Effectiveness of the population health and environment approach in improving family planning outcomes in the Gurage, Zone South Ethiopia

Family planning (FP) is defined as the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births [1]. The major purpose of FP at macro-level is balancing population growth with carrying capacity of the environment. Experience over the last couple of decades in Ethiopia has shown that as human population increased, the population carrying capacity of the environment decreased. A high population growth rate induces increased demand for resources and the rate at which these resources are exploited. Population and environment are connected inextricably [2]. In Ethiopia, environmentally harmful and economically counterproductive methods of exploiting land and associated resources (forests, animal resources, etc.) are resorted to in order to meet immediate needs. As a consequence of this, climatic conditions are becoming erratic and soil quality is declining at an alarming rate. Therefore, FP intervention is an environmental imperative to respond to this subtle interplay between population growth, environmental degradation and poor nutrition and health leading to a spiraling race to poverty. However, in less developed countries including Ethiopia, there is limited access to birth control, as well as cultural practices encourage women to stay home and have babies, leading to rapid population growth.

Results from the 2011 Ethiopian Demographic and Health Survey showed a good progress towards increasing FP coverage nationwide with an increase of CPR among married women to 27 % from 15 % CPR in 2005 [3]. However, this improvement is still far from the ambitious goal set by the Ethiopian government to achieve a CPR of 65 % by 2015. With an annual population growth rate of with 2.6 %, the population of Ethiopia will double after 27 years [4].

To address the current low rate of FP outcomes in Ethiopia, population, health and environment (PHE) offers a step in the right direction in a flexible and innovative way to keep pace with today’s rapidly changing world and lays the foundation for empowering the generations to come [5]. In 2009, PHE Ethiopia consortium developed the following definition of PHE: “holistic, participatory development approach whereby issues of environment, health and population are addressed in an integrated manner for improved livelihoods and sustainable well-being of people and ecosystems.” In general, unlike the vertical FP services used hitherto, PHE initiatives aim to address the complex connection between humans, their health and the environment in providing FP services.

PHE interventions are a coordinated and integrated set of activities that include goals and interventions in the PHE sectors. Evidence from around the world demonstrates that the PHE approach is the way forwards for sustainable solutions to population and environmental problems. A study in the Philippines [6] demonstrated that an integrated development programming incorporating population, health, and the environment (PHE) was effective in lowering population growth rates and preserving the environment compared with single-sector development interventions. It has also been shown that an integrated approach to conservation and reproductive health generates higher impacts on human and ecosystem and on health outcomes compared to the independent vertical interventions [6-7]. Better reproductive health outcomes including increased contraceptive access and a significant decrease in the average number of children born to women and trends showing a significant reduction in income-poverty among young adults and added values has been reported [6, 8]. It is believed that the PHE approach has lead to an increase in access to FP and reproductive health services in remote communities in Madagascar, Kenya, Southern Asian coral triangle and Philippines [8]. Experiences from Madagascar and Philippines showed that the PHE approach of integrating the environment into reproductive health and FP programs not only integrated health into natural resource management projects prompting greater participation of women and adolescent girls, but also encouraged men and adolescent boys to get involved [8-9]. The integrated PHE approach leads to a more effective and sustainable solution to the population and environmental issues through empowering women and ensuring their involvement in the conservation activities [10] and through the economies of scale that the strategy ensures [6]. For instance; in the Philippines, an integrated approach improved both reproductive health and coastal resource management more than single-sector programs strongly suggesting that the integrated approach adds value [6]. The PHE approach also helps build trust with community as it aims at their priority issues including health services offering a fertile entry point for fostering community dialogue and concerted effort at the grassroots level.

It has been demonstrated that the integrated approach makes the PHE approach more effective and sustainable than delivering these services in stand-alone or parallel programs [6-7]. PHE projects in Ethiopia have been designed by local organizations and communities to identify goals that cannot be met without addressing basic needs and rights. For instance, Gurage People Self Development Organization (GPSDO) has incorporated agriculture extension and soil conservation into its family planning (FP) work to improve both food security and the health of women and children in the zone. As PHE interventions are relatively new in Ethiopia, there is a need to determine the effectiveness of the Ethiopian PHE model for achieving FP goals. This study aims to compare FP outcomes between PHE Woredas and non-PHE Woredas of the Gurage Zone.

