# Introduction amily planning (FP) began to be viewed as a way of making changes in women's lives, securing women's empowerment and ensuring their well being (Cleland J, 2006). Unmet need for FP is the number or percent of women currently married (in union) who are fecund and who desire to either terminate (do not want anymore) or postpone (at least 2 years) childbearing, but who are not currently using a contraceptive method (John A, et al., 2002). Around the world, about 222 million women have an unmet need for FP and 645 million women have their needs met through the use of a modern contraceptive method such as intra-uterine device (IUD), pills, injectables or sterilization [9]. Every minute, nine children under age 5 die in Africa which resulted in death of 4.8 million children annually. Family planning could prevent many of these deaths by enabling women to bear children during the healthiest times for themselves and their children (David O, 2008). Evidence on the benefits of FP for maternal and child health, poverty reduction strategies and women's empowerment is quite clear. In Sub-Saharan Africa for example, it is estimated that provision of FP services reduces unintended pregnancies by 77% (i.e. from 17 million to 4 million annually); reduces unsafe abortions from 5.2 million to 1.2 million; and reduces the number of women in need of medical care from unsafe abortion from 2.2 million to 500,000. It is therefore clear that FP is a valuable economic investment. Reducing unmet need would significantly reduce unintended pregnancies, abortions, and maternal and child deaths. A current projection for Ethiopia estimates 56 million pregnancies from 2005 to 2015, of which nearly 24 million would be unintended. By meeting unmet need in Ethiopia, there would be almost 6 million fewer unintended pregnancies, which would lead to nearly 2 million fewer abortions. Moreover, more than 1 million infant and child deaths (under age 5) would be averted and nearly 13,000 maternal deaths would be averted over the 10-year period (Family Planning Conference, 2009). Ethiopia has among the highest levels of unmet need for contraception in Africa. The 2011 Ethiopia Demographic and Health survey (EDHS) found that 25.3 % of women had unmet need for FP, 16.3 % for spacing and 9 % for limiting. Unmet need for both spacing and limiting is higher among rural residents than their urban counter parts. The general unmet need for FP among urban and rural dwellers is 15% and 27.5% respectively (ICF International, 2012). Particularly, it would have a substantial contribution in the improvement of the health status of women and children. Unmet needs for contraception have a tendency to be influenced unequally among different settings mainly due to the effect of socio-economic and demographic variables. The availability of accurate information and high quality FP services enable people to make informed choices. In Ethiopia, however, it is clear that factors affecting FP use are area-specific and require different approaches. Hence, this study examined the factors in different settings (urban and rural); the findings would help as an input for policy makers and health planners in the area to respond to the fertility preferences of the population while simultaneously improving maternal health, slowing the rate of population growth, and contributing to achievement of national goals. Therefore, this study tried to determine the prevalence and identify the key socio-demographic determinants of unmet need for FP in the district. # II. # Methods # a) Study area and period The study was conducted in Enemay district, northwest Ethiopia, from 20 th March to 10 th April 2013. # b) Study Design A community-based comparative crosssectional study was carried out to determine the prevalence and identify the key socio-demographic determinants of unmet need for FP services. # c) Study Population The source population constituted all married women in the reproductive age and married women in the selected kebeles were the study population. d) Sample size determination Table 1 : Assumptions for sample size calculation, Enemay district, Northwest Ethiopia, 2013 The sample size was determined based on double population proportion according to the assumptions in the above table (Table 1). The proportion of unmet need for FP among currently married women 15% and 