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Factors associated with long-acting familyplanning service utilization in Ethiopia: asystematic review and meta-analysisTamirat Tesfaye Dasa1* , Teshager Worku Kassie1, Aklilu Abrham Roba1, Elias Bekele Wakwoya1 andHenna Umer Kelel2
Abstract
Background: Even though the modern contraceptive use was improved in Ethiopia, the utilization of long-actingfamily planning services is still low because of numerous factors. The aim of this systematic review was tosynthesize logical evidence about factors associated with long acting family planning service utilization in Ethiopia.
Methods: The participants of the study were married women of reproductive age in Ethiopia. This search includedall published and unpublished observational studies written in the English language conducted before April 30,2018, in Ethiopia. Electronic and non-electronic sources were used. PubMed, MEDLINE (EBSCO), CINHAL (EBSCO),Embase (EBSCO), POPLINE and the search engines like Google, Google Scholar Mednar and world cat log wereused. The overall selected search results were 15 studies. Each study was evaluated using the Joanna BriggsInstitute Quality Assessment Tool for Observational Studies. Data synthesis and statistical analysis were conductedusing ReviewManagerVersion5.3.5.
Results: Women’s inadequate knowledge level [OR, 0.29; 95% CI: 0.10, 0.83, P = 0.02], women’s age between 15 and 34[OR, 0.82; 95% CI: 0.53, 0.93, P = 0.01], not having electronic media [OR, 0.65; 95% CI: 0.53, 0.79, P < 0.0001] and womenfrom rural area [OR = 0.65;95% CI:0.50, 0.81, P = 0.0009] were less likely associated in the use of long-acting family planningservices. The odds of utilizing long acting family planning methods were high among non-government- employedwomen and husband [OR, 1.77; 95% CI: 1.29, 2.43, P = 0.0004], [OR, 1.69; 95% CI: 1.33, 2.15, P < 0.0001] respectively. Havingno previous exposure to any modern family planning method [OR = 2.29; 95%CI: 1.83, 2.86, P < 0.00001] and womenhaving no discussion with husband [OR = 1.92 (95%CI: 1.50, 2.45) P < 0.00001] were more likely associated in theutilization of long-acting family planning services.
Conclusion: Lack of information and knowledge, having discussion with husband, being women of younger age, havingless than five living children, being government-employed women and husband, not having electronic media, and beingresidents in rural area were significant barriers for underutilization of long acting family planning methods in Ethiopia.Hence, the investigators suggest that key stakeholders should design interventions strategies to avert attitudinal, culturaland informational barriers towards long-acting family planning methods.
Systematic review registration: PROSPERO: 2018: CRD42018096373.
Keywords: Long-acting contraceptive, Married women, Ethiopia, Systematic review and meta-analysis
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: [email protected] Health and Maternal, School of Nursing and Midwifery,College of Health and Medical Sciences, Haramaya University, P.O. Box 235,Harar, EthiopiaFull list of author information is available at the end of the article
Contraception andReproductive Medicine
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 https://doi.org/10.1186/s40834-019-0095-z
IntroductionThe modern contraceptive use has steadily increasedover the past 15 years in Ethiopia. The contraceptiveprevalence rate in 2000 was only 6.3%, which acceleratedto 35% in 2016. However, utilization of long-acting fam-ily planning methods (LAFPM) is still low compared tothe injectable contraceptives [1, 2]. According to theEthiopian Demographic and Health Survey (EDHS) 2016Report the most commonly used contraceptive methodfor currently married women in Ethiopia are injectable(23%) followed with implants (8%). The total fertility ratein Ethiopia is 4.6 children per woman and 22% percentof currently married women have an unmet need forfamily planning. Shifting towards LAFPM is the beststrategy to ensure continuity of the family planning ser-vice in a country like Ethiopia where there is high fertil-ity rate and unmet need for family planning [2].Long-acting family planning methods (LAFPM) can be