Study area and setting

The Gurage zone is located in the central and southeastern mountainous area of Ethiopia in the Southern Nations, Nationalities and Peoples Region (SNNPR). It consists of 13 Woredas (Fig. 1), of which, GPSDO works in nine Woredas involving 250 kebeles (The smallest political administrative units). It is implementing an integrated package of environmental protection, livelihood improvement, health and education interventions (PHE integration) in 45 kebeles located within four Woredas: Cheha, Getta and Mehur-Aklil. The population of the zone is 1.4 million, of which 90 % live in rural areas. The Gurage Zone is one of the most densely populated zones in Ethiopia, with the maximum density reaching 441 persons per square kilometer. The national average for Ethiopia is 281 persons per square kilometer, while the average for SNNPR is 106 persons per square kilometer. The primary occupation in the zone is subsistence farming. As a result of the high population density and traditional farming practices, there is extensive soil erosion in the area. Crop yields have also declined as the quality of the soil has declined due to overuse. This environmental degradation contributes to food insecurity in the zone. Few families own livestock and most farm plots are less than one acre. According to the zonal agricultural department, only 10 % of families have at least one complete meal per day. Many husbands also migrate to the cities and have business there and come back to their rural wives on the Meskel Holiday, which is celebrated in September. The Woreda health offices use the holiday an opportunity to distribute family planning services to prevent unwanted pregnancies.

Power (1- ß) =95 %

Zα/₂₌Standard normal variable at 95 % confidence level (1.96)

P1 = Expected CPR in non-PHE Woredas (P1) =33.46 % [11].

P2 = 43 % with an assumed odds ratio of 1.5,

R = Ratio of sample population from PHE to non-PHE Woredas (1:1).

This gives a minimum sample size of 480 married women. Multiplying this by a design effect of 2 for the cluster sampling gives a final sample size of 960 married women.

For the in-depth interview 22 key informants pooled from different stakeholders were purposively selected from GPSDO staff, Health Extension Workers (HEWs), development agents (DAs), Community Based Reproductive Health Agents (CBRHAs), Woreda officials from relevant sectors such as health, agriculture, forestry workers education and students both in PHE and non-PHE Woredas.

Within each Woreda, kebeles were randomly selected as community survey sites. To the extent possible, the Woredas and kebeles were matched with similar demographic characteristics to make a fair comparison across PHE and non-PHE sites. The total sample from the quantitative study was allocated to the different Woredas in the PHE and non-PHE areas proportional to the size of their population. Within each kebele, the study subjects (married women 15–49 years) were selected using simple random sampling technique (Fig. 2).

A total of 962 married women in the reproductive age group were included in the study giving the response rate of 100 %. The mean age of the women was 35(±6.8) years in the PHE Woreda and 34(±6.5) years in non-PHE Woreda. A total of 62.9 % of the women in the non-PHE Woredas and 69.8 % of them in PHE-Woredas had not gone to school or had attended informal education, while the rest had varying degrees of education (P < 0.001). Contrary to the finding on women, 36.5 and 45.4 % of the husbands in the PHE and non-PHE Woredas, respectively did not go to school or had attended informal education (P < 0.001). Regarding current school attendance, 50 % of the women in the PHE and 49 % of the women in the non-PHE Woredas were attending school at the time of the survey (P = 0.99). Mean family size was 6.2(±5.6) persons in the non-PHE Woredas; while it was 5.7(±4.1) in the PHE ones (P = 0.145).

The results showed that the percent of women who had heard about FP methods was similar between the PHE and non-PHE Woredas (92.5 and 95 %, respectively). There was no significant difference in the number of FP methods the women knew out of 13 total methods. However, when asked about the eight commonly used FP methods, women in the PHE Woredas mentioned 3.03(±1.64) methods while those in non-PHE Woredas knew 2.74(±2.26) methods (P = 0.032).

There was no significant difference in the CPR between the two woredas (70.7 % PHE vs 73.9 % non-PHE). However, the percent of new acceptors of modern FP methods was higher in the non-PHE Woreda (69.5 %) compared with the PHE Woredas (26.2 %, P < 0001). There was no significant difference in the percent of women who had heard of at least three contraceptive methods and in the percent of women who knew at least one source of modern FP methods between the two woredas.

When we examine the CPR by age category of women, there was a significant difference between the different age groups in both PHE and non-PHE Woredas showing that the CPR is lower in the younger age groups and in the older age groups.

Similarly, in the PHE Woredas, a larger percent (30.2 %) of men support the use of FP by themselves compared with the non-PHE Woredas (7.3 %), which is another striking finding (P < 0.001), Table 1.

Regarding the reason for FP use among the current users, more women in the PHE Woredas practiced FP for limiting their children (50.9 % vs. 29.3 %), while a larger proportion of women in the non-PHE Woredas used FP for spacing their children (55.2 % vs. 30.4 %), (Fig. 3).