27.5% for urban and rural respectively was taken from EDHS 2011 (ICF International, 2012). The sample size was calculated using Epi Info sample size calculator for cross-sectional study. With consideration of design effect of 2 and non-response rate of 5%, the total sample size was 770. e) Sampling method and procedures Multi-stage sampling followed by systematic random sampling method was employed; five out of the 25 rural kebeles and three urban kebeles were selected to represent the rural and urban residents by using lottery method respectively. The peri-urban kebeles of the district were excluded from the study to avoid mixing of urban and rural populations. The sample size for both rural and urban areas was allocated proportionally; systematic random sampling technique was used to reach the study units (households). Women of reproductive age who were living with their husband were included in the study. Data were collected using semi-structured questionnaires adapted by reviewing literatures and suited to the local situation [31,36,39]. The questionnaire was prepared first in English and was The data were collected by 12 trained diploma nurses and was supervised by 3 BSc nurses. During data collection, if there were more than one eligible woman in households, one woman was selected randomly; where there was no an eligible woman in the sampled households, the next household was visited and in case it was closed revisit were done. # h) Data quality control In order to maintain quality of data, data collectors and supervisors ware trained and questionnaire guide was prepared. Pre-test was done on 5% of the total sample and based on the findings of the pre test the questions were modified. The collected data were checked for completeness and consistency by the principal investigator and supervisors and were communicated to data collectors. Moreover, double data entry was performed to 10% of the data to check for consistency. # i) Data processing and analysis The collected data were cleaned and fed to Epi Data version 3.1 and analysis was done by using SPSS version 16 statistical software. Variables with p-value of less than 0.2 in bivariate analyses were entered for multivariable logistic regressions to analyze the associated factors for unmet need for family planning. Standard deviations, odds ratios and 95% confidence intervals with p-value less than 0.05 as statistical significant were used for data presentation. # j) Definitions Unmet need for FP : The number or percent of women currently married (in union) who are fecund and who desire to either terminate (do not want anymore) or postpone (at least 2 years) childbearing, but who are not currently using a contraceptive method [8]. Kebele : The lowest government administrative hierarchy. # k) Ethical Considerations Ethical clearance was obtained from the ethical committee of Debremarkos University. The study participants were informed about the objective, rationale and expected outcomes of the study and oral consent was obtained either to participate or refuse for the interview. Majority 326 (62.7%) of the study subject got FP services from health centers followed by health posts 171 (32.9%). On the other hand, majority 617 (82.0%) of the respondents took less than an hour for round trip to get FP services. About 476 (63.0 %) of respondents ever discussed about FP services with healthcare providers and 437 (57.9%) visited by healthcare providers within the last 12 months prior to this study (Table 4). # III. # Results # a) Demographic and socio-economic characteristics of the study subjects # d) Sources of information about FP methods Two hundred fifty four (33.5%) of urban and 307 (63.7%) of rural married women got information about FP methods form health extension workers. No one of the rural respondents got information from television while 119 (15.7%) of the urban respondents got the information from television. # e) Reasons for not-use of FP methods Out of 755 married women, 520 (68.9%) were current users of FP methods; of these, 369 (48.9%) were using for spacing and 151 (20%) for limiting. The contraceptive prevalence rates for urban and rural residents were 266 (70.7%) and 254 (67%) respectively. The main reasons for not using FP methods for both urban and rural residents were health concern and fear of side effects 74 (38.34%), less perceived