Utilization of modern contraceptives and associated factors among women of homeless reproductive age in Adama town, Oromia, Ethiopia

Abstract

Background

Family planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods. Contraceptive utilization is a practice that helps individuals or couples avoid unwanted pregnancy. A lack of family planning puts homeless individuals at a higher risk of unwanted pregnancies and sexually transmitted infections. However, there is little data about modern contraceptive utilization among homeless women in the study area.

Objectives

It has aimed to assess the utilization of modern contraceptives and associated factors among homeless reproductive-age women in Adama town, 2023.

Methods

A community-based cross-sectional study was conducted in Adama town among 286 homeless women. A convenience sampling technique was used. The data were collected through face-to-face interviews using a pretested structured questionnaire. The collected data were cleaned, coded, and entered into Epi Info, and the data were exported to the Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics were used to characterize the study population. The associations between dependent and independent variables were modeled using binary logistic regression. The adjusted odds ratio (AOR) and 95% confidence interval (CI) were used to estimate associations, and a P value < 0.05 was considered to indicate statistical significance.

Results

Out of the planned 289 respondents, 286 (98.9%) were participated. The prevalence of modern contraceptive utilization was 56.6% [95% CI: (50.7, 62.2)]. Among the utilizers, implants (52.5%), injectables (42%), and pills (5.5%) were used. Homeless women aged 25–34 years [AOR = 4.22, 95% CI: (1.77, 10.05)], a formal education [AOR = 3.04, 95% CI: (1.21, 7.60)], a slept off-street [AOR = 2.81, 95% CI: (1.25, 6.34)], a monthly income greater than or equal to 2400 Ethiopian birr [AOR = 4.18, 95% CI: (2.11, 8.29)], a sexual intercourse AOR = 3.14, 95% CI: (1.17, 8.40)], and a history of pregnancy after joining the street life [AOR = 9.21, 95% CI: (3.67, 23.12)] were factors significantly associated with the utilization of modern contraceptives.

Conclusion

The prevalence of modern contraceptive utilization among homeless women was relatively higher than in previous studies. The associated factors for contraceptive utilization included age, education, place for sleeping, income, sexual intercourse and history of pregnancy after joining the street life. The Regional and Adama town Health Bureau and facilities should develop targeted interventions (considering age, educational, and other disparities) to reduce the unmet need for modern contraception and halt unnecessary health outcomes among homeless women, their children, and families.

Introduction

Family planning refers to a conscious effort by a couple to limit or space the number of children. Modern contraceptive methods include pills, injectable, male and female condoms, emergency contraception, implants, intrauterine contraceptive devices (IUCDs), female and male sterilization [1].

Street women are women who make their lives on street life by begging, sleeping on streets, or on roadsides [2, 3]. Those who had no formal homes or who were sleeping on streets, verandas, balconies, were classified as "on-street", while those who had houses to go for sleep at night were termed "off-street” [3, 4]. A homeless individual is defined as one who lacks a fixed, regular and adequate night time residence [2, 5]. Living on the street is a severe societal, social and individual problem in developing countries due to specific complicated social and family-related problems such as poverty, domestic violence, physical and sexual abuse [5, 6].

Globally, studies on the use of contraceptives for women experiencing homelessness are limited. In developed countries, it is double the general population and most pregnancies were unintended [7]. In Scotland it was 43% [8]. A study conducted in Bangladesh reported that 34.5% of street reproductive-age women utilized modern contraceptives [9]. In Africa, the majority of homeless women in Nairobi, Kenya utilized injectables (26.63%) and implants (24.07%) [10].

Pregnancy and childbirth-related complications are the leading causes of maternal death and disability worldwide [11]. In addition to the lack of a safe and suitable home, homeless women are exposed to substance use, poor nutrition, unintended pregnancy, stress, and a lack of other necessities. Homeless women are a highly vulnerable group at risk of pregnancy and childbirth-related complications in developing countries, including Ethiopia [12, 13]. The pregnancy rate is very high among women living on the street due to unwanted sexual intercourse [6].