The qualitative data also indicated that 54 energy saving stoves were distributed both in the rural and urban areas of the in the PHE Woreda compared with non-PHE Woreda, where a total of 50 stove were distributed only in the urban areas. The stoves in the PHE Woreda were produced locally by organized women’s group, while the ones in the non-PHE Woreda were purchased from other areas. An in-depth interview with women using the energy saving stoves in the PHE Woreda indicated that in the energy saving is getting more acceptance.

The findings showed that the PHE Woredas had better integrated PHE issues and networking at the community level. The fact that there was no significant difference in the CPR between PHE and non-PHE Woredas could be due to the effect of the Meskel campaign as the study was carried out right after the Meskel holiday. We did a subgroup analysis excluding the new acceptors of family planning to investigate if there is a difference among those women who were not new acceptors of family planning by avoiding the confounding effect of the Meskel holiday. The result showed a significantly (P < 0.0001) higher CPR in the PHE Woreda (78 %) compared to the non-PHE Woreda (52 %) indicating the effects of the positive behavioral changes that the PHE approach had introduced. Our findings also showed significant positive change in family planning behaviors in the PHE Woredas. Knowledge about FP methods that are commonly used was significantly higher in the PHE Woredas and larger proportion of husbands in the PHE Woreda supported the idea that husbands’ should use family planning methods. This finding is similar to the findings of a study in Philippines [6], which showed that an integrated model showed a better outcome compared with the single-sector models in terms of improvements in health, individual FP and reproductive health practices, and community-level indicators of food security and vulnerability to poverty.

The fact that a significantly higher proportion of couples used family planning methods for limiting the number of children in the PHE Woreda as compared to the non-PHE Woreda indicates the positive attitudinal change that the PHE approach has brought in building the norm of having smaller family size as the data also showed that desire for additional children is significantly lower in the PHE Woreda. The fact that the study was conducted immediately after the Meskel Holiday might have inflated the CPR in the both woredas.

Husbands’ support of their wives’ FP use was strongly associated with current use of FP methods. Studies in Ethiopia and Kenya also showed that communication between husband and wife on FP issues and husband’s support (approval) of FP use by his wife are critical factors determining FP outcomes including CPR and unmet need [13-14]. In this study, men in the PHE Woreda also support using FP methods themselves. These findings suggest the need for enhancing dialogue and advocacy to involve husbands in FP issues to improve FP outcomes.

The findings also showed that there is better integration of environmental conservation activities in the PHE Woredas into FP and health activities. For instance, there is better acceptance of fuel saving stoves, better afforestaion, and more diversified, environmentally friendly income generation activities in the PHE Woredas. This might be due to the positive attitude among community members as a result of the PHE-facilitated awareness creation activities using students as a medium and through community mobilization efforts by community based reproductive health agents (CBRHAs). Studies showed that the PHE approach empowers women and facilitates their involvement in the conservation activities [10] ensuring an effective and sustainable solution to population and environmental issues [6]. A report also indicated that despite the different challenges, PHE projects generate improved attitudes towards conservation and may play a critical role in laying the groundwork for successful conservation, particularly in areas where goodwill and trust in conservation organizations is not as strong [15].

Evidence shows that efforts to scale up programs in Madagascar and the Philippines has been relatively successful due to early and continued recognition of the interplay between FP and environmental issues by the conservation community and recognition by FP advocates and other health partners of the benefits of partnering with conservation organizations, among others [5, 6, 16, 17]. Efforts to address unmet need for FP in rural communities in Madagascar have been strongly influenced by local, regional, national and international FP, conservation, and development initiatives as well as through focused site-based PHE projects [18]. This implies that a very close partnership with the different sectors especially the natural resources management office is critical in ensuring the sustainability and scale up of the program.

With an ever increasing population and concomitant decline of natural resources, the findings highlight the effectiveness of PHE approach in promoting family planning outcomes in the rural communities of Ethiopia. This approach is critical and needs to be scaled up to address the problem food insecurity and malnutrition that is frequently encountering human population [19–22] especially in developing countries.

Although the study demonstrated significant differences between the PHE and non-PHE Woredas in terms of family planning behaviors, the following limitations need to be considered in interpreting the results. Due to the cross-sectional nature of the data, it was not possible to see the effect of improved family planning behaviors on the actual fertility practices. Due to lack of baseline population based data, it was not possible to show the effect of the PHE approach through the comparison of the difference of differences analysis. However, conscious effort has been made to minimize biases that could creep in by making the two woredas similar in terms of many of the known parameters that are relevant to the study. In fact the control woreda (Gumer) was closer to the main road which could have facilitated family planning outcomes in the control woreda. As the study was conducted during the Meskel Holiday, the family planning outcome measures were inflated in both woredas. Therefore, a subgroup analyses of the non-new acceptors was done to compare what has been happening during the last 5 years (2008–2012) before the survey when the project was in operation.