HHSIZELARGE\*EVERUSEDBCP is an interaction term between the two variables, HHSIZELARGE and EVERUSEDBCP, that evaluates the effect of the use of BC products in larger-sized households of three or more on the economic welfare of the male respondent. Larger-sized households used in this study indicate that the household has an adult male with a spouse and at least one dependent.

Ei (where i = 0,1,2,3,4,5,6 and 7) are parameters to be estimated; and Z is the equation error term, initially assumed to have zero mean and constant variance.

#### **4. Results**

The socio-economic characteristics of these 300 respondents, based on frequency analysis, are presented in **Table 1**. The age range of the respondents was between 20 and 69. However, the dominant age group of the respondents was the 30 to 49 years group; this group had about three-quarters of all the respondents (77.7%). The vast majority of the respondents has some formal schooling with only 4.6% never attending school. About two-thirds of the respondents were formally married (66.9%) while about one quarter were in various cohabitation arrangements with partners ((26.2%).

In terms of religious affiliation, Christianity was declared as the dominant religion with over three-quarters (76.8%) of the respondents indicating this religion as their preference. Following Christianity, the most popular religious affiliation was traditional African religions, either in their sole forms or mixed with Christianity or Islam;

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

#### **Table 1.**

*Characteristics of the male survey respondents based on frequency analysis.*

this mixed preference was indicated by about one in seven of the respondents (14.2%). Ghana has nine broad ethnic groups. The largest ethnic group among the respondents was Ewe. The second largest group was Akan and this was followed by Dangme/Ga groups.

In terms of employment, artisans were the largest group followed by selfemployed people from other categories and then by private sector employees, farmers and government sector employees. With regards to the use of BC products, about one in seven of the respondents (13.9%) had used these products during the 12 months before the start of the survey. This proportion was slightly smaller than the proportion of the respondents who had used these products during past periods (14.9%).

**Table 2** represents the summary socio-economic characteristics in terms of average or mean figures. The average age was 35.6 years, ranging from 22 to 60 years. The number of years of formal schooling acquired was 11.0 years. The average number of people living in a household was 6.0 and the average number of children was 3.8, 2.1 male children and 1.7 female children. The average monthly income received by the adult male was about 499 Ghana cedis during the year, 2019. Given that one United States dollar was worth on average 5.22 Ghana cedis in 2019, the average monthly income translated to about 96 US dollars. The amount of money spent on BC products and contraceptives, over the previous year, was 24 Ghana cedis or about 4.6 United States dollars.

As indicated in the literature, the quality attributes of available and accessible health services and systems influences the use of BC products and contraceptives. **Table 3** contains the scores for the various quality attributes of health services and health systems declared by the respondents. The lowest-ranked service or facility was *Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

**Table 2.**

*Summary of characteristics of male survey respondents based on averages.*

the sanitary condition of the facility. The average quality score for this attribute was 1.705. On the other hand, the highest ranked attribute was the ease of access to the health centre or clinic with an average score of 4.301 out of the maximum score of 5.0. Services provided by doctors at the health centre or clinic were generally considered to be in the very good to excellent range and further the quality values exceeded those indicated for services provided by nurses and pharmacists (refer to **Table 3**). The quality of services provided by pharmacists and nurses at the health centre and clinic

*The assessment of the quality of services or access to services that you received at the health centre that you last visited based a Likert scale of 0 to 5 denoting excellent quality, 4 very good quality, 3 moderate quality, 2 low quality, 1 very low quality and zero (0) for no quality at all. Source: Data from survey undertaken in November and December 2019.*

#### **Table 3.**

*Quality assessment scores of health services and systems by respondents.*

was generally similar; however the average quality scores were slightly higher for services provided by nurses.

The study identified nine BC products and methods which were known by the male respondents. These are reported in **Table 4**. The traditional method of planned abstinence from the spouse for a period of time, after the delivery of a child was the most familiar BC method or product. Male condom was the second most important BC method or product. Other BC methods and products identified by the male respondents were vasectomy, rhythm or calendar method, traditional herbs, outercourse, drinking of local gin before sex, and taking drugs to prevent pregnancy.