permanent or reversible; are methods that prevent preg-nancy more than three years per application which in-clude subdermal implants, intrauterine devices (IUD) andmale and female sterilizations. These methods have manyadvantages compared to other family planning methods.They are convenient, very effective, long-lasting, reversibleand cost-effective. In addition to these the effectiveness ofLAFPM are not dependent on compliance with taking theoral contraceptives daily or taking the regular injection atclinics; therefore they prevent the failure rate due to theincorrect use [3]. It is estimated that 1,250 unwanted preg-nancies would have prevented if 5000 oral contraceptiveusers were to switch to intrauterine device or implantsover a period of years [4].Different pocket primary studies were conducted in dif-
ferent parts of Ethiopia to determine the factors associatedwith utilization of long-acting family planning methods(LAFPM). There are few comprehensive studies done inEthiopia about LAFPM. The study conducted by Yonatanet al. assessed the practice and intention to use long-actingand permanent contraceptive methods among marriedwomen in Ethiopia by using systematic review and meta-analysis [5]. However, this study did not address the factorsassociated with the utilization of long-acting contraceptivesin Ethiopia. Therefore, the aim of this study is tosummarize the evidence of factors associated with LAFPMutilization among married women in Ethiopia. The summa-rized evidence obtained from this study helps the con-cerned bodies to identify existing gaps and proposestrategies to increase the utilization of long-acting familyplanning methods (LAFPM) in Ethiopia.
MethodsProtocol and registrationThis review was developed based on the PRISMA (Pre-ferred Reporting Items for Systematic Reviews and Meta-
Analyses) guideline [6](See Additional file 1). The reviewhas been registered protocol by the International prospect-ive register of systematic reviews (CRD42018096373).
Eligibility criteriaThe study participants were married women of reproduct-ive age in Ethiopia. They were from all socio-economicstatus, all ethnic groups and language. This search in-cluded all published and unpublished observational(cross-sectional and case-control) studies on factors affect-ing long-acting family planning service utilization amongmarried women of reproductive age in Ethiopia. It in-cluded studies conducted before April 30, 2018 and werewritten in the English language. Reviews, commentaries,editorial, case series/report, and patient stories were ex-cluded from the systematic review process.
Information source sand search strategyThis systematic review and meta-analyses is conducted ac-cording to PRISMA (Preferred Reporting Items for System-atic Reviews and Meta-Analyses) guideline [6]. Theinvestigators retrieved information from electronic andnon-electronic database sources. Electronic databasesources: PubMed, MEDLINE (EBSCO), CINHAL (EBSCO),Embase (EBSCO) and POPLINE were used to retrieve pub-lished articles. Non-electronic sources used; direct Googlesearch, Google Scholar, Mednar and world cat log.Combination of search terms were used with (AND,
OR, NOT) Boolean (Search) Operators. The searchstrategy included the use of Title/Abstract related to:(“family planning service” “AND” “Factors associated” or“Determinants” or “Predicators” “AND” Ethiopia) takenfrom the review questions. Non-electronic sources usedwere combined with direct Google search, GoogleScholar, Mednar and worldcat log. In addition, the inves-tigators searched manually for grey literature and otherrelevant data sources such as email and unpublishedthesis/papers with planned dates of coverage. The searchstrategy for CINHAL is outlined in (Additional file 2).
Study selectionAll search articles were exported to the EndNote X8 cit-ation manager and duplicated studies were excluded. Thenstudies were screened through by careful reading of thetitle and abstract. The three authors (TT, EB and TW)screened and evaluated studies independently. The titlesand abstracts of studies that clearly mentioned the out-comes of the review (factors associated//determinants/pre-dictors/ of family planning service utilization) wereconsidered for further evaluation to be included in the sys-tematic review and meta-analysis. Then the full-text of thestudies were further evaluated based on objectives,methods, participants/population and key findings (Factorsassociated/affecting/determinants/predicators/long-acting
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 2 of 14
family planning methods utilization. The two authors (AAand HU) independently evaluated the quality of the studiesagainst the checklist. Any discrepancy was resolvedthrough discussion or through asking a third reviewer ifconsensus could not be reached.The overall study selection process is presented using
the PRISMA statement flow diagram [7] (Fig. 1).