risk of pregnancy 51 (26.42%), opposition from partners 18 (9.33%), religious prohibition 17 (8.81%), familial opposition 17 (8.81%), ambivalence to plan when to get pregnant 15 (7.77%) and availability of preferred methods 8 (4.15%). The main reasons for not using FP methods for 29 (31.5%) urban and 45 (41.7%) rural study subjects were health concerns and fear of side effects followed by less perceived risk of pregnancy 25 (27.2%) and 26 (24.1%) for urban women and rural respectively. # f) Unmet need for family planning The overall unmet need for FP was 193 (25.6) of which 119 (15.8) was for spacing and 74 (9.8) for limiting (Figure 1). Women and their partners with educational level of secondary and above (AOR=0.201; 95%CI: 0.13-0.213) and (AOR=0.231, 95%CI: 0.144-0.295) respectively were also less likely to have unmet need for FP when compared to with no formal education. # Volume XIII Issue IV Version I Married women who had not been visited by healthcare providers within the last 12 months prior to the study were 2.63 times more likely to have unmet need for FP compared to women who had been visited (AOR=2.630, 95%CI: 1.452-6.926). Moreover, married women whose partners did not support the use of FP methods were 2.08 times more likely to have unmet need compared to those whose partners support FP use (AOR=2.08, 95%CI: 1.46-9.408). On the other hand, married women who had not decided their total number of children before their first pregnancy were 1.871 (AOR=1.871, 95%CI: 1.208-6.147) times more likely to have unmet need for FP than their counter parts. h) Factors associated to unmet need for family planning (rural) Age at first marriage 18 and above was negatively and significantly associated to unmet need for FP compared to marital age of less than 18 (AOR=0.260, 95%CI: 0.189-0.368). On the other hand, primary as well as secondary and above educational level of married women were negatively and significantly associated to unmet need for FP when compared to no formal education (AOR=0.355, 95%CI: 0.280-0.831) and (AOR=0.324, 95%CI: 0.053-0.999) respectively. Moreover, married women whose husbands' educational levels of secondary and above were less likely to have unmet need for FP compared to those whose partners had no education (AOR=0.428, 95%CI: 0.319-0.895). Married women who had ever discussed about FP issues with healthcare providers were also less likely to have unmet need for FP than their counterparts. Currently menstruating was significant predicting factor for unmet need for FP (AOR=0.3619, 95%CI: 0.209-0.696). On the other hand, married women whose partners do not support the use of FP methods were 3.73 times more likely to have unmet need for FP services compared to those whose partners support FP use (AOR=3.73, 95%CI: 1.293-4.770) (Table 7). IV. # Discussion The prevalence of unmet need for FP services was 25.6%, which is comparable to the national prevalence (25.3%) and is slightly higher than in eastern Nepal (21.7%) and in Amhara region, Ethiopia (22.1%) (ICF International, 2012; Sellen D., 2012); this figure is lower than the prevalences Endersa, Tigray region (48%), Butajira (52.4%), Belesa (39.5%) and Kobo (47.3%) (Assefa H, 2011; Ghebreselasie R, 2006; Awang N. L, 2011). These variations might be attributed to the expanding health services coverage and increased awareness of FP and maternal health services. In most parts of Ethiopia, rural esidents are usually of low education and socioeconomic status and have limited access to FP services. This study also revealed that the prevalence of unmet need for FP in urban and rural areas were 18.4% and 32.7% respectively; the discrepancy was wider than the national figure which was 15% and 27.5% (ICF International, 2012). Higher unmet need in rural areas might reflect limited awareness and acceptability of FP services in rural areas. About two-third married women were FP method users; this is higher than in Kobo, northern Ethiopia (38%) (Choudhary S, 2011); the variation might be due to increased awareness on FP. Women who married before their 18 birth anniversary were more likely to have unmet need in both areas. This might show awareness of legal marriage in the rural area was inadequate and on the other hand women who marry at their 18 and above were able to plan and manage their family size because they had more exposure to FP methods