**Table 5** shows the most important single sources of information for the BC methods and products. There were no source of awareness for five BC methods and

*The scoring is based on 5 denoting that item is very high level of awareness, 4 represented high level of awareness, 3 indicated moderate level of awareness, 2 represented low level of awareness, 1 represented very low level of awareness and zero (0) represented total lack of awareness of the particular birth control method. The coefficient of variation is the standard deviation divided by the mean score. Source: Data from survey undertaken in November and December 2019.*

#### **Table 4.**

*Ranking of the level of awareness of birth control methods by respondents.*

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

#### **Table 5.**

*The most important source of information for various birth control methods as declared by the respondents.*

products. These were rhythm method, traditional herbs, outercourse, drinking of local gin before sex, and taking drugs to prevent pregnancy. Further, peers and friends were the most source of information for the BC methods and products: withdrawal before ejaculation and vasectomy. Television was the major source of information for the male condom. This result on male condom was also established by Anaman and Okai [25], for females.

The intensity of the use of BC methods and products is summarized in **Tables 6** and **7**. **Table 6** provides information on the use intensity during the previous 12 months before the survey, considered to refer to current use. The information in **Table 7** refers to past use intensity of the various BC methods and products. The commonest BC method or product was the male condom. Withdrawal before ejaculation was the second most important BC method or product. The findings of

*The scoring is based on 5 denoting that item is very high level of use, 4 represented high level of use, 3 indicated moderate level of use, 2 represented low level of use, 1 represented very low level of use, and zero (0) represented total lack of use of the particular birth control method. The coefficient of variation is the standard deviation divided by the mean score. Source: Data from survey undertaken in November and December 2019.*

#### **Table 6.**

*Ranking of the level of intensity of current use of birth control methods by respondents.*

*The scoring is based on 5 denoting that item is very high level of use, 4 represented high level of use, 3 indicated moderate level of use, 2 represented low level of use, 1 represented very low level of use, and zero (0) represented total lack of use of the particular birth control method. The coefficient of variation is the standard deviation divided by the mean score. Source: Derived from survey data, November to December 2019.*

#### **Table 7.**

*Ranking of the level of intensity of past use of birth control methods by male respondents.*

this study corroborate the disconnect between the awareness of BC methods and products and their relatively low intensity of use in Ghana established by other studies such as [26, 27].

**Table 8** provides the reasons given by the respondents for *not currently using* BC methods and products. The assertion that BC methods and products were meant for women and not men was the most important reasons given by the male respondents for their non-use of these products during the current period (within 12 months of the survey). The dislike of the BC methods and products was cited as the second most important reason for their non-use by the male respondents. The third most important reason was the perceived harmful side effects from the use of these products.

**Table 9** summarizes the suggested reasons for non-use of BC methods and products during the past periods. The results assembled in **Table 9** are similar to those reported in **Table 8** with very close figures for the percentages of the male respondents expressing similar sentiments with regards to the three most important reasons *Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

#### **Table 8.**

*Reasons given by the male respondents for not currently using birth control methods and products based on the percentage of respondents.*

#### **Table 9.**

*Reasons given by the male respondents for not using birth control methods and products during the past based on the percentage of respondents.*

for non-use of BC methods and products. Non-use of BC methods and products for religious and cultural reasons were cited by the respondents in both **Tables 8** and **9**. However, this reason was generally regarded as not important given the relatively low percentage of respondents expressing this sentiment.

The results of the analysis of the likelihood of use of BC methods and products are reported in **Table 10**. Out of the seven independent variables, five were statistically significant in influencing the likelihood of the use of these products. The statistically significant variables included the formal educational attainment of the male respondent and also the educational attainment of his spouse. However, highly educated male respondents who were married to highly-educated female partners had decreased likelihood of using BC methods and products. As expected, the level of awareness of BC methods and products led to increased likelihood of the use of these products.

*Number of observations for regression analysis was 300 and % observations correct was 86.7. Dependent Variable is log (PROBUSEBCP/1-PROBUSEBCP) (the natural logarithm of the odds ratio in favor of use of BC products and contraceptives).*

*\*\*\*Statistical significance of the parameter at the 1% level.\*\*Statistical significance of the parameter at the 5% level. \*Statistical significance of the parameter at the 10% level.*

#### **Table 10.**

*Binary logit regression analysis of the current use of birth control products and contraceptives versus selected socioeconomic characteristics of the respondents.*

Further, when the level of awareness was combined with the educational attainment, the likelihood of the use of BC methods and products declined. This particular result would suggest that male respondents who had relatively lower levels of formal educational attainment were more likely to use BC methods and products when they had increasing levels of awareness information about these products. Hence, this result paved the way for more aggressive forms of publicity of information about BC methods and products targeted at relatively lower educated male respondents.