Data collection processAfter the selection of appropriate articles, data were ex-tracted by two investigators independently (TW and EB)using a data extraction template and presented throughMicrosoft word 2016 (containing author & year, setting,study design, sample size, study subject, data collectionmethods, primary outcome of interest and specific fac-tors associated with LAFPM utilization) (Table 1). Theaccuracy of the data extraction was verified by compar-ing the results with the data extraction by the secondthree investigators (TT, AA, HU), who independentlyextracted the data in a randomly- selected subset of pa-pers (30% of the total).The quantitative data (the total sample size (n) and
specific factors associated with utilization of long-actingfamily planning methods) were extracted from the in-cluded articles and summarized using Microsoft Excel2016 for meta-analysis and synthesis.
Data itemsThe determinants of long-acting family planningmethods (LAFPM) utilization were the main outcome
variables which were achieved by this systematic reviewand meta-analysis. The outcome variables were mea-sured either by a direct report from the included studiesor indirectly based on the statistics reported in the indi-vidual studies. To quantify the outcome “Factors associ-ated with long-acting family planning methodsutilization” the investigators considered studies whichreported as determinants of LAFPM in their statisticsdifferently and specifically, women’s knowledge level,women’s age; women’s education level; husband’s educa-tion level; number of living children; joint husband-wifediscussion; women’s occupation; husband’s occupation;the presence of media; the residence of setting; previoushistory of utilizing family planning method and others tocomprehensively quantify the determinants. The resultwas interpreted by odds ratio.
Risk of bias in individual studiesInvestigators critically evaluated the risk of bias from in-dividual studies using the Joanna Briggs Institute QualityAssessment Tool for observational studies. To minimizethe risk of bias comprehensive searches (electronic/data-base search and manual search) were used and alsoincluded published, unpublished facility or community-based studies and thesis. Cooperative work of the au-thors was also critical in reducing bias, in setting aschedule for the selection of articles based on the clearobjectives and eligibility criteria, deciding the quality ofthe article, in regularly evaluating the review process,and in extracting and compiling the data. Publication
Fig. 1 Description of schematic presentation of the PRISMA flow diagram to select and include studies, 2018
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 3 of 14
Table
1Descriptio
nof
stud
yparticipantsandcharacteristicsof
Stud
iesinclud
edin
thesystem
aticreview
andmeta-analysis
No.
Autho
rs&years
Settingof
thestud
yDesignof
thestud
ySample
size
Stud
ysubject
Data
collection
metho
ds
Prim
aryou
tcom
eof
interest
Specificfactorsassociated
with
utilizatio
nof
long
-acting
family
planning
metho
ds(LAFPM)utilizatio
n
1.Alemayeh
u,M.
etal.2012[8]
Com
mun
ity-
based
Cross-
sectional
460
Marriedwom
enof
reprod
uctiveage
Structured
Interviewer
Utilizationof
long
-actingandpe
rmanen
tcontraceptivemetho
ds(LAPC
M)
-Kn
owledg
e,Num
berof
preg
nancies,Desire
for
morechildren
2.Bu
lto,G
.A.
etal.2014[9]
Com
mun
ity-
based
Cross-
sectional
519
Marriedwom
enof
reprod
uctiveage
Structured
interview
Dem
andforLAPC
MAge
,Desire
formorechild,D
urationof
desire
forachild,
Num
berof
childrenever
born,D
iscussionwith
apartne
ron
ametho
dto
use
3.Geb
re-Egziabh
er,
Destet
al.
