Utilization of modern contraceptives and associated factors among street women in Dire Dawa, Eastern Ethiopia: a mixed study

Introduction Unwanted pregnancy and sexually transmitted diseases are the major problems in street women because of the non-utilization of modern contraceptives. To the best of our knowledge, no studies have assessed the utilization of modern contraceptives and associated factors among street women in the study area. Therefore, this study aimed to determine the utilization of modern contraceptives and its associated factors among street women. Methods A community-based cross-sectional study using mixed methods was conducted from February 16th to April 10, 2021, among all censuses and 615 reproductive-aged street women. Face-to-face and in-depth interviews were employed to generate quantitative and qualitative data, respectively. Binary logistic regression was used to analyze the association between modern contraceptive utilization and independent variables with statistical significance set at p < 0.05. Qualitative data were analyzed using a thematic approach. Results Approximately half 279 (50.3%) (95% CI: 46.3%, 54.4%) street women currently used modern contraceptives. Factors significantly associated were women aged 25–34 years [AOR = 5.5, 95% CI: 1.2–24], distance from a nearby health facility within 30 min [AOR = 9.2, 95% CI: 1.6–51], getting advice from health professionals [AOR = 14.3; 95% CI = 5.3–38.4], discussed with their sexual partners about the utilization of modern contraceptives [AOR = 6.2, 95% CI: 2.4–16.5], a history of pregnancy [AOR = 2.7, 95% CI: 1.2–6], the desire to have a child after two years [AOR = 2.2, 95% CI: 1.1–4.7], and women who faced rape in street life [AOR = 5.4; 95% CI = 1.9–15.3]. Fear of side effects, misperceptions, and the desire to have a child are the main identified themes for the key barriers to using modern contraceptives. Conclusion The proportion of street women currently using modern contraceptives was low. Age, distance from the health facility, discussion with health professionals, discussion with sexual partners, history of pregnancy, desire time to have a child in the future, and history of rape were factors significantly associated with the use of modern contraceptives. Most of the participants’ reasons for the lack of use of modern contraceptives were fear of its side effects.