The results of the regression analysis of the linkage between economic welfare of the male respondents, as indicated by his adjusted personal income, acting as the dependent variable, and various independent variables including the ever-use of BC products are reported in **Table 11**. Using the popular Ramsey Reset test of model specification [28], the model reported in **Table 11** was adequately specified with the Ramsey Reset probability (p) value of rejection of the null hypothesis of correct specification being 0.168 above the critical p value of 0.10 used in the study. Based on the Lagrange Multiplier (LM) test of heteroscedasticity [29], the model also had no significant heteroscedasticity. The power of the model as measured by the R2 was 0.22; this value would be considered to be modest.

The results shown in **Table 11** indicate that the parameters of all the independent variables were statistically significant. The positive enhancing effects on the economic welfare of the male respondent were due to the status of the person being currently married and also being Muslim. The significant parameters related to the two age variables indicated the existence of a curvilinear relationship between age and economic welfare, consistent with the reproductive life cycle hypothesis used in this study. Differentiating the estimated economic welfare equation with respect to age, the age at which economic welfare started to increase was 47.8 years, assuming other things constant.

The result dealing with the MALEEDUSSS variable showed that respondents who completed secondary school education had significantly lower levels of economic

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

*R2 = 0.240 Adjusted R2 = 0.222. Dependent Variable is the natural logarithm of the average monthly personal income of male respondent adjusted for by household size (LPINCOMEM). Significance level of Ramsey Reset test of correct model specification 0.168. Significance level of Lagrange Multiplier (LM) test of heteroscedasticity 0.140.*

#### **Table 11.**

*Regression analysis results of the relationships between a male respondent's economic welfare indicated by his adjusted personal income versus his use of contraceptives and his other socio-economic characteristics.*

welfare than other respondents with different types of educational attainments, ranging from no schooling to completion of university education. Increasing household size led to declining economic welfare of the male respondent given the burden of larger household sizes. The effect of the use of BC products and contraceptives in larger-sized households was established. There was positive enhancing effect on the economic welfare of the male respondent from the use of these products for households of sizes, three or more. Thus, households that have started producing children benefitted from the use of these products, possibly due to increased levels of choices to earn incomes, arising from more spacing of births.

#### **5. Conclusions and discussion of policy implication of the study**

#### **5.1 Summary of major findings and conclusions**

This paper reports the findings of a survey of 300 adult males in all 39 communities of the Amasaman Area Council, Accra, Ghana that elicited information on the perceptions and use of BC products and contraceptives. Nine different BC methods, products and contraceptives were used by the male respondents. Peers and friends were the major source of information about these products. The educational attainment of the male respondent and that of his spouse were statistically significant in increasing the likelihood of use of BC products and contraceptives by the male respondents.

As expected, the degree of awareness of BC products and contraceptives significantly influenced the likelihood of use of these products. Awareness also acted as a moderating variable with combination of formal educational attainment of the male respondent in influencing the likelihood of current use of birth control methods in a negative fashion. This result suggested that males with lower levels of formal educational attainment, and who had higher awareness of BC products and contraceptives, were more likely to use these products.

Economic welfare was shown to be higher for married male respondents than those who were not married. Muslim respondents had significantly higher average income than non-Muslims. The significant parameters related to the two age variables indicated the existence of a curvilinear relationship between the age of the male respondent and his economic welfare; this result was consistent with the reproductive life cycle hypothesis used in this study. Average income of the male respondents increased from 47 years of age onwards.

As expected, larger household sizes were associated with lower levels of economic welfare. However, the ever-use of BC products and contraceptives, in families with larger household sizes, led to increased economic welfare. Given that larger household sizes were defined in the analysis as a dummy variable to denote household sizes of three or more people, this classification would indicate that large households were those involving a married couple with at least one child or dependent. Hence, the economic welfare enhancement obtained from use of BC products and contraceptives was a benefit accruing to households with children.