2017
[10]
Com
mun
ity-
based
Cross-
sectional
524
Wom
enof
reprod
uctiveage
Structured
interview
Utilizationof
Implant
Employmen
t,Num
berof
metho
dsever
used
4.Geb
remariam,
A.&
Add
issie,A.
2015
[11]
Com
mun
ity-
based
Cross-
sectional
591
Marriedwom
enStructured
interview
Intentionto
useLA
PCM
Partne
r’sed
ucation,Participantoccupatio
n,wantsmore
child
with
in2years,Kn
owLA
PCMs,Husband
supp
ort
LAPM
use
5.Geb
remichael
etal.
2015
[12]
Com
mun
ity-
based
Cross-
sectional
342
Marriedwom
enStructured
interview
Accep
tanceof
LACM
Theattitud
eof
respon
dent
towards
ActingReversible
Con
tracep
tiveacceptance
6.Guidance,
Shim
elsW
udie
etal.
2015
[13]
Unm
atched
Case-
control
360
MarriedWom
enInterview
Use
ofLong
-ActingReversible
Con
tracep
tive
Age
ofrespon
dent,O
ccup
ation,Husband
-wife
discussion
7.Med
hanyie,A
.et
al.2017[14]
Com
mun
ity-
based
Cross-
sectional
540
wom
enof
reprod
uctive
agegrou
p
Structured
interview
Use
oflong
-actingfamily
planning
Reside
nce
8.Mekon
nen,
Getache
wet
al.2014[15]
Com
mun
ity-
based
Cross-
sectional
763
Wom
enof
reprod
uctiveage
Structured
interview
Use
oflong
-actingand
perm
anen
tcontraceptive
Age
,Kno
wledg
eof
Long
-actingandpe
rmanen
tcontraceptivemetho
ds
9.Melka,A
.S.
etal.2015[16]
Com
mun
ity-
based
Cross-
sectional
1003
Marriedwom
enof
reprod
uctiveage
grou
ps
Structured
interview
Utilizationof
long
-actingand
perm
anen
tcontraceptive
metho
ds
Education,Occup
ation,Num
berof
livechildren,theJoint
decision
onfertility
with
apartne
r,Haveradio/TV
10.
Meskeleand
Mekon
nen
2014
[17]
Com
mun
ity-
based
Cross-
sectional
416
Wom
enStructured
interview
Use
long
-actingandpe
rmanen
tcontraceptive
Educationalstatus,Attitu
descore(com
posite),Heard
myths
andmisconcep
tions
11.
Serawit,L.and
Alemayeh
u,W.2012[18]
Facility-
based
Unm
atched
Case-
control
270
wom
enof
reprod
uctiveage
Structured
interview
Use
oftheintrauterin
econtraceptivede
vice
Educationalstatus,Age
ofyoun
gestchild,IUCD
causes
infection
12.
Shiferaw,K.and
Musa,A.2017[19]
Facility-
based
Cross-
sectional
400
wom
enof
reprod
uctive
agegrou
p
Structured
interview
Utilizationof
long
-acting
reversiblecontraceptive
Occup
ationof
wom
an,Ethnicity,Religion
13.
Tamrie,
YirgaEwne
tuetal2015
[20]
Com
mun
ity-
based
Cross-
sectional
441
Mothe
rsin
the
Postpartum
Perio
dStructured
interview
Use
ofLong
-actingReversible
Con
tracep
tion
Educationof
participant,Previous
useof
long
-acting
reversiblecontraceptive,Cou
nseled
onlong
-acting
reversiblecontraceptive
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 4 of 14
Table
1Descriptio
nof
stud
yparticipantsandcharacteristicsof
Stud
iesinclud
edin
thesystem
aticreview
andmeta-analysis(Con
tinued)
No.
Autho
rs&years
Settingof
thestud
yDesignof
thestud
ySample
size
Stud
ysubject
Data
collection
metho
ds
Prim
aryou
tcom
eof
interest
Specificfactorsassociated
with
utilizatio
nof
long
-acting
family
planning
metho
ds(LAFPM)utilizatio
n
14.