Introduction
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. Modern contraceptive methods include the pill, injectable, male and female condoms, emergency contraception, implants, intrauterine contraceptive device (IUCD), female and male sterilization, standard day method (SDM), and lactational amenorrhea method (LAM) [1]. Worldwide, there are 1.9 billion women in the reproductive age group (15-49 years) in 2019, 1.1 billion need family planning; of which 842 million are using contraceptive methods, and 270 million have an unmet need for contraception [2,3]. In Ethiopia, 41% of currently married women use modern contraceptive methods, and 1% use natural methods [1].
The prevalence of modern contraceptives among women of reproductive age has increased worldwide between 2000 and 2019 by 2.1% (55 to 57.1%) [2]. Reasons for this slow increase include a limited choice of methods; limited access to services, particularly among young, poorer, and unmarried people; fear or experience of side-effects; cultural or religious opposition; poor quality of services; users' and providers' bias against some methods; and gender-based barriers to accessing services [2,4]. Target 3.7 of the Sustainable Development Goals (SDGs) calls on countries "by 2030, to ensure universal access to sexual and reproductive health-care services, including for family planning, trends in contraceptive prevalence and need for family planning satisfied with modern methods indicate where increased investments and commitments by governments and international organizations are needed for the realization of reproductive rights for all people, and to help fulfill the pledge of the 2030 Agenda for Sustainable Development that "no one will be left behind" [3].
The World Health Organization has clarified that modern contraceptive methods are essential for preventing pregnancy-related health risks in women, reducing infant mortality, helping to prevent HIV/ AIDS, empowering people and enhancing education, reducing adolescent pregnancies, and slow population growth [5,6].
Sexual and reproductive health problems are responsible for one-third of the health issues of women of reproductive age (15-49 years). Unsafe sex is a major risk factor-particularly among women in developing countries. Therefore, it is important to obtain services for 222 million women who do not receive the contraception services they need [7].
Street women are women who make their lives on street life by begging, sleeping in streets, or on roadsides. Those who had no formal homes (homeless) and sleep on streets, verandas, balconies, etc. at night were classified as "on-street" while those who have houses to go for sleep at night while making their lives on the street life were termed as "off-street" [8]. They are the most marginalized, neglected part of society, with very negligible access to health care, including modern contraceptives, and a lack of awareness of health services. The circumstances in which they live and work increase their vulnerability to sexual exploitation and abuse and put them at a higher risk of unwanted pregnancies, sexually transmitted infections, and HIV/AIDS [9,10]. In addition, research has revealed that women living on the streets are less likely to benefit from basic reproductive health services, including modern contraceptives modern contraceptives. This study aimed to determine the utilization and associated factors, and explore the key barriers to modern contraceptive utilization among street women in Dire Dawa.
In this study, a community-based cross-sectional study design was conducted among all censuses and 615 reproductive-aged street women from February 16th to April 10, 2021. Face-to-face and in-depth interviews were employed to generate data for both methods. Data were analyzed using the SPSS software version 25 and a thematic approach for quantitative and qualitative, respectively.
The findings of this study showed that the proportion of street women who currently used modern contraceptives was 279 (50.3%). Factors significantly associated were age, distance from the health facility, discussion with health professionals, discussion with sexual partners, history of pregnancy, desire time to have a child, and history of rape.
The key barriers to using modern contraceptives are fear of side effects, misperceptions, and the desire to have a child.
In conclusion: this study demonstrated that the proportion of street women currently using modern contraceptives was low. Health professionals and health extension workers should give health education that integrates well-organized street women's groups and community health extension workers that may help reduce women's fear of potential side effects. To correct the misperceptions and myths about modern contraceptives too.
Keywords: Modern contraceptives, Reproductive-age, Street women, Dire Dawa as living in the poorest segment of society [11]. To address this problem, most homeless females do not have access to information regarding sexual health and safety. Homeless mothers showed a profound lack of knowledge or interest in birth control and reproductive health, and 50% of them did not believe that birth control was important [12].
Similarly, studies have shown that unwanted pregnancy and sexually transmitted diseases (STDs) are the major problems in street women because they do not use modern contraceptives [8,[13][14][15].
Street women are a segment of the population in absolute poverty. Around half of them are sexually active and have a history of pregnancy, even more than one pregnancy after they come into street life. One-third of street residents face sexual assaults in their street life [8]. Unwanted pregnancy and its consequences necessitate the use of modern contraceptives to control birth. STDs and unwanted pregnancies besides homelessness have negative consequences for the women themselves, their children, siblings, and societies [16].
Few studies have focused on the utilization of modern contraceptives among street women in the country with only a quantitative method [8,[17][18][19], and no recent comprehensive data regarding this in the study area in particular. In addition, as the findings of these previous studies varied, to obtain evidence-based epidemiological data in our study area, these studies only used quantitative data collection methods, unlike our study that used both quantitative and qualitative methods to explore the key barriers of modern contraceptive utilization by street women. Therefore, this study aimed to determine the utilization and associated factors, and further explore the key barriers to modern contraceptive utilization among street women in Dire Dawa.

Study area and period
The study was conducted in Dire Dawa City from February 16th to April 10, 2021. Dire Dawa City is 515 km from Addis Ababa to the East. According to 2019 population projections, 313,000 people (63%) live in the City of Dire Dawa and 180,000 people (37%) live in rural areas [20]. The total fertility rate is 3.1 for women of reproductive age (15-49 years) [21]. In terms of the distribution of public health facilities, the city has 2 public hospitals, 8 health centers, 5 higher clinics, 12 medium clinics, and one FGAE. The administration has 9 urban Kebeles.

Study design and population
Community-based mixed (quantitative and qualitative) studies were also conducted. All reproductive-aged street women who lived in Dire Dawa City were included, while pregnant and critically ill street women were excluded.

Sampling and sampling procedures
All Census reproductive-aged (15-49 years) street women in Dire Dawa City during the data collection period. We conducted a pre-phase assessment and estimated the number of reproductive-aged street women, with 667 reproductive-aged street women. Of these, we excluded 4 critically ill and 48 pregnant women. Finally, 615 reproductive-aged street women were interviewed with a response rate of 90.24%. Fourteen (14) street women were included in the supplementary qualitative method based on the saturation of the data.

