Utilization and associated factors of emergency contraception among women seeking abortion services in health institutions of Dessie town, North East Ethiopia, 2018

Objective The aim of the study was to assess utilization and associated factors of emergency contraception among women seeking abortion services in Health Institutions of Dessie town, North East Ethiopia, 2018. Results Among the interviewed 784 women 400 (51%) utilized emergency contraception. Women’s age of 20–24 years [AOR: 2.10, (95% CI 1.200,3.671)], urban residence [AOR: 2.02 (95% CI 1.273, 3.218], being single [AOR: 1.71, (95% CI 1.176, 2.485)], being knowledgeable on emergency contraception [AOR: 5.66, (95% CI 3.976,8.070)], and having favorable attitude towards emergency contraception [AOR: 2.75 (95% CI 1.946, 3.881)] were significantly associated factors with the utilization of emergency contraceptives. Emphasis has to give on health education on emergency contraceptives focusing on those women who are from the rural area, older and married women.


Introduction
Emergency contraception refers to birth control modalities that will be used after unprotected sexual intercourse within defined time limits to prevent unwanted pregnancies [1]. Emergency contraceptive is indicated after unprotected sexual intercourse, following sexual abuse, misuse or non-use of contraception [2].
Worldwide, approximately 40 percent of the pregnancies (85 million) were unintended [3]. Women with unintended pregnancy may face the dilemma between terminating the pregnancy or allowing unwanted birth [4].
Every year, In developing countries, at least 22,000 women dies from abortion-related complications [8]. An estimated 620,300 induced abortions were performed in Ethiopia in 2014 [5]. Even if performed safely, abortion might be painful and may have psychological and physical stress for the women [6,7].
There are two main emergency contraceptives (EC) modalities; these are the Oral emergency contraceptives and intrauterine devices. The oral EC have various degrees of protection against pregnancy according to the time that they were taken. If it is taken within 72 h of unprotected sexual intercourse, they reduce the risks of pregnancy by 95% [8,9]. Post-coital insertion Cu-IUD within 5-7 days after unprotected sexual intercourse in addition to being an effective method of emergency contraception it can also serve as a safe and effective method of long-term contraception [10].
If emergency contraception are easily available and distributed along with appropriate advocacy activities, millions of unwanted pregnancies and abortions can be averted [11]. Furthermore, the use of EC reduces the cost of expenditures on medical care by preventing unintended pregnancies [8].
In Ethiopia, even though EC pills are distributed free of charge through the support of the non-governmental Feleke et al. BMC Res Notes (2019) 12:684 organization and there are many over the counter preparations for sell, still there is a law utilization of emergency contraceptive pills. Therefore, the aim of this study was to assess utilization and associated factors of emergency contraception among women seeking abortion care services in the health institutions of Dessie town.

Study design, period and setting
An institutional-based cross-sectional study was conducted from August 2, 2018, to January 30, 2019 in Dessie town health institutions. Dessie town is located at 401 km from the capital city of Ethiopia, Addis Ababa. The town has five Hospitals (one public referral, one public general and three private), eight health centers and twenty-seven private clinics. Currently, there are 10 health institution fully providing safe abortion care services for the community. In those health institutions, 6 months prior to the data collection period, there were 2830 safe abortion cases.

Sample size and sampling procedure
To estimate a sample size of 784 participants were calculated with single population proportion formula with the following assumptions. The magnitude of EC utilization 9.7% from a previous study done in Diredawa [12], 95% confidence interval, 3% margin of error, a design effect of 2 and non response rate of 10%. Initially, 10 health facilities that provide abortion service were stratified into 5 governmental and 5 private institutions. Then after, out of the 5 institutions, 3 were selected from each group by simple random sampling technique. After proportionally allocating the total numbers of the participants, a systematic random sampling method was employed to select the actual study participants.

Operational definitions
Utilization of EC: if a woman has any history of EC usage [13,14].
Knowledgeable: Respondents who scored above the mean value of the knowledge assessment questions [15].
Favorable attitude: Respondents who scored above the mean value of attitude assessment questions [15,16].

Data collection instrument and process
Data was collected by face to face interview using a semistructured and pre-tested questionnaire which is prepared first in English and translated to Amharic and then translated back to English to assure consistency. Ten BSc midwifery holders were involved in the data collection while two MSc holders supervised the data collection process.

Data analysis
Data were entered with epi-info version7 and analyzed using SPSS version 20 software. Bivariate and multivariable logistic regression analyses were conducted to identify predictors for emergency contraceptive utilization. Variables found to be significant on Bivariate analysis (p < 0.2) were included in the multivariable model. Adjusted odds ratios and 95% confidence intervals were generated. p-value < 0.05 were considered statistically significant.