and were mature enough to do so. Only 26% of urban and 18.3% of rural respondents had discussed about family planning issues with their partners. This was lower than a study from Belesa, north Gondar that revealed around 45% of wives had experiences of FP discussion with partners (Mihret N, 2008). The possible reason for this difference might be inadequate behavioral change communication in the area. As the educational status of women improves they would have more awareness about the FP services and hence unmet need decreases. These findings were supported by the Demographic and Health Survey analysis of Kenya which indicates better educated women -secondary level or higher have considerably less unmet need (17%) than women with little or no education (26%) [38]. Husband educational level secondary and above was also negatively associated with unmet need for FP in both urban and rural residents; a study in Butajira district revealed a similar pattern (Mekonnen W. and Worku A, 2011). The main reasons for not using FP methods for both urban and rural residents were health concerns and fear of side effects, less perceived risk of pregnancy, religious prohibition, familial opposition and ambivalence to plan when to get pregnancy; these findings were supported by the findings of a studies done in Nigeria and Iraq (Laya K.S, 2012). Discussion with health care providers about FP issues was negatively and significantly associated to unmet need for FP, this is in line with studies done in Kobo, Northern Ethiopia Awang N. L, 2011) and Nigeria (Laya K.S, 2012). Menstrual status of married women was significantly associated to unmet need for FP in the rural area but not in urban area; this might be due to their misperception of less likely to become pregnant in the absence of menstruation. The overall prevalence of unmet need for FP was high; age at first marriage, educational status of respondents and partners and partner attitude towards FP use were independent predictors of unmet need for FP in both urban and rural areas. Moreover, desired number of children, healthcare providers visit, age of respondent, menstrual status and discussion about FP were the main predicting factors of unmet need for FP. The local government should strive to create awareness and implement the legal age for marriage so as to increase marital age at least to 18 years and above to contribute for the decrement of unmet need for FP. Health extension workers should strengthen the visiting and awareness creation of women and their partners towards the importance of FP services utilization; education for women should be scaled up. ![of the extent of unmet need for FP among currently married women of reproductive age and associated factors are of paramount importance in tackling the problem of unmet need for FP, which paves the way for the improvement of the prevailing socioeconomic problems of the country.](image-2.png "") 2Prevalence and Associated Factors of Unmet need for Family Planning among Married Women in EnemayDistrict, Northwest Ethiopia: A Comparative Cross-Sectional Study0132YearEnemay district, Northwest Ethiopia, 2013Volume XIII Issue IV Version ICharacteristicsUrban N%Rural N%Total N%( D D D D ) D D D D KAge15-1992.4318.2405.320-246016.05213.711214.825-298422.37620.116021.230-3410828.79825.920627.335-397519.95514.513017.2>=404010.66717.710714.2ReligionOrthodox31583.836796.869491.9Muslim5113.671.8516.8Protestant102.751.3101.3Educational status of respondentNo formal education23161.431282.354371.9Primary education6617.65213.711815.6Secondary and above7921.0154.09412.5Educational status of husbandNo formal education14538.627071.241555.0primary education10527.97720.318224.1Secondary and above11931.6307.914919.7Don't know71.92.591.2Occupational status of respondentsHouse wife/farmer33087.837197.970192.85governmentalandnongovernmental4612.282.1547.15employee 3Most, 344 (91.5%), of the urban and 337FP methods and 358 (95.2%) of urban and 361 (95.3%)(88.9%) of the rural study subjects had pregnancyof rural respondents knew at least one FP methodhistory and of which 666 (97.8%) had given birth.respectively (Table 3).Regarding family planning information, 375 (99.7%) ofurban and 374 (98.7%) of rural respondents heard about 4Ethiopia, 2013 5VariablesUnmet needAOR (95% C.I)P-valuefor FPCOR (95% C.I)(Overall)YesNoAge of respondents15-19363.1(1.28, 