#### **5.2 New contributions and policy implications arising from the study**

This paper makes three contributions to the existing literature dealing with the use of BC products and contraceptives by males and the related policy implications arising from the pattern of male behavior identified in this study. The first contribution is that this study indicated the expected result that increasing awareness of BC products and contraceptives led to the increased likelihood of use of these products by the adult males. Further, it was shown that the increasing awareness of these products for less educated respondents led to increased likelihood of their use by these people. This result would suggest that educational and publicity campaigns of State and Community organizations should target more resources and efforts in RH care and delivery to the less educated sections of the adult male population. The current approach of non-targeted informational programmes, based on uniform spread of awareness messages across the general population of men, may not be very productive.

The second contribution of the study is related to the establishment of evidence of increased economic welfare of male household heads due to the use of BC products and contraceptives, and particularly for those adult males with larger household sizes; this result was possibly due to the increased spacing of births achieved through the use of these products. This result would suggest that targeting of awareness campaigns related to these products would also need to put emphasis on men with large household sizes as they would benefit more in terms of economic welfare arising from the use of these products.

The third contribution of this paper, which closes a gap in the literature, is the finding of very high awareness by the respondents of the traditional Ghanaian method of birth control and family planning related to the male partner avoiding sex with his spouse/partner for a period of time, often one year or more. Despite its very high awareness, and its pre-eminent ranking as the most well-known form of birth control method, among the 300 responding adult males in this study, only about four percent of the respondents were using or had used this method of birth control. This would suggest the need of policy makers and State and community organizations involved with RH care and delivery to bring back the emphasis on the traditional method of birth control related to controlled abstinence after the delivery of children by the spouses and partners of males.

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

Generally, religious and cultural barriers against the use of birth control methods and products were not considered important by the respondents as they were ranked as reasons for non-use of BC products by less than 10% of the sampled respondents. This result would suggest that the low use of traditional abstinence birth control method was largely related to the information market failure problem; this could be resolved by repeated messaging of its importance by State and Community organizations involved in RH care and delivery to adult males in Ghana.

#### **Acknowledgements**

The author thanks all the 300 male respondents for participating in the study. The study was conducted as part of the author's doctoral research work at the Nobel International Business School, Accra, Ghana. The author completed her doctoral research work in December 2021. She received no external funding for this research study. I acknowledge contribution and effort of my research assistant Dennis Nii-Okai Aryee MBA; and the assistance of Professor Kwabena Asomanin Anaman of the Department of Agricultural Economics and Agribusiness, University of Ghana in the development of the statistical models.

#### **Author details**

Hanny-Sherry Ayittey Integrated Investments, Accra, Ghana

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 10** Family Planning Helps the World

*Richard Grossman*

#### **Abstract**

It is generally recognized that voluntary family planning is essential for the lives and health of individuals in today's world. What is less frequently acknowledged is that family planning has decreased the growth of human population over the past decades. Despite many wonderful advances since the industrial revolution, humans have caused massive deterioration of the natural world. Examples include climate disruption caused by the increase in greenhouse gases and the sixth mass extinction of species. Without modern, voluntary family planning, these negative effects would have been greater. This chapter recommends increased attention to the global public health benefits of family planning by reducing the numbers of unintended births and thus the number of people contributing to our environmental deterioration.

**Keywords:** contraception, abortion, environment, social justice, public health

#### **1. Introduction**

*Family planning is the most humane vehicle for achieving sustainable social and environmental justice.*

*Jensen and Creinin*

We are accustomed to think of the advantages of Family Planning (FP) to individuals and perhaps to families, but not of the global benefits. This chapter mainly focuses on these benefits to society and to our environment. Throughout the chapter I include access to safe abortion services along with FP [1].

First, I would like to mention the need for more methods of FP, especially for men. At present we have a large variety of methods for women. However, no method is acceptable to all women, and no method is failure-free. Hopefully, improved FP methods will continue to be developed, for both women and men.

In addition, I need to admit to the lack of equity. FP is available to most people in rich countries. However, even in one of the richest countries, the USA, there are geographic locations where it is difficult to access FP services. This has been improved by telemedicine and also by the ability to get FP, including birth control pills, by mail. Nevertheless, there are "abortion deserts", where a woman has to travel long distances in order to abort an unwanted pregnancy. With today's political climate in the USA, access to safe abortion services even is more difficult.