Yalew,
Saleam
lakAdb
aruet
al2015
[21]
Facility-
based
Cross-
sectional
487
Wom
enusersof
family
planning
Structured
interview
Thede
mandforlong
-acting
contraceptiveusers
Occup
ationalstatus,Num
berof
children,Num
berof
discussion
swith
husband,
decision
maker
touse
15.
Zene
be,C
.B.etal.
2017
[22]
Facility-
based
Cross-
sectional
317
wom
enreprod
uctive
agegrou
p
Structured
interview
Utilizationof
long
-actingand
perm
anen
tcontraceptive
Educationalstatus,Inform
ationabou
tlong
-actingpe
rmanen
tcontraceptivemetho
ds(LAPC
M),Previous
useof
LAPC
M
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 5 of 14
bias was explored using visual inspection of the funnelplot. Besides, Egger’s Regression Test was carried out tocheck statistically symmetry of the funnel plot [23].
Synthesis of dataData synthesis and statistical analysis were conductedusing Review Manager (RevMan) version 5.3.5. A meta-analysis of observational studies was carried out, basedon the recommendations of the I2 statistic described byHiggins et al. (an I2 of 75/100% and above suggestingconsiderable heterogeneity). The investigators checkedfor potential publication bias through visual inspectionof a funnel plot, and Egger’s Regression Test. Publicationbias was assumed for P-values of less than 0.10. The re-sults of the review were reported according to thePRISMA guidelines. The findings of the included studieswere first presented using a narrative synthesis andfollowed by meta-analysis chart.
ResultDescription of review studiesA total of 327 articles were identified through the majormedical and health electronic databases and other relevantsources. From all identified studies, 120 articles were re-moved due to duplication while 207 studies were reservedfor further screening. Of these, 176 were excluded afterbeing screened according to titles and abstracts. Of the 31remaining articles, 16 studies were excluded due to incon-sistency with inclusion criteria set for the review. Finally,15 studies which fulfilled the eligibility criteria were in-cluded for the systematic review and meta-analysis. Gen-eral characteristics and descriptions of the studies selectedfor the meta-analysis were outlined in (Table 1).
Factors associated with utilization of long-acting familyplanning servicesThe results of this review have shown many factors asso-ciated with long-acting family planning servicesutilization in Ethiopia. Significant associated factors werethe woman’s knowledge level, woman’s age, woman’seducation level, husband’s education level, number ofliving children, joint husband-wife discussion, woman’soccupation, husband occupation, the presence of media,the residence of setting, and previous history of usingfamily planning method. The review also verified that in-come was not a significant predictor of long-acting fam-ily planning services utilization.
Woman’s knowledge level on family planningThe level of woman’s knowledge was significantly associ-ated with long-acting family planning servicesutilization. Women who had inadequate knowledge onmodern family planning were less likely to utilize longacting family planning services compared to womenwho had adequate knowledge [OR, 0.29; 95% CI: 0.10,0.83, P = 0.02]. Heterogeneity test indicated I2 = 94%,hence the random and fixed effect model was employedinterchangeably for analysis. In addition, a sensitivityanalysis was done, and no change was illustrious in theoverall odds ratio (OR) (Fig. 2).
Woman’s ageThe woman’s age was significantly associated withutilization of long-acting family planning services. Theodds of utilizing long acting family planning serviceswere low among women 15 to 34 years of age as com-pared to those aged between 35 to 49 years [OR, 0.82;
Fig. 2 Association between woman’s knowledge levels with utilization of long-acting family planning services in Ethiopia, 2018
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 6 of 14
95% CI: 0.53, 0.93, P = 0.01]. Heterogeneity test indicatedI2 = 87%, hence random and fixed effect model wasemployed interchangeable for analysis, but no significantchange on heterogeneity in both models. So, the investi-gators assume to employ fixed effect model for analysisbecause there was a small change in overall summary re-sults (Fig. 3).