In Ethiopia, a study reported that about half (50.3%) of street women utilized modern contraceptive [2]. In the northern part of Ethiopia, a study showed that 38.9% of street reproductive age women utilized modern contraceptive [3]. Among modern contraceptive users, a study reported that nearly three fourth used injectables (74.3%), followed by pills (11.4%), norplants (7.1%), condom (4.3%) and IUCDs (2.9%) [4].

The use of modern contraceptive methods is important for reducing fertility as well as maternal, infant and child morbidity and mortality [14]. Women living in the street are not aware of the services and have limited access to healthcare, including modern contraceptives despite their vulnerability to unwanted pregnancy and sexually transmitted diseases (STDs) [15,16,17]. The Ethiopian health sector also does not prioritize their issues.

The Ethiopian health sector prioritizes improving primary healthcare and optimizing maternal healthcare services, including modern contraceptive methods. However, it still ignores street women who are suffering from unintended pregnancy [18]. Moreover, there is little data about modern contraceptive utilization among street women in Ethiopia, particularly in Adama town. The study assessed the utilization of modern contraceptives and associated factors among women of reproductive age in Adama town, Oromia region, Ethiopia, 2023.

Methods

Study area and period

The study was conducted in the Oromia Regional State, East Showa Zone, Adama town, on March 12 to March 17, 2023. Adama is located 100 km from Addis Ababa, the capital city of Ethiopia. In 2021, the total population was estimated to be approximately 435,222 [19]. Adama town has one compressive specialized hospital (governmental), six private general hospitals, 13 health centers, 2 non-governmental MCH centers (Family Guidance Association Ethiopia and Marie Stopes International Ethiopia), and several private MCH clinics. Data regarding the number of street reproductive age group women in Adama town are difficult to obtain as they move from place to place. Ministry of Labor and Social Affairs estimated that more than 830 street reproductive age group women are living in Adama town [20]. The potential sites where street women are churches, bus stations, and main road and market areas.

Study design, study population and inclusion criteria

A community-based cross-sectional study design was used. All reproductive age groups of homeless women who lived in Adama town during the data collection period and who fulfilled the inclusion criteria were considered for the study. The inclusion criteria were all reproductive age groups of homeless women in the town, excluding severely ill women.

Sample size determination

The study used a single population proportion formula by assuming that the prevalence of modern contraceptives among street tribe women from Dire Dawa city (50.3%) [2], 95% confidence interval, 5% of marginal error, and 10% non-response rate.

$$\begin{array}{lll} n&=(z\alpha/2)^2\times\mathrm{P}(1-\mathrm{p})/\mathrm{d}^2\\&=(1.96)^2\times 0.503 (1-0.503)/(0.05)^2\\&=384\end{array}$$

Based on the above assumption, 384 was the sample size. Since the exact number of source population of participants was less than 10,000, which was 830, we used correction formula of nf = ni / (1 + ni/N); where nf = corrected sample size, ni = uncorrected sample size, and N = total number of all the source population. Therefore, the required minimum sample was obtained from the above estimate by making some adjustments: nf = 384 / (1 + 384/830) = 263 plus a 10% non-response rate; thus, the total sample size was 289.

Sampling procedures

Before actual data collection, all the sites (5 churches, 2 bus stations, main roads, 3 mosques, and 2 market areas demarcated) were selected purposively to get the homeless women in the town carefully identified. Ultimately, a convenience sampling technique was applied to arrive at the required sample size. The study included all homeless reproductive age group women who met the inclusion criteria and volunteered to participate. Homeless women are mobile they were asked whether they had been interviewed to avoid duplication efforts and also had a demarcation or labeling on their fingernails by the interviewer.

