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.

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).

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.

As the CPR are very high in both woredas, we suspected that this could be due to the effect of Meskel holiday when there is a campaign on promoting family planning that has resulted in the culture of using family planning by the community. Meskel is a religious holiday commemorating the day on which the true Jesus’s cross was found. It is warmly celebrated in the month of September among Orthodox Christian in Ethiopia in general and in Gurage Zone in particular. In Gurage zone, usually husbands, who are mostly merchants in the towns, will come back to their rural wives. The Woreda Health Offices and health facilities target this holiday to distribute family planning methods. Therefore, we did subgroup analysis for married couples who are not new acceptors of modern family planning methods (those who are not acceptors of family planning for the first time during the last 1 year). As presented in Table 1, CPR was significantly (P < 0.0001) higher (78 %) in the PHE Woreda compared to non-PHE Woreda (52 %).

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).

As presented in Table 2, multivariable linear regression model showed after adjusting for different variables, women’s educational level, women’s occupation and husband’s occupation were significantly associated with knowledge of FP methods. Higher knowledge of FP methods was positively associated with increased years of education of the women (P < 0.0001), woman’s occupation of being a farmer (P = 0.005), women’s occupation of being a student/private employee (P = 0.001).

We did sub-group analysis of women by excluding the new acceptors showed a similar finding regarding the predictors of knowledge of family planning. We also analyzed the predictors of current use of FP methods. On multivariable logistic regression model, after adjusting for different socio-demographic variables, older age of the women (P = 0.01) and husband’s desire for more children were negatively associated with current contraceptive use (0.032). On the contrary, husband’s support of FP use by his wife was very strongly associated with the current use of contraceptives (Table 3). Women whose husbands support their use of FP were 17 times more likely to use FP at the time of the survey (P < 0.0001).

A second multivariable logistic regression analyses using women who are non-new acceptors of family planning methods showed number of children that the woman has (P = 0.001), husband’s support of use of family planning methods by his wife (P < 0.0001) and living in the PHE Woreda (P < 0.0001) were strong positive predictors of current use of family planning methods. Women whose husbands support their use of family planning methods were over 20 times more likely to use family planning methods. Similarly, women in the PHE Woreda were over four times as likely to use family planning methods at the time of the survey (Table 4).

Analyses of data from key informant interviews also indicated that family planning services are better integrated and decentralized into the grassroots level in the PHE Woreda (Table 5). It was observed that family planning services are linked to conservation activities with stronger use of schools as a medium for reaching parents. In-depth interviews with different sectors showed that, in the PHE Woreda, issue of family planning are integrated with health and environment. For instance, in giving health education, the issues of population are linked to the effect that they have on the environment and health. The Gurage People Self Development Program (GPSDO) program coordinator in the PHE Woreda stated:

“…We have a philosophy of economics of scale in integrating the issues of population, health and environment. Students are involved in afforestaion and area closure activities in addition to passing the key messages to their parents. Rather than making different interventions at different times, integrating our intervention that addresses the issues of population, health and environment caters for the best use of resources. For example we have a very strong integrated school health program. We use school students as medium to educate their parents on family planning, health and environmental issues. We have school education program, students are educated by different sectors including health and agriculture on the link between population, health and environment. Health education is given twice per month in 5 schools. The other strategy is community mobilization where PHE has a capacity building and facilitation role.”

There was also a diversified source of income generation mainly owned by women targeting environment and family planning. A significantly (P < 0.0001) higher proportion of households in the PHE Woreda (9.8 %) were using the energy saving stoves compared with those in the non-PHE Woredas (2.7 %). However, there was no difference in the percent of cooking places that have air vent (windows) between the PHE and non-PHE Woreda (Table 6).

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.

One of the women using the energy saving stove stated the following to show how beneficial the stove is,

“…we were about to sell our children in exchange for getting fuel, now as user of the energy saving stove, we are reaping the benefits. I am also one the women in involved in the production of the stove. We are very happy in producing as it is highly needed and accepted by the community.”

The chair person of women‘s group working on energy saving stove production and income generating scheme in the PHE Woreda (Cheza Kebele) stated the following in trying to explain how their income generating scheme Operates:

“…The project…GPSDO/PHE provided us a capacity building training on the production of energy saving stoves and assisted us with materials such constructing a house which we use for storing materials such as cement, metallic moulds and supplied us with inputs used for stove production. The kebele gave us a space to construct the house. Our group has now 28 members and we are now very skilled in producing the energy saving stoves and we are even training others. Initially, we use to sell a single stove for 23 Birr. Currently, the demand has increased and a single stove is sold for 200 Birr.”

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.