Woman’s occupation statusAn Odds Ratio revealed that there was a significant as-sociation between woman’s occupation and utilization oflong-acting family planning services [OR, 1.77; 95% CI:1.29, 2.43, P = 0.0004]. The non-government employed
woman was 1.8 times more likely to have long-actingfamily planning services as compared to government-employed woman (Fig. 4).
Husband’s occupation statusThe results of the review showed statistically significantassociation between husband’s occupation and women’sutilization of long-acting family planning services.Women whose husbands were non-government em-ployees utilize LAFP services than those whose husbandswere government employees (OR, 1.69; 95% CI: 1.33,2.15, P < 0.0001). The heterogeneity test indicated an I2
value of 15% (Fig. 5).
Fig. 4 Association between woman’s occupations with utilization of long-acting family planning services in Ethiopia, 2018
Fig. 3 Association between woman’s age with long-acting family planning services utilization in Ethiopia, 2018
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 7 of 14
Women’s education levelThe findings of the review indicated a significant associ-ation between women’s education level and utilization oflong-acting family planning services. Women who haveno formal education were 0.59 times less likely to utilizelong-acting family planning services as compared towomen who had primary education and above [OR =0.59;95% CI: 0.40, 0.87, P = 0.007]. Heterogeneity test in-dicated I2 = 77%, hence random effect model was as-sumed in the analysis. Sensitivity was done of analysisbut did not bring significant change in the overall sum-mary results of OR (Fig. 6).
Husband’s education levelThe results of the analysis indicated significant associ-ation between husband’s education level and utilizationof long-acting family planning services. A husband whohad primary education and lesser was less likely toutilize long-acting family planning services as comparedto women who attended the secondary and above educa-tion [OR = 0.53; 95% CI: 0.41, 0.70, P < 0.00001] (Fig. 7).
Joint husband-wife discussionThe odds ratio of the analysis indicated a significant as-sociation between husband-wife discussion andutilization of long-acting family planning services.Women who discussed about family planning methodswith their partner utilize long acting family planningmethods nearly two times than those who did not[OR = 1.92 (95% CI: 1.50, 2.45) P < 0.00001]. The inves-tigators considered a fixed effect model for the analysisbecause the I2value was 94%. In addition, a Sensitivityanalysis was done, and no significant change was ob-served in the overall summary results of odds ratio(OR) (Fig. 8).
Monthly incomeThere was no significant association between monthlyincome and utilization of long-acting family the planningservices [OR = 1.68; 95% CI: 0.20, 14.01, P = 0.63]. Het-erogeneity test indicated I2 = 98%, hence random effectmodel was assumed during analysis (Fig. 9).
Fig. 6 Association between women’s education with long-acting family planning service utilization in Ethiopia, 2018
Fig. 5 Association between husband occupations with long-acting family planning service utilization in Ethiopia, 2018
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 8 of 14
Presence of electronic mediaPresence of electronic media was significantly associ-ated with utilization of long-acting family planningservices. Women who do not have electronic media(radio/television) are less likely to utilize long-actingfamily planning services as compared to women whohave electronic media [OR, 0.65; 95% CI: 0.53, 0.79,P < 0.0001]. Heterogeneity test indicated I2 = 92%,hence the fixed-effect model was assumed in the ana-lysis. To reduce the heterogeneity, a Sensitivity ana-lysis was done, and no change was recognized in theoverall OR. In addition, the investigators applied bothmodels interchangeably and heterogeneities were thesame (Fig. 10).
Number of living childrenA significant association was found in utilizing long-act-ing family planning services between partners who haveless than five living children and greater than or equal tofive children (OR,0.72; 95% CI:0.54, 0.94, P = 0.02). Butthere was considerable heterogeneity found (I2 = 92%).Hence, the fixed-effect model was assumed during ana-lysis. Here the investigators employed both models inter-changeably for this analysis but no heterogeneity changewas found (Fig. 11).