12.027)*1.580(0.916, 2.314)20-2411491.891(1.014, 11.345)*1.247(0.442, 10.462)25-2912721.03(0.342, 12.431)1.621(0.239,11.860)0.04930-3415931.001.0035-3914611.423(0.208, 10.282)1.094(0.708, 2.452)>=4014263.34(2.701, 11.319)*2.605(1.105, 4.003)*Age at first marriage<18621941.001.00>=1871130.193 (0.229, 0.433)*0.390 (0.282, 0.649)*0.001Educational status of respondentNo formal education581721.001.00Primary education9560.491 (0.477, 0.825)*0.145 (0.134, 1.479)secondary and above2790.082 (0.075, 0.420)*0.201 (0.130, 0.213)*0.001Educational status of husbandNo formal education281171.001.00Primary education12930.671 (0.539, 0.935)*0.078 (0.037, 3.134)Secondary and above28910.308 (0.201, 0.470)*0.231 (0.144, 0.295)*< 0.001Do not know160.696 (0.420, 1.384)0.294 (0.281, 2.881)Occupational status of respondentsHouse wife/ farmer233551.001.00Government employee6250.057 (0.018, 0.585)*0. 239 (0. 232, 0.411)*0.027Merchant/other private work8490.041 (0.027, 0.345)*0.200 (0.128, 2.300)Visited by a healthcare providers in the last12 monthsYes311801.001.00No381271.737 (1.014, 8.279)2.630 (1.452, 6.926)*0.048Partner attitude towards FP useApprove322381.001.00 60132YearVolume XIII Issue IV Version IExplanatory VariablesUnmet need forCOR (95 % C.I)AOR (95 % C.I )P-valueD D D D ) D D D D KFP(overall)(YesNoAge of respondents15-1913183.00(1.411, 14.247)*2.357 (1.689, 5.691)*<0.00120-2411410.869 (0.757, 1.840)2.630 (1.347, 8.262)*25-2928482.425(1.326, 10.609)2.018 (1.525, 4.820)*30-3419791.001.0035-3924310.774 (0.454, 1.319)0.243 (0.046, 1.278)>=4029380.763 (0.471, 1.237)0.207 (0.040, 1.082)Age at first marriage<181042041.001.000.003>=1820510.769 (0.537, 0.984)*0.260 (0.189, 0.368)*Educational status of respondentNo formal education1072051.001.00<0.001Primary education13390.639 (0.478, 0.980)*0.355 (0.280, 0.831)*secondary and above4110.697 (0.519, 0.871)0.324 (0.053, 0.999)*Educational status of husbandNo formal education191791.001.000.01Primary education26510.210 (0.108, 0.618)*1.780 (0.833, 3.804)Secondary and above18120.620 (0.435, 0.804)0.428 (0.319, 0.895)*Don't know111.000 (0.063, 15.988)9.477 (0.230, 30.221)Ever discussed about FP methodswith healthcare providers0.033 © 2013 Global Journals Inc. (US) Prevalence and Associated Factors of Unmet need for Family Planning among Married Women in Enemay District, Northwest Ethiopia: A Comparative Cross-Sectional Study ## Acknowledgements We would like to thank Debremarkos University and Gamby College of Medical Sciences for their financial support; we would like to extend our gratitude to all the study participants. * Family planning: the unfinished agenda ClelandJ The Lancet 368 2006 * Determinants and Consequences of High Fertility. Synopsis of the Evidence CSadia 2010 * Prevalence and determinants of unmet need for family planning in Nnewi, south-east Nigeria AOIgwegbe JOUgboaja ENMonago International Journal of Medicine and Medical Sciences 1 8 2009 * Revising Unmet Need for Family Planning SarahE KBradley NTrevor JoyDCroft CharlesFFishel Westoff DHS Analytical Studies 25 2012 ICF International * Family Planning and Child Mortality Rate Decline in Subsaharan Africa AdébiyiGermain BSimona B 2001 * Awareness and determinants of family planning practice in Jimma ATBeekle CMccabe Ethiopia. International Nursing Review 53 2006 * Unmet Need for Contraception in the Developing World and the Former Soviet Union: An Updated Estimate JohnARoss LWilliam Winfrey International Family Planning Perspectives 28 3 2002 * Adding It Up: Costs and Benefits of Family Planning Services SSusheela JacquelineD Estimates for New York Guttmacher Institute 2012 * Trends and Determinants of Unmet Need for Family Planning in Kenya ODavid 2008 56 * Conference on Family Planning: Research and Best Practices Munyonyo, Uganda 2009 * Ethiopia Demographic and Health Survey 2011. 