Socio-demographic characteristics
A total of 784 women were involved in the study making a response rate of 100%. The mean age of the respondents was 24.28 years with SD of ± 4.74. The majority of 621 (79.2%) were urban residents, and 420 (53.6%) were single (Table 1).

Sexual and reproductive characteristics of respondents
Four hundred three (51.4%) of respondents had started first sexual intercourse less than the age of 18. Among the respondents, 342 (43.6%) have one or more children. Six hundred four (77%) were first time arrival for termination of pregnancy, 179 (22.8) had a prior history of induced abortion, among those who had a history of induced abortion, 135 (75.4%) had one episode, and 28 (15.6%) had more than three induced abortions.

Distance from home to the nearby health institution (in terms of time elapse)
The respondent's distance from home to the nearby health institution ranges from 1 min to 720 min. Majority of the respondents 638 (81.4%) stated that stated they could reach in the nearby health institution within 30 min.

Utilization of regular family planning methods
Five hundred forty-one (69%) had ever used regular contraceptive methods. Among those who had ever used regular contraceptive method 397 (73.4%) used an injectables contraceptive.

Knowledge and attitude about emergency contraceptive
The overall summary index for knowledge and attitude of the respondents about EC disclosed that 434 (55.4%) were knowledgeable and 376 (48%) had a favorable attitude towards EC.

Factors associated with the utilization of emergency contraception
On the bivariate analysis factors that significantly associated with EC use were: women's age of 20-24 years, urban residence, being orthodox by religion, being single by marital status, father's educational status more than primary and above, having one children and above, knowledgeable on EC having favorable attitude towards EC From In multivariate binary logistic regression analysis; age of respondents 20 (Table 2).

Discussion
This study finds out that 400 (51%) of women who came for abortion service had ever used EC (95% CI 47.9, 54.6). This is in agreement with the study that was done among abortion care seekers in China (48.8%) [17].
This finding is lower than the studies that were done in North India (70%) in Durban South Africa (62.1%) and among women of the reproductive age group in India [18][19][20]. Possible reasons for this difference might be due to the differences in the study area, study population, and knowledge about EC. In the North Indian study, the participants were recently married and data were collected from a single government health institution. Additionally,  their knowledge score was also higher than the current study. In the Durban study, the main source of information about EC were health care professional's contrary to the current study where the majority of the respondents obtained information about EC from their friends who might not share correct information that intern leads to low utilization. This finding is higher than studies that were done among abortion seekers in Jimma specialized hospital were none of them ever used EC, Dire-dawa (9.7%) and India (1.155%) had ever used EC [12,21,22]. this difference might be due to the difference in socio-demographic, cultural or developmental differences of the study with India. In the Jimma and Diredawa study, the knowledge and attitude of the participants were lower than the current study, which may reduce utilization of EC.
Women's age was a significant factor to EC use. Women in their age 20-24 years were 2.10 times more likely utilized EC as compared with women aged ≥ 30 years. This is in agreement with the studies conducted among abortion seekers in Dire-dawa [12], and South Africa [23]. Possible reasons for this might be women in this age group might not use regular contraceptive methods consistently due to cultural influence which might lead them to use EC. In addition, this group of women is mostly college students that might have the opportunity to get information about EC after unprotected sexual intercourses from their peer which intern increase the utilization.
Residence was an important determining factor for EC use. Those women who were living in an urban area were 2.02 times more likely utilized EC as compared with those who were living in the rural area. This is consistent with the study that was done in Arbaminch [24]. The possible reasons might be women living in urban areas could be more exposed to media, which might create awareness about family planning methods including EC. Another explanation could be the fact that EC is more accessible in the urban areas than their rural counterparts. On the contrary, a shortage of media coverage in the rural area could have a negative influence utilization of EC for women living in the rural area.
Marital status was significantly associated with EC use. Women who were single were 1.71 times more likely to utilized EC as compared with those who were married. This is in agreement with the study that was done in Dire-dawa [22]. The possible explanation could be single women might not use regular contraceptive methods consistently which increases the utilization. In addition, single women could have unplanned sexual intercourse not feasible to use regular contraceptive methods which intern leads to more utilization of EC.
Women who were knowledgeable about EC were 5.66 times more likely to utilize. This is coherent with studies that were done among abortion seekers in Dire-dawa [22], South Africa [24]. This might be explained by knowing effectiveness, where they can get when they can use EC may help to use EC.
Attitude towards EC was significantly associated with the use of EC. Participates who had a favorable attitude towards EC were 2.75 times more likely to utilized EC. This is consistent with studies done in Debre-Markos higher institutions [25]. The above reports might be explained with women who have a favorable attitude towards EC might want to know more about EC and to use it.

Limitations of the study
Questions that had sensitive nature like age of first sexual intercourse, history of previous induced abortion might create social desirability bias.