Sampling techniques
After the census of street women in demarcated sites in nine kebeles, 667 women of childbearing age lived in the streets. The demarcated sites in each Kebele include main roadsides, isolated slum areas (bridge sides), around taxi/ bus stations, traffic lights sides, road junctions, around Churches and/or Mosques, and streets where street women usually reside and/or sleep. Finally, a census survey of street women of reproductive age who fulfilled the eligibility criteria was included. Since street women are mobile and have no specific addresses, the probability of being interviewed by street women at other sites is high. To avoid interviewing more than once, women were asked whether they had previously been interviewed for modern contraceptive awareness and utilization within the period of data collection. For the qualitative method: purposive sampling techniques were used to select the interviewees.

Operational definitions
We define street women as women who make their lives on street life by begging, sleeping in streets, or on roadsides. Those who had no formal homes (homeless) and sleep on streets, verandas, balconies, etc. at night were classified as "on-street" while those who have houses to go for sleep at night while making their lives on the street life were termed as "off-street" [8]. In this document, we frequently used interchangeably for both street women and beggar women to convey the same meaning.
Street women's awareness of modern contraceptives was assessed using simple knowledge questions about modern contraceptives (if they have ever heard, able to mention methods, know the importance, source of the information, and site to get MCs). Modern contraceptive ever user: A woman who has ever used any of the modern contraceptive methods [17]. Modern contraceptive current users: women using modern contraceptive methods at the time of the survey [17,18].

Data collection instrument and measurements
Data were collected through face-to-face interviews using piloted and validated surveys, which were adapted from the literature. The tool included different sections, such as sociodemographic characteristics, awareness and utilization of street women toward modern contraceptives, and reproductive health and sexual exposure-related factors [8,8,11,[17][18][19]22]. First, we prepared the tool in English and then translated it into the local language and back to English. Nine trained health professionals collected the data, and three supervisors and investigators supervised the data collection process. We collected data at the demarcated sites where more street women live, and the data collection times were Monday to Sunday, especially in the morning and afternoon.
Open-ended questions were used through in-depth interviews to collect the qualitative data. During the interviews, the dialog was recorded using a tape recorder, and field notes were recorded using a notebook and pen/ pencil. Two trained health professionals collected the data. After the note taker and the interviewer introduced themselves, the purpose of the study and confidentiality of the data was explained to the participants, and the probing questions were forwarded to the participants. The in-depth interview took approximately 30 min to complete. Finally, the investigators transcribed the collected data in the full text on the same day.

Data quality assurance
Data quality was assured by senior researchers and the adapted questionnaire was checked and revised. The training was provided for data collectors for a 2-days emphasis on the tool, the art of interviewing especially to address the sensitive question by tactic full manners, ethical issues, and the significance of the study, as well as how to approach the participants. During the preassessment phase, we conducted a pre-test on 20 women of data collection tools, and necessary corrections on the instrument were incorporated. Each data collector checked the questionnaires for completeness before visiting the participants. The investigators checked the data overnight. Then, necessary feedback was offered to the data collectors every morning.
The recorded data were transcribed on the same day to incorporate all the women's information, including their facial expressions, and only two interviews were recorded per day. Field notes were taken side by side with a tape recorder and expanded within 24 h to use as a backup in cases where the records failed. We checked the field notes and transcripts and recorded the interviews each day for errors to correct the timing. The interviews were then transcribed carefully, and data coding and thematic analyses were performed.

Data processing and analysis
The data were checked for completeness and consistency. Finally, the data were entered into Epi-data 3.1 and exported to SPSS version 25.0. Frequency and percentages were used to illustrate the study findings in the tables and text. We analyzed the association between the outcome and independent variables using a binary logistic regression model. Variables with a p < 0.2 in the bivariate analysis were used for multivariable logistic regression analysis. Hosmer and Lemeshow's goodnessof-fit test was used to assess whether they fulfilled the necessary assumptions. We measured the direction and strength of the statistical associations using odds ratios with 95% confidence intervals (CIs). AOR with 95% confidence intervals (CIs) at p < 0.05 was considered as a statistically significant association with modern contraceptive utilization.
Qualitative data were translated and analyzed using a thematic approach with ATLAS.ti 8. We developed themes after reflexive reading of the translations. All authors cross-validated emerging themes.