2012 ICF International Addis Ababa, Ethiopia and Calverton, Maryland, USA Central Statistical Agency * Addressing Unmet Need for Long Acting Family Planning in Ethiopia: Uptake of Implanon and Characteristics of Users EHenry MAKibret YTYigezu EOliveras 2011 * Effects of Preceding Birth Intervals on Neonatal, Infant and Under-Five Years mortality and nutritional status in developing countries: Evidence from the demographic and health surveys OShea Rutstein International Journal of Gynecology and Obstetrics 89 2005 * Quality of family planning services in northwest Ethiopia MFantahun Ethiop.J.Health Dev 19 3 2005 * Fertility Regulation and Reproductive Health in the Millennium Development Goals: The Search for a Perfect Indicator RMueller AGermain American Journal of Public Health 1 97 2007 * The extent and reasons of unmet need for uamily planning among women of reproductive age group in rural area of Haryana SChoudhary NSaluja SSharma DGaur SPandey 10.5580/1bc2 The Internet Journal of Health 12 1 2011 * Prevalence and determinants of unmet need for family planning in a district of eastern region of GPBhandari KCPremarajan NJha 2006 * Nepal. Kathmandu University Medical Journal 4 2 * Strengthening Family Planning with Communitybased Nutrition interventions in Ethiopia DSellen SSharif BTefera ZHyder 2012 The World Bank, 1818 H Street, NW, Washington DC 20433 * Unmet need for family planning and its determinants among currently married women in Kobbo woreda, North-East of Amhara GMolla HBelete Ethiopian Journal of Reproductive Health 5 1 2011 * Determining the factors associated with Unmet need for family planning: a cross-sectional survey in 49 districts of Pakistan WHameed ASKhurram MBilgrami MIshaqe PJPH 1 1 2011 * Strengthening family planning policies and programs in developing countries: an advocacy toolkit. Policy project 2005 United States Agency for International Development (USAID) * Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method GSedgh RHussain ABankole SSingh No. 37 2007 Guttmacher Institute New York Occasional Report * CGordon RSabates RBond WubshetT 2011 * Women's Education and Modern Contraceptive Use in Ethiopia International Journal of Education 1948-5476 3 1 * Currently married women with an unmet need for contraception in Eritrea: Profile and determinants GWoldemicael RBeaujot Canadian Studies in Population 38 2011 * Unmet need for family planning in Iran AAhmadi JIranmahboob XXV IUSSP International Population Conference 2005 * Prevalence and Determinants of Unmet Need for Family Planning among Women in India KSLaya Research and Social practices in Social Sciences 7 2 2012 * Family planning service utilization in Mojo town, Ethiopia: A population based study AGizaw NRegassa Journal of Geography and Regional Planning 4 6 2011 * Assessment of the magnitude, determinant of unmet need for family planning SSita 2003 Ethiopia Addis Ababa * Determinants of unmet need for contraception among currently married couples in west belessa woreda, North gondar of amhara NMihret 2008 Ethiopia * Factors Affecting Unmet need for family planning HAssefa Ethiop J Health Sci 21 2 2011 * Unmet Need for Family Planning JNGribble Population reference Bureau * Determinants of low family planning use and high unmet need in Butajira District WMekonnen AWorku Journal of reproductive Health 2011 * Magnitude and determinants of unmet need and Barriers of family planning (among wives, husbands and couples) in Enderta district RGhebreselasie 2006 Tigray region Ethiopia. Addis Ababa University * The effect of counseling in meeting the unmet need for family planning NLAwang 2011 Ateneo de Zamboanga University * Fulfilling Unmet Need for Family Planning Can Help Kenya Achieve Vision NCAPD Policy Brief 13 2010. 2030 * Assessment of unmet need for family planning and factors influencing modern contraceptive utilization among women of reproductive age group in Girar Jarso District GAshenafi 2011 North Shoa Zone, Oromia National Regional State, Ethiopia. Addis Ababa University * Unintended pregnancy: Consequences and solutions for a worldwide problem CKlima Journal of Nurse-Midwifery 43 6 1998 * women's health in the developing world BLisa MNawal Reviews in Obstetrics & Gynecology 2 2 2009 * Strategies for reducing maternal mortality: getting on with what works OCampbell WGraham Lancet 368 9543 2006 * Effects of Preceding Birth Intervals on Neonatal, Infant and Under-Five Years, Mortality and Nutritional Status in Developing Countries OShea Rutstein International Journal of Gynecology and Obstetrics 2005 * Unwanted Pregnancy and Associated Factors among Nigerian Women GSedgh BAkinrinola A OB International Family Planning Perspectives 32 4 2006 * Benefits of Meeting the Contraceptive Needs of Ethiopian Women Brief Washington, DC Guttmacher Institute/UNFPA 2010. 2010 Guttmacher Institute/Ethiopian Society of Obstetricians and Gynecologists.