Study Area and Period
The study was conducted from August 10/2021 to October 10/2021 in Ginde beret district public health facilities. Ginde beret district is one of the districts in West Shoa Zone Oromia Region, Ethiopia. The district is located 193 kilometers from Addis Ababa toward north-west. The district is administratively divided into 33 kebele (smallest administrative unit), 3 urban and 30 rural. The district is bordered on the south by Jeldu, on the southwest by Ambo district, on the west by the Guder River which separates it from the Horo Guduru Wollega Zone, on the north by the Abay River which separates it from the Amhara Region, on the east by Abuna Gindeberet district.
According to Gindeberet district Health office, the district's population in 2021 was projected to be 159,016(80,557 Males and 78,459 Females. There is one public hospital, Six Public Health Centers and thirty-three Health posts in the district. Family Planning Services are available in all Public Health Facilities in the district. The total numbers of reproductive age group in the district were 35,190 of them Depo-Provera users were 14,428
Study Design
Facility based Cross-sectional study was conducted in Public Health Facilities of Gindeberet district, Oromia, Ethiopia.
Population
Source Population
All pregnant women who were using DMPA before current pregnancy, attending ANC at public health facilities in Gindeberet district
Study Population
All pregnant women who were using DMPA before current pregnancy, attending ANC at public health facilities in Gindeberet district during the study period.
Inclusion and Exclusion Criteria
Inclusion criteria
Women who meet the following criteria were chosen as appropriate study participants
- Used DMPA at least single injection prior to discontinuation
- Stated an expressed intention to become pregnant as the reason for discontinuation
- Did not used any form of birth control (male or female) after discontinuation of DMPA
- Married or living with her husband or sexual partner (having regular intercourse to become pregnant).
Exclusion Criteria
Pregnant women, who used DMPA but became pregnant due to a method failure, as well as pregnant women who were seriously ill and unable to communicate were excluded. Women who were less than 18 years were not included in the study because of difficulties to get informed consent.
Sample Size Determination and Sampling Technique
Sample size determination
Sample size calculation for objective one
Sample size was calculated using single population proportion formula taking into account that 45.9% of women had delayed fertility return after discontinuing DMPA use (based on previous study conducted in Addis Ababa) (25) .Using 5% margin of error, and a 95% confidence level (d=0.05).Based on this assumption the actual sample sizes for the study was n = (Z α/2) 2 (P (1-P)/ d 2
By considering 10% for non-response rate i.e.,38 and the final sample size was 420.
Where; n= the required sample size
p= proportion of women delayed return to fertility after discontinuation of using DMPA
Zα/2 =the value of Z in a standard normal distribution (95% confidence level corresponding to alpha level of 0.05 which is equal to 1.96)
d = the Margin of error between the sample and the population (0.05)
Sample size calculation for the second objective
Variable which has strong association with delay in fertility return from study conducted at Addis Ababa was selected, at 95% of confidence level, at 80% of power, ratio of unexposed to exposed
In which, the maximum sample size was taken (n=420) from objective one.
Sampling Technique
The study was conducted in all seven public health facilities found in Gindeberet district. In all health facilities, the numbers of women who have stopped DMPA in the past two years were 2405 and the required numbers of sample was allocated proportionally based on their respective number of clients who discontinued DMPA in each Health Facility. Since the number of women who had used DMPA and currently pregnant were limited, all eligible participants were recruited as they come to health facilities based on the inclusion criteria until required number was meet and consecutive sampling technique was used to select study subjects. Study Participants were chosen using the following formula based on proportional allocation for each Health Facility:
n= nf x N Depo-Provera discontinued in respective Health Facility /N total
n=sample size in their respective health facility
nf = n1+n2 +n3 +n4+n5+n6+n7 estimated final sample size
N total = N1 + N2…. (Numbers Women who discontinued DMPA in each Health Facility
Variables
Dependent Variable
Delay in Fertility return after discountution of DMPA
Independent Variables
Socio Demographic Characteristics: Age, Family income, Years stayed in marriage.
Reproductive Variables: Gravidity, Sexual Frequency, Age at first sex, previous utilization of contraception.
DMPA related factor: Number of DMPA used in cycles.
Operational Definition
Return of Fertility after discontinuation of DMPA- defined as the establishment of a proven pregnancy later than 15 weeks following the last 3-month injection (the assumed normal protection period of 12 weeks plus an arbitrarily defined and clinically valid safety-period of 3 weeks 13
Delay in Fertility return after discontinuation of using DMPA - Resumption of fertility after 10 months of discontinuation of using DMPA while having regular sexual intercourse 13
Not delay in Fertility return after discontinuation of using DMPA-Resumption of fertility at or before 10 months after discontinuation of using DMPA while having regular sexual intercourse13
Regular Sexual Intercourse- Sexually active at least once per week with couple or sexual partner.19
Fertility returns to current pregnancy - obtained from duration of current pregnancy estimated by U/S or GA on the day of data collection date minus date of Depo-Provera discontinuation.
Date of Depo-Provera discontinuation -calculated from the last date of Depo-Provera injection protection period of 12 weeks plus clinically valid safety-period of 3 weeks while not using any contraception method.
Data Collection tool and Techniques
An interviewer-administered structured questionnaire with reviewing client’s record was used to collect the data. The questionnaire was adapted to the local situation and the study area from previously conducted studies to fit to the purpose of the study. The domains of questions included in the tool were socio-demographic characteristics, Reproductive characteristics and Depo-Provera related characteristics. The questionnaire was first prepared in English and then translated into Afan Oromo by language expert. The questionnaire was translated back into English by another language expert in order to check if the translation was consistent with the English version. Finally, Afan Oromo questionnaire was administered by seven trained female midwives who were working in the health facilities with close follow-up of one supervisor. In addition, the participants were interviewed after they completed their follow up visit as an exit interview.
Data Quality Assurance
Both the data collectors and the supervisor were trained for one day on the purpose, sampling technique, ethical concerns, data collection tools and the data collection process in order to ensure the quality of data. In the entire data collection period, the investigator supervised them and the collected data were examined for completeness every two days by the supervisor. Incomplete questionnaires were excluded from further analysis. The questionnaire was pretested on 5% of the sample size (21 women) in Bake kelate Health Centre, Abuna Gindeberet prior to the actual data collection. Some modifications were made on the questionnaire based on the findings of the pretest. Also, the reliability of the tool was tested with Cronbach’s alpha coefficient and it was found 0.83.
Data Processing and Analysis
After data collection, each questionnaire was checked for its completeness and the data were coded and entered using Epi-info version 7 and exported to the Statistical Package for Social Sciences (SPSS) version 25 to be cleaned and analyzed by the investigator. Descriptive statistics were calculated and summarized using frequencies and median. The delay in return to fertility after discontinuation of using DMPA was dichotomized using the median months of delay in return to fertility as a threshold.
Then, the description of study participants by their different socio-demographic, reproductive health characteristics and Depo-Provera related Characteristics were presented using tables, chart and text. Bivariate and multivariable logistic regressions were applied to analyze the association between the dependent and independent variables. Variables with p-value < 0.2 with COR on bivariate logistic regression were considered as candidates for multivariable logistic regression. Model fitness was checked through Hosmer–Lemeshow goodness of fit test and it was fitted. Multi-collinearity test was done and no multi-collinearity was found. In multivariable analysis, the association between independent variables and the outcome variable was measured using AOR, 95% CI and PV <0.05 were considered as statistically significant.