One might think that distance should be no problem in countries with good transportation, however, this is not so. A study performed in the USA has shown that when there is a FP clinic is close to a high school, female students are less likely to drop out of school [2].

Access to FP services in developing countries is often difficult if not impossible. The difficulty is because of multiple factors including distance, language differences and "stock outs". Often cultural and religious beliefs are serious barriers to accessing and using FP [3].

It is unfortunate that there is no perfect contraceptive method for women, and there is much less available for men. As I write this (April, 2023), I am pleased to note that new oral contraceptive is available that may be safer than past combination pills. Drospirenone/estrol (Nextstellis®) is available in the USA, but is very expensive for those who do not have adequate insurance coverage. Progestin-only oral contraceptives have been around for decades. The have a record of great safety, although breakthrough bleeding and pregnancy rates may be higher than with combined oral contraceptives. Despite the excellent record of safety, the FDA currently requires a prescription for a woman to purchase progestin-only pills. Thanks to the organization "Free the Pill" in the USA our FDA is looking at making this pill available over-the-counter, which will help reduce its cost and make it more accessible.

#### **2.  This permits a woman to finish her education and to start a career before parenting, if that is what she chooses to do. The role of women in developed countries has changed markedly in the 60+ years since oral contraceptives first became available. Although there have been many other factors causing these changes, certainly "the pill" has had a major effect.

Family planning has been called one of the top 10 public health achievements of the 20th century by the US Centers for Disease Control [4]. It allows for longer intervals between the births of children and for smaller family size. By decreasing the number of pregnancies a woman has in her lifetime and increasing intervals between pregnancies, FP has also reduced the mortality and morbidity of women. Because of the longer birth interval, and because each child can receive more resources, FP has helped to save children's lives—especially in developing countries. Improved barrier methods, such as female condoms and nonlatex male condoms, have decreased transmission of HIV and other sexually transmitted infections.

We now have LARCs—Long-Acting Reversible Contraceptives, including hormonal implants and several IUDs. LARCs have very low failure rates, partly because they do not require doing something (such as taking a pill) on a regular basis. Most of the IUDs available in the USA are hormonal. These are being evaluated to find out if they are effective for use longer than their original approval [5]. In addition, they may be useful for postcoital (emergency) contraceptive use [6].

Copper containing IUDs, such as the T 380A (Paragard®), are also very effective for emergency contraception, if inserted within 5 days of unprotected intercourse. Other emergency contraceptive methods include levonorgestrel tablets (which are available without a prescription in many countries) and ulipristal. Although supplanted by more effective methods of emergency contraception, in some areas the only available method may be the Yuzpe regimen. This is using oral contraceptive pills containing ethinyl estradiol and norgestrel, although other formulations may also be effective. Current research has found that emergency contraceptive pills do not work by causing an abortion.

There are many good sources for information about birth control. One that is objective and geared to people in the USA is: www.plannedparenthood.org. The World Health Organization (www.who.int) is a good worldwide source for information.

#### **3. Abortion**

There are estimated to be 121 million unintended pregnancies worldwide each year [7]. Some of these are miscarried, some intentionally aborted and some go to term. The World Health Organization states that, globally, about 60% of unintended pregnancies are aborted, and almost half of the abortions are "unsafe". They estimate the total number of global induced abortions at 73 million annually [7].

"Unsafe abortion" is the term that is often used for abortions that are performed outside of the medical system. Usually these abortions are expensive, exploitive and dangerous. Women choose to have an unsafe abortion when they live where abortion is illegal or severely restricted. The risks of an unsafe abortion include serious illness such as hemorrhage or infection, and may result in sterility or death.

It is interesting that abortion is no less common in countries where it is illegal [7]. Perhaps this is because many of these countries also limit access to contraception. Many of the countries where abortion is illegal have high levels of patriarchy and religiosity, with the beliefs that sex should only happen within a marriage. This goes along with limited or no sexuality education, so young women are likely to not be prepared to deal with aggressive males.

#### **4. Global benefits of family planning**

The main thrust of this chapter is the benefits of FP to humans, other species and to the environment. I will look at examples in order to make the point that, in addition to helping us, FP helps us to preserve biodiversity and decrease environmental impact.