Previous utilization of family planning methodsThis review demonstrated that there was no significant as-sociation between previous utilization of family planning
Fig. 8 Association between husband-wife discussions and utilization of long-acting family planning services in Ethiopia, 2018
Fig. 7 Association between husband educations with long-acting family planning service utilization in Ethiopia, 2018
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 9 of 14
methods and utilization of long acting family planning ser-vices(utilization) in the random model (OR, 3.16; 95% CI:0.84, 11.85; P = 0.09). However, significant differenceswere found in the fixed effect model (OR = 2.29; 95%CI:1.83, 2.86, P < 0.00001). Women who were not previouslyexposed to family planning use were 2.29-folds more likelyto utilize long-acting family planning services as comparedto women who had previous exposure. But considerableheterogeneity was found too high (I2 = 96%) between thestudies in both models. Furthermore, significant differ-ences were found between the two groups in the fixed ef-fect model (Fig. 12).
Residence of the settingThe residence of women was significantly associatedwith utilization of long-acting family planning services(utilization). Results of this review revealed that resi-dence (as defined as rural and urban) was one of theaffecting factors that determined the utilization of long-
acting family planning services. Women from rural areaswere less likely to use long-acting family planning ser-vices than those (women) from urban areas (OR = 0.65;95% CI: 0.50, 0.81, P = 0.0009). Heterogeneity test indi-cated I2 = 69%, hence the fixed-effect model is assumedin this analysis because the confidence interval was verynarrow (Fig. 13).The risk of publication bias of the study presented in
funnel plots (Figs. 14) and (15).
DiscussionThis comprehensive study provides vibrant informationof overall factors that limit utilization of long-actingfamily planning services in Ethiopia. In this review, atotal of 15 studies done both in the community and fa-cility-based setting in different regions of Ethiopia wereincluded. From the included studies, 10 were commu-nity-based cross-sectional studies [8–12, 14–17, 20].Three other studies were institutional based cross-
Fig. 10 Association between presences of media with utilization of long-acting family planning services in Ethiopia, 2018
Fig. 9 Association between income and utilization of long-acting family planning services in Ethiopia, 2018
Dasa et al. Contraception and Reproductive Medicine (2019) 4:14 Page 10 of 14
sectional studies [19, 21, 22]; the last two studies wereunmatched case-control [13, 18].According to the Ethiopian Demographic and Health
Survey Conducted in 2016, The utilization of long-act-ing family planning methods in Ethiopia was very poor[2]. The findings of this systematic review and meta-analysis revealed many factors that contribute tounderutilization of LAFPM. Among the leading factors,the previous history of using family planning methodwas the main one. Women who had experience of usinglong-acting family planning method was not encour-aged to reuse it again [10, 11, 20, 22]. It might be re-lated to. Cultural attitudes and religious beliefs, fallacythinking (like, it might cause infertility), inadequateknowledge about LAFPM (side effects) as well as ad-verse effects (amenorrhea, unscheduled bleeding pat-terns, weight gain etc.) contributing for not usingLAFPM again, this may be associated With inad-equately trained family planning counselor and do not
provide the service all the times in all health institu-tions [24]. Attitudinal change and adequate informationare the main factors that help mothers to be a user oflong-acting family planning in this regard. Secondly,discussion with husband was the critical factor thatlimits long-acting family planning services utilization[10, 13, 15, 16, 21]. This is because of husbands are nothappy in using of long-acting family planning, becausethey want to have more children. It needs extra workon the attitude change to alter this habit.In addition, Being young adult women (Maternal age
between 15 and 34 years), women with no formal educa-tion, husband’s education level below primary education,having less than five living children, being government-employed women, women’s husband being a governmentemployee, having no electronic media at home, living ina rural area, and low maternal knowledge about LAFPMwere among the factors contributing to the poorutilization of long-acting family planning services in
Fig. 12 Association between previous uses of family planning method with utilization of long-acting family planning services in Ethiopia, 2018
Fig. 11 Association between numbers of living children with utilization of long-acting family planning services in Ethiopia, 2018
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Ethiopia [8–12, 14–17, 19–22]. This is comparable withthe review of the Asia Pacific region [25].
