women educated above college/university were 5 times (AOR=5, 95% CI; 1.44-17.7) more likely to utilize implants than women cannot read and write (Table 3).

DISCUSSION

Accessibility to appropriate family planning methods should be considered as individuals and couples right since it has indispensable advantage to empower women. It is central to efforts to reduce poverty, promote economic growth, raise female productivity, lower fertility and improve child survival and maternal health (11). This study was mainly identified for magnitude of implant users and predictors determining its utilization status among women of reproductive age group. Accordingly, utilization of implant contraceptive was 15.6%.

This finding was almost all comparable with the study obtained from married women of reproductive age group that was conducted in Southern Ethiopia, i.e. (15.1%) and study obtained from implant utilization among reproductive age women at Ejere Health Center, West Shewa Zone of Oromia region had used implants for contraception [12,13].

This result was high as compared to Ethiopian Demographic Health Survey (8%) [14]. The difference might be due to study area. Our study area was conducted only in Bahir Dar city, but EDHS covers many parts of Ethiopia including rural and urban.

Additionally, the result is higher than the prevalence of implants contraceptive reported from five studies, Mekelle town (7.5%) Jinka (7%), Butajira (5%) and a facility based study in Guatemala 8% [15-17].

In this study, the main reasons complained by the women for not using implant contraceptive methods were, desire of more children (28.7%), hearing implant affect daily activity (19.85%), fear of side effects (26.4%).

The main source of information to use implant as contraceptive among family planning users in study area was health care workers and mass media. This finding is consistent with the study done in South Eastern Ethiopia which shows that the source of information was health care workers and mass media [12].

There was a significant association between shifting of contraceptive methods and implant utilization. Mothers who shift or change contraceptive method were 3.3 times (AOR=3.36, 95% CI; 1.607-6.844) utilize implants as compared to those who did not shift. This finding was consistent with the findings obtained in Mizan AmanTown [18], Mekelle [19] and Burkina Faso [20].

There was also a significant association between media use in the house and implant utilization. Women who use media in the house were 5 times more (AOR=5.4, 95% CI; 2.197-13.59) likely utilize implants than those who do not use media. Additionally, women who educate above college or university were 5 times more likely (AOR=5, 95% CI; 1.44-17.7) utilize implants.

CONCLUSION

Utilization of contraceptive implants was found to be low. Shifting from one contraceptive method to the other, media use in the house and level of education were the determinant factors for implant utilization.

Additionally, knowledge and attitude of study participants were low. Therefore, to scale up utilization of implants, community and facility level awareness creation could help and appropriate counseling about the side effects and management method could be reinforced.  Additionally, educating women could also improve utilization of implants.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethical approval and clearance was obtained from Bahir Dar University College of Medicine and Health sciences Department of Midwifery for approval and formal letter was written. Informed written consent was also obtained from the study participants after the purpose of the study was fully explained. Confidentiality of information and privacy was maintained.

AVAILABILITY OF DATA

The datasets used and/or analyzed during the study are available from the corresponding author on reasonable request.

ACKNOWLEDGEMENT

I would like to acknowledge Dar University, College of Medicine and Health Sciences, Department of Midwifery. My sincere and deepest gratitude would go to Bahir Dar City Administrative Health Bureau for writing letter of permission for selected health facilities. I also would like to extend our heartful thanks to data collectors, supervisors and all reproductive age women for their kind support in giving us the data. 

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