Data collection tools and procedure

The data collection tool was adapted from different studies, with some modifications [2, 21, 22]. Although there was a standard for women based on their age, it was adopted from the previous studies [2, 4]. The questionnaire was initially prepared in English and subsequently translated into the Afan Oromo and Amharic languages to maintain consistency and uniformity. Data collection was carried out with structured face-to-face interviewer-administered questionnaires by ten trained female diploma health workers (six nurses and four midwives) and supervisors (four BSc nurses). The majority of the data were recruited around the mosques on Friday morning followed by orthodox churches on Sunday morning. The remaining was collected around bus stations and marketing areas on Tuesday and Thursday.

Data processing and analysis

The collected data were coded and entered into Epi-info version 7.2 and subsequently exported to SPSS version 22 for analysis. Frequency and percentage were calculated to characterize the study participants, and results are presented in tables and text. Binary logistic regression was used to identify factors associated with modern contraceptive utilization. First, the assumption for binary logistic regression was checked before analysis. A standard model-building approach was used to fit the regression model. In the process of fitting the model, first, bivariable logistic regression analysis was performed to assess the crude relationship between the independent variables and the dependent variable. Variables with a P value less than 0.2 were considered candidates for multivariable logistic regression analysis.

The final model fitness was assessed for multicollinearity using variance inflation factors (VIFs), and goodness of fit (GOF) (Hosmer–Lemeshow test). VIFs of less than 5 or no multicollinearity were detected, and the p-value for (GOF) was greater than the significance level (p value = 0.05) and accepted. Then all candidate variables were subsequently adjusted for inclusion in the multivariable logistic regression to identify the variables that had significant associations with the dependent variable. After controlling for the effect of possible confounding effects, the magnitude of the association between the dependent and independent variables was estimated using an adjusted odds ratio (AOR), and a 95% CI and P value less than 0.05 were used as cutoff points to determine the presence of an association.

Data quality control

A pretest was conducted in Bishoftu town on a five percent sample size before the actual data collection. Possible modification concerning clarification of content and simplification of wording was considered after pretesting of the questionnaires. The training was provided for interviewers for one day on emphasis on the tool and the art of interviewing, especially to address sensitive questions by tactic full manners, ethical issues, and the significance of the study, as well as how to approach the participants. The completeness of each interviewer was checked before visiting the participants. The data processing was overseen by four BSc nurses. The data were double entered to verify the missing values.

Variables of the study

Dependent variables—Utilization of modern contraceptives.

Independent variables—Socio-demographic and economic characteristics (age, residence before joining street life, marital status, place for sleeping, education, year of life on the street, average monthly income, disability and types of disability). Reproductive and facility-related characteristics such as knowledge about contraceptive service delivery place, health facility visited, time to reach health facilities on foot, information about modern contraceptive use, modern contraceptives mentioned by participants, source of information about modern contraceptives, advantages of modern contraceptives mentioned, place of modern contraceptives utilized. Reproductive health and sexual intercourse characteristics include having sexual intercourse, sexual partner, history of sexual violence after joining the street, history of pregnancy after joining street, planned pregnancy, history of abortion, desire to have a child in the future, time to have future pregnancy.

Operational definitions: Street women: women who make their lives on street life by begging, sleeping on streets, or on roadsides [3].

On-street: those who had no formal homes (homeless) and sleep on streets, on the verandas, or on balconies at night [2].

Off-street: those who have houses to go for sleep at night while making their lives on the street life [4].

Modern contraceptive methods include products or medical procedures that interfere with reproduction through sexual intercourse; these methods include female sterilization, male sterilization, pills, intrauterine devices, injectables, implants, and condoms [3].

Modern contraceptive utilization: Women in the reproductive age group reported using any method of modern family planning or contraceptive during the data collection period [3].

Homeless: An individual is defined as one who lacks a fixed, regular and adequate nighttime residence [2].

Formal education: the structured education and training system that runs from primary and secondary school through college and on to university.