Sociodemographic characteristics of street women
Of the total, 555 street reproductive-aged women were interviewed, resulting in a response rate of 90.24%. The mean age of the women was 28.52 years (SD ± 7.47). Most women were aged 25-34 years (47%). The majority, 467 (84.1%) and 456 (82.2%) women were Oromo and Muslim followers, respectively. Regarding the educational status of women, 380 (68.5%) were unable to read and write. The mean duration of street women who stayed in street life was 5.98 years (SD ± 5.32) ( Table 1).

Awareness of street women about modern contraceptives
Most 516 (93%) women said they had information (heard) about modern contraceptives, and injectable 455 (88.2%) was the most commonly mentioned. More than half 260 (50.4%) of their sources of information were health professionals. The majority of the participants, 465 (90.3%) agreed that modern contraceptives had their advantages. More than half 363 (70.4%) of the street women were discussed with health professionals about modern contraceptives ( Table 2).

Utilization of modern contraceptive methods among street women
Of the total women, 356 (64.1%) in this study used one of the modern contraceptives while 279 (50.3%) (95% CI: 46.3%, 54.4%) were currently using modern contraceptives.
Among the current modern contraceptive users, 159 (57%) used implants followed by injectable 99 (35.5%,  pills, condoms, and IUCD. Most of the 238 (85.3%) participants took it from health centers followed by the hospital, FGAE, and pharmacy where 16 (5.7%), 14 (5%), and 11 (3.9%), respectively. Regarding the reason for not using modern contraceptives currently were fear of perceived side effects 103 (37.3%) followed by being sexually not active 102 (36.96%), lack of knowledge 39 (14.1%), lack of interest 27 (9.78%), lack of access 4 (1.4%), and only one woman did not have a reason. Among those who were not currently using contraceptives, 191 (69.2%) did not plan to use modern contraceptives in the future.

Sexual behaviors and reproductive health of street women.
Of the total, 333 (60%) practiced sexual activity in the six months prior to data collection. Over sixty percent, 339 (61.1%) of the participants had a history of pregnancy after engaging in street life. Ninety-nine (17.8%) reported that they had a history of rape while living on the streets (Table 3).

Qualitative result
Most of the participants had no formal education and their ages were between and 25-34 years old. Regarding their duration of street life, more than half of them reported that they were on the street for 5 years and above. Three thematic categories emerged from the collected data: fear of side effects, misperceptions about modern contraceptives, and desire to have a child.

Fear of side effects
Most of the participants' reasons for the lack of use of modern contraception were fear of its side effects, especially after using implants and injectable methods, such as weight loss, severe headache, irregular bleeding, behavioral changes such as mood swings, and anger.

Misperceptions about modern contraceptives:
Street women overestimate the side effects of modern contraceptive methods based on hearsay from their friends and relatives about the methods. They perceived it to cause infertility; it is not used by poor women (street women) because it needs highly nutritional food (like milk, meat), and even kills women on the street. Negative anecdotes of modern contraceptive health issues have decreased when using contraceptive methods. In particular, they considered the implants and injectables to be bad.