Strengths and limitationsThe investigators used extensive and comprehensivesearch strategies from multiple databases. Published, un-published studies and grey literature were included.Studies were evaluated for methodological quality usinga standardized tool. Although the literature search wassystematic and assessed all related studies within the de-sired scope, it is possible that relevant publications, e.g.publications reported in non-English language and locallanguages must have been missed. Studies with abstractwere the only ones included. This may affect the find-ing’s inclusiveness. This study doesn’t include any find-ings (studies) from Benishangul-gumuz Region. This
may affect the generalization of this study but still, thestudy will be applicable to all parts of Ethiopia.
ConclusionLong-acting family planning methods are underutilizedin Ethiopia due to lack of information and knowledgeabout them. This leads women to develop a negative at-titude towards these methods, the so-called joint hus-band-wife discussion inhibits utilization of LAFPMs. Inaddition, being young adult women (maternal age be-tween 15 and 34 years), women with no formal educa-tion, husband’s education below primary level, havingless than five living children, being government-employed women, women’s husband being a governmentemployee, not having electronic media at home, and res-iding in a rural area were among the factors contributing
Fig. 14 Publication bias on maternal age
Fig. 13 Association between residence and utilization of long-acting family planning services in Ethiopia, 2018
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to the poor utilization of long-acting family planningservices in Ethiopia. Hence, the investigators suggestthat key stakeholders should design interventions likebehavioral change communication (BCC) and commu-nity health education through health extension workers(women discussion group in the village) to avert attitu-dinal and informational barriers towards long actingfamily planning methods.
Additional files
Additional file 1: Preferred Reporting Items for Systematic Reviews andMeta-Analyses: The PRISMA Statement 2009 Checklist. (DOCX 19 kb)
Additional file 2: Sample search string for CINHAL and MEDLINE databases,EBSCOhost Interface. (DOCX 14 kb)
AbbreviationsIUD: Intrauterine Device; LAFPM: Long-Acting Family Planning Methods;MeSHs: Medical Subject Headings; OR: Odds Ratio; PRISMA: Preferred ReportingItems for Systematic Reviews and Meta-analysis
AcknowledgmentsWe would like to thank the College of Health and Medical Sciences, HaramayaUniversity (Ethiopia) for the non-financial support.
Authors’ contributionsTT, TW, AA, HU and EB conceived and designed the review. TT, TW and EBcarried out the draft of the manuscript and TT is the guarantor of the review.TT, TW and EB developed the search strings. TT, EB and TW screened andselected studies.TW and EB extracted the data. AA and HU evaluated thequality of the studies.TT, AA and TW carried out analysis and interpretation.TT, TW, AA, HU and EB rigorously reviewed the manuscript. All authors readand approved the final version of the manuscript.
Authors’ information(TT, TW, AA, HU and EB) Lecturers at School of Nursing and Midwifery,College of Health and Medical Sciences, Haramaya University and ArbaMinch Univeristy, Ethiopia.
FundingNone.
Availability of data and materialsThe data that support the review findings of this study are available uponsubmitting a reasonable request to the corresponding author.
Ethics approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Competing interestsThe authors declared that have no competing interests.
Author details1Reproductive Health and Maternal, School of Nursing and Midwifery,College of Health and Medical Sciences, Haramaya University, P.O. Box 235,Harar, Ethiopia. 2College of Medicine and Health Sciences, Arba MinchUniversity, Arba Minch, Ethiopia.
Received: 29 September 2018 Accepted: 4 July 2019
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