Results

Sociodemographic and economic characteristics

Among all, 286 (98.9%) responded to the interview. The median age of the participants was 23 years old with IQR of 10. Approximately two-thirds (65.7%) were from urban areas. Regarding marital status, 115 (40.2%) were divorced. The majority (82.5%) had a formal education. More than three fifth (64.3%) were sleeping on the street and 165 (57.7%) had lived on the street for more than 6 months (Table 1).

Table 1 Sociodemographic and economic characteristics of women in the reproductive age group living in Adama town, 2023

Reproductive characteristics

About two-thirds of the participants (68.2%) were aware of the use of contraceptives methods. Awareness of specific methods was 42.1% for injectables. The majority of participants (43.0%) had heard from health professionals. Among those who had information about modern contraceptives, all (100%) reported that they knew the advantages of modern contraceptives for either birth spacing or birth control. Among those who knew the advantages of modern contraceptives, almost all (99.4%) of them knew the place to get contraceptive services. Approximately half (47.9%) did not know where contraceptive services were available (Table 2).

Table 2 Reproductive and facility-related characteristics among women of reproductive age in Adama town, 2023

Utilization of modern contraceptive methods among participants

Of the total participants, one hundred sixty-two (56.6%) [95% CI: (50.7, 62.2)] utilized modern contraceptive methods, while 85 (52.5%) had utilized implants.

Reproductive health and sexual intercourse characteristics among participants

Approximately one-fifth (16.1%) had sexual intercourse, and one-third (32.9%) had a history of sexual violence after joining the street. Nearly one-third of the participants (30.8%) had a history of pregnancy after joining the street, and one-fourth (25.5%) had unplanned pregnancies. Similarly, nearly one-tenth of them (9.8%) had a history of abortion. However, almost one-fifth of them (19.2%) wanted to have a child in the future (Table 3).

Table 3 Reproductive health and sexual intercourse characteristics among women of reproductive age in Adama town, 2023

Factors associated with the utilization of modern contraceptives among homeless women

After controlling for the effects of confounding variables, six variables, age, education, place of sleep, income, sexual intercourse, and history of pregnancy after joining street life were found to be factors significantly associated variables in multiple logistic regression analysis.

Accordingly, the odds of modern contraceptive use were higher (four times) [AOR = 4.22, 95% CI: (1.77, 10.05)] among participants who aged 25–34 years than those who aged 15–24 years old. The odds of modern contraceptive use were higher (three times) [AOR = 3.04, 95% CI: (1.21, 7.60)] among participants who have formal education than their counterparts. The odds of modern contraceptive use were higher (nearly three times) [AOR = 2.81, 95% CI: (1.25, 6.34)] among participants who slept-off the street than their counterparts. The odds of modern contraceptive use were higher (four times) [AOR = 4.18, 95% CI: (2.11, 8.29)] among participants who have a monthly income greater than or equal to 2400 ETB (20.86 $) than their counterparts. The odds of modern contraceptive use were higher (three times) [AOR = 3.14, 95% CI: (1.17, 8.40)] among participants who have sexual intercourse than their counterparts. The odds of modern contraceptive use were higher (nine times) [AOR = 9.21, 95% CI: (3.67, 23.12)] among participants who have a history of pregnancy after joining street life than their counterparts (Table 4).

Table 4 Factors associated with the utilization of modern contraceptives among homeless women of reproductive age in Adama town, 2023

Discussion

In this study, the prevalence of modern contraceptive utilization was 56.6%. This study's finding is comparable with other similar a study conducted in Dire Dawa town [2]. However, the finding was higher than studies conducted in Scotland, UK (43%) [8] and Bangladesh (34.5%) [9].The difference could be due to the small sample size in the previous studies and the time gap between the studies. Similarly, it was higher than studies conducted in Shashemene (36.5%) [21], Amhara regional state zonal towns (38.9%) [3], Gondar (34.3%) [4], Bahir Dar (31.1%) [22], and Hawasa (37.4%) [23]. The possible explanation for the discrepancy might be due to the current study participants having more awareness of the use of contraceptive methods and they knew the advantages of modern contraceptives for either birth spacing or birth control.