Most of the world's environmental problems, including climate disruption and loss of biodiversity, would be improved if there were fewer people on the planet. During the past century we have seen remarkable decreases in the rate of population growth, largely due to the use of voluntary FP. Unfortunately, the importance of FP and its relationship to population growth has been largely overlooked by medical and public health people. Furthermore, some people involved in the social sciences seem to actively deny that the planet is overpopulated [8]. Much of this denial comes from religious beliefs and from the regrettable past history of genocide, forced sterilization and eugenics [9].

The good news is that almost half of the world's countries have a total fertility rate (TFR) of less than 2.1, which is the number for replacement fertility [10]. This means that their population will decrease, if the fertility stays below that number, although it may take several decades for that to happen.

How large can the human population be and still be sustainable? I like to use the Ecological Footprint (EF) to compare how we are using Earth's resources with what is available. In short, the EF breaks down our use of resources to land area—land on which to live, to raise food, to develop resources and to dispose of waste.

Globally, there are about 12.2 billion hectares of bioproductive land and of water. Shared evenly among the current roughly 8 billion people on earth, that would be about 1.5 hectares (3.75 acres) for each person. However, many people use more than that. For instance, the average EF for a person in the USA is about 7 hectares (17.2 acres).

The average Ecological Footprint for everyone on Earth is 2.77 hectares—significantly larger than the 1.5 acres that are available. As a consequence, we are using the earth's resources faster than they can regenerate. Calculations suggest that it would take 1.8 planets Earth to support all the humans at the rate at which we are using resources and generating waste. The excess over what the planet can support sustainably is called "overshoot" [11].

One way to calculate a sustainable human population is to divide our current population by the overshoot fraction—8 billion divided by 1.75, or about 4.5 billion people. Unfortunately, one of the shortcomings of the EF is that it does not allow any resources for nonhuman species. With a small allowance for all other flora and fauna, we might find that 4 billion humans would be a sustainable population. If we want the planet to be really healthy, the human population should be about 3 billion people.

There are other, perhaps more accurate ways of calculating the size of a sustainable human population. Mostly they end up with estimates in the range of 2 to 3 billion people, as stated above. For a readable review of this subject, I suggest the book "A Planet of 3 Billion" by Christopher Tucker for more information about a sustainable human population.

The bottom line is that our current human population is not sustainable. In fact, our current population, with the average consumption, is about 2 or 3 times what could be maintained indefinitely. Without modern FP, our numbers would have been much, much larger than the current 8 billion!

Let me explain why I focus on population rather than on consumption. In the formula that describes human impact on the environment, I = P × A × T (Impact equals Population times Affluence (or Consumption) times Technology), population is just as important as affluence. However, remember that there are more than 120 million unintended pregnancies every year! [12]. That means that there are many, many women who wish to have control over their fertility—but I know very few people who wish to decrease their affluence. Indeed, globally we live in a sea of advertisements and other media that urge us to buy and consume more, not less.

I do not give the T in the above formula much attention. For instance, I've replaced the lightbulbs in our home with compact fluorescent light bulbs, then with LEDs. We have solar panels on our roof that make most of our electricity and also power our plug-in hybrid vehicle. However, my wife's and my Ecological Footprint is still much larger than 1.5 acres, since these technological modifications only reduce our impact slightly.

To sum up, it would be great to have everyone decrease their footprints down to what is available (1.5 hectares) if we all shared equally. Unfortunately, that is very unlikely. For the average person in the USA it would mean shrinking their footprint by almost 80%, from 7 to 1.5 hectares! Imagine what it would take to have such a small footprint. There are so many things you could not do, and so many things you'd have to do without to have such a small footprint. You would probably have to live in a small house, eat primarily beans and rice or other simple foods with very little meat or none at all. You would have to walk, bike or take public transportation; a car would be impossible. You would have no frills, no TV and probably lots of hard work. It is no wonder that people are not enthusiastic about decreasing their consumption!

On the other hand, millions of people already are trying to control their fertility. Over half a million abortions are performed every year in the USA [13]. It is estimated that there are about 121 million unintended pregnancies globally [7]. The number of women who do not have access to effective contraceptive methods is estimated to

#### *Family Planning Helps the World DOI: http://dx.doi.org/10.5772/intechopen.111801*

be 218 million [14]. Access to voluntary contraception and abortion are certainly the "low hanging fruit" when it comes to decreasing human impact.