Discussion
In this study, 279 (50.3%) street women were currently using modern contraceptives. This prevalence is higher than that reported in Chicago, USA, which showed that 16 women (30%) [23]. This difference might be because of the very small sample size in the previous study, and the elapsed study period. Similarly, this finding is higher than that of studies conducted in Ethiopia such as North-West (Bahir Dar and Gondar) in 2012, which was 70 (34.3%), Amhara Regional State Zonal Towns in 2020 which was 235 (38.9%), Bahir Dar 2020 was 73 (31.1%), SNNRP in 2019 which showed that 129 (37.4%), Shashemene which was 54 (36.5%), and Bole sub-city Addis Ababa revealed that 18 (21.4%) [8,11,17]. The discrepancy might be that, in the current study, a high number of women received advice from a health professional about modern contraceptives., Most of the previous studies used a small sample size that may affect the prevalence; in addition, the current study included women in only one city with a large sample size, unlike the other studies in North-West with two cities, Amhara Regional State Zonal Towns and SNNRP. This study showed that injectables, implants, and pills are the most commonly used modern contraceptives. This is similar to the studies conducted in Northwest Ethiopia (Gondar and Bahir Dar cities) and Bahir Dar [8,17]. This may be because they are the most familiar and commonly used contraceptive methods at the national level, which leads them to recall and used it.
In this study, fear of side effects was the main reason for not currently using modern contraceptives. The qualitative result, which was the main reason for not using modern contraceptives, also supported this fear of its side effects. This is in line with the quantitative finding of a study conducted in Northwest Ethiopia (Gondar and Bahir Dar cities) [8]. This may be because of hearsay from friends or others, overestimation of the health risk of the side effects of modern contraceptives as its normal has a minimal side effect, while it would have rarely adverse side effects.
Sociodemographic characteristics significantly associated with street women aged 25-34 years were 5.5 times more likely to utilize modern contraceptives than those aged 15-24 years. A study conducted in Bahir Dar supports this finding [8]. This might be because those 25-34 years old street women are more likely to give birth, and they are more sexually active, which may lead to the use of modern contraceptives.
In this study, women who discussed modern contraceptives with a health professional were 14.3 times more likely to utilize modern contraceptives than their counterparts. These findings support the findings reported in Bahir Dar Town [17]. An explanation might be that as the participants receive counseling from health professionals, they can get the chance to understand the modern contraceptive methods, know the benefits of MCs, and about the side effects and misconceptions that can lead them to use them.
The odds of the utilization of street women toward modern contraceptives among those women discussed with their sexual partners about the utilization of MCs were 6.2 times more likely to utilize it than their counterparts. This finding is consistent with a study conducted in the Amhara Regional State Zonal Towns [19]. This could be because discussion might increase awareness about the value of contraception and initiate the study participants to use contraceptives.
Street women who faced sexual assault or rape in street life were 5.4 times more likely to currently utilize modern contraceptives than their counterparts. This finding is in line with a study conducted in the northwest (Gondar and Bahir Dar cities) [8]. This is because, as they face many problems, they are alert to care for themselves for the complications of unplanned and unwanted pregnancy because of unprotected sexual intercourse, which results in poor outcomes of abortion. This has led to the use of modern contraceptives.
In this study, the time taken to arrive at a nearby health facility on the foot was another predictor variable. Women who arrived at a nearby health facility on the foot within 30 min were 9.2 times more likely to utilize modern contraceptives than those who took more than 30 min. Other studies did not perform an association or were not associated. The justification might be that distance obviously can affect the seekcare of health behavior, as they are low-socioeconomic and may lack transportation costs to reach health facilities to get family planning services.
In our study, street women who had a history of pregnancy after joining the street were 2.7 times more likely to utilize MCs than their counterparts. This finding is consistent with a study conducted in the Amhara Regional State Zonal Towns in 2019 [19]. A possible reason might be that they have the chance to have desired children or that they may suffer from the complication of pregnancy at this time, which initiates them to utilize modern contraceptives.
This study has some limitations: as the participant's reports of some sensitive variables such as sexual activity, abortion, and rape could be affected by social desirability bias, and they might have said that they may hide the truth. As we took all censuses of reproductive age street women, we faced some difficulties, such as the difficulty of searching the streets, and some women did not know their exact age. We faced an approximately 10% nonresponse rate due to participants' refusal and incomplete responses.

Conclusion
The proportion of street women currently using modern contraceptives is low. Factors associated with the utilization of modern contraceptives included age, arrival at a nearby health facility on foot, discussion about MCs with health professionals, discussion with sexual partners about the utilization of MCs, history of pregnancy after joining the street, desire time to have a child in the future, and history of rape in the street. Fear of side effects, misperceptions and myths, and desire to have a child are the main identified themes for the key barriers to using modern contraceptives. Besides, the above issues better to develop different strategies that can approach and increase the awareness and knowledge about modern contraceptives different methods, use and service availability, and accessibility among street women. Health professionals and health extension workers should give health education that integrates well-organized street women's groups and community health extension workers that may help reduce women's fear of potential side effects. Additionally, to correct the misperceptions and myths about modern contraceptives too.