The current study showed that implants (52.5%) and injectables (42%) are the most commonly used modern contraceptives, followed by pills (5.5%). These findings are comparable with other studies conducted in Scotland, UK [8] and Nairobi, Kenya [10]. Similarly, it was comparable with studies conducted in Dire Dawa, Shashemene, Gondar, Bahir Dar, and Hawasa [2, 4, 21,22,23]. The 2019 Ethiopia Mini Demographic and Health Survey also reported that the most popular contraceptive methods were injectable (27%). This could be due to the women’s preferences after they received family planning counseling [24].

In this study, age was associated with the utilization of modern contraceptives. Homeless women who aged 25–34 years were four times more likely to utilize modern contraceptives than those aged 15–24 years and supported by the previous studies in Bahir Dar and Dire Dawa [2, 4]. This could be a result of the fact that homeless women between the ages of 25 and 34 are more likely to become pregnant and engage in sexual activity, both of which may encourage the use of modern contraceptives.

Homeless women who had a formal education were three times more likely to utilize modern contraceptives and agreed with previous studies in Bangladesh [9] and Shashemene [21]. The possible justification for the similarity might be homeless women who had a formal education have better status, knowledge, and access to utilize modern contraceptives and they know more of its advantages.

Homeless women who slept off the street were nearly three times more likely to utilize modern contraceptives than women who slept on the street and supported by a study in Bahirdar [22]. The possible explanation could be homeless women who have rented houses to go for sleep at night while making their lives on the street life have more family responsibilities to control birth.

In this study, homeless women who had monthly incomes greater than or equal to 2400 ETB were four times more likely to utilize modern contraceptives than those who earn below 2400 ETB. This finding is in agreement with those of a study conducted in Bangladesh [9]. In Ethiopia, modern contraceptives are freely provided by public health facilities to all women between the ages of 15 and 49; hence, a woman's income doe not affect her ability to get this service. However, access to education, basic healthcare, and health information are significantly impacted by a woman's income [24].

Sexual intercourse was also associated with the utilization of modern contraceptives. Compared with those who had no sexual intercourse, homeless women who had sexual intercourse were three times more likely to utilize modern contraceptives. These findings are supported by previous studies in in Dire Dawa, and Bahirdar [2, 22]. It is likely that as they engaged in sexual activity, they had more awareness about the risk of unintended pregnancy and encouraged to utilize modern contraceptive.

Homeless women who had a history of pregnancy after joining street life were nine times more likely to utilize modern contraceptives than their counterparts. This finding is similar with previous a study in Southern Ethiopia [23]. Similarly, it is in agreement with studies in Northwest Ethiopia and Dire Dawa town [2, 3]. This could be due to they may suffer from complications associated with pregnancy which obligate them to utilize modern contraceptives in health facilities and become aware and counselable about modern contraceptives during delivery.

Limitations of the study

The current study has some limitations which will be addressed by future researchers. One of this study’s limitations was the study design. Either under or over prevalence report of modern contraceptive utilization might occur due to recall bias. The current study had a small sample size. Therefore, future researchers should develop strong study design to address the current study’s limitation.

Conclusion

The prevalence of modern contraceptive utilization among homeless women of reproductive age was relatively higher than the previous studies; however, it was lower than the national targeted contraceptive prevalence rate. Implants and injectables were commonly used. Age, education, place for sleeping, income, sexual intercourse, and history of pregnancy after visiting the street were factors significantly associated with the use of modern contraceptives. The Regional and Adama town health bureau and facilities should have targeted strategies and interventions to address the unmet need for modern contraception for homeless women. In addition, the health extension programs should consider homeless women for the different Sexual and Reproductive Health service provisions including contraceptive services.