There are other, more quantitative ways to appraise the role of FP in lowering our impact [15]. In this part of the discussion, I would like to use climate disruption caused by carbon dioxide (and other greenhouse gasses) as a proxy for all anthropogenic environmental problems. This is because climate disruption is in everyone's mind—as well it should be. Furthermore, climate disruption has been studied a great deal, and in more quantitative ways, than other environmental problem.

For various reasons, the potential for FP to help solve the evolving disaster of climate disruption has been given much less attention than it deserves [16]. An article written in 2010 claims: "Using an energy–economic growth model that accounts for a range of demographic dynamics, we show that slowing population growth could provide 16–29% of the emissions reductions suggested to be necessary by 2050 to avoid dangerous climate change" [17]. Although it may be too late to achieve such a benefit by the year 2050, there are still large advantages to supporting FP for further in the future. Another study suggests that not only is FP effective, but it may be the least expensive means to slow climate disruption [18]. Another article gives an overview of CO2 emissions in the past and projections using demographics [15].

However, there are other environmental problems than just climate disruption. Extinction of species, global toxification and other impending tragedies may be as bad as, or even worse, than climate disruption. Working together, all this deterioration of the environment will cause problems that we can only begin to imagine. Do not forget that all of these problems are anthropogenic!

#### **5. What could be worse than climate disruption?**

Most people understand the CO2 that we emit is caused by people using fossil fuels. However, the connection between human endeavor and the extinction of species may not be so obvious. What is the association between humans and extinction of species? There are a half dozen ways that we are accelerating the loss of species. Paleontologists have known that species have always become extinct, and estimate that the baseline rate is in the range of 1 per million living species per year. The current estimated rate is at least 100 times that, and probably 1000 times or more. One estimate is that there are 8.7 million species on earth and in the oceans [19]. Using the most likely rate of extinction, that would suggest that more than 8000 are being driven to extinction each year. This has been called the "sixth mass extinction" [20].

The biggest reason for extinctions is loss of habitat. Many species of plants and animals require specific conditions to thrive. There are also species, called "endemics", that only live in small areas. If their habitat is disturbed, they die. This is the reason for the Endangered Species Act in the USA. Before any significant development is allowed to occur, the Act requires a survey looking for endangered species. It is sad that all other countries do not have similar laws, and that often the laws (where they exist) aren't always enforced. Unfortunately, the press of the growing human population has already caused the extinction of many species.

Each human on the planet requires a place to live and food to eat. The species who had lived on the land before us are evicted; unfortunately, those individuals who

survive the bulldozers frequently have no place to go. Often the land used to grow our food is treated with chemicals that are incompatible with the life that had been there [22]. Nonhuman species are being challenged and too often killed off by our civilization in a variety of ways.

Briefly, here are the five other ways that we are causing species to go extinct: (1). The changing climate makes it difficult for some species. For instance, the pika is sensitive to heat. It is a small mammal that lives in cold, mountainous regions. As the climate gets hotter, it can move up in altitude to stay cool. However, they will have no place to go when the mountain tops aren't cold enough. (2). Humans have introduced diseases, such as the fungus that causes white nose syndrome in bats.  We have also introduced exotic species that out-compete vulnerable local species. An example is the salt cedar or tamarisk, which has locally displaced native trees such cottonwoods. (4). In the last century chemists have synthesized thousands of new chemicals. Even though they are given cursory testing for safety before being marketed, some of them have had disastrous unintended consequences. DDT is an example of a chemical with severe unintended consequences [23]. (5).  Carolina parakeets were numerous at one time, but their colorful plumage became fashionable for ladies' hats. These beautiful birds were hunted to extinction.

We do not know how we will be affected by the mass extinction of other species. We do know that we are a part of the web of life, and that all parts of the web are interdependent. To some extent, all species are important, although some are much more important than others. As our understanding of this web increases, we find out that some species that we thought were of little import are actually essential. Slime molds are an example. They appear unbidden in gardens and woods as unwelcome guests; some of them look like someone vomited on the ground. However, they are helpful because they recycle nutrients [24].

Humans have invested in developing just a few species for our nourishment. Much of our food comes from only a few crops, such as wheat and rice. Likewise, much of the meat we eat comes from just a few species of animals, such as pigs and goats. Although this permits efficient factory farming, it makes us very dependent on just a few species of plants and animals. When there is a disease such as the potato blight in Ireland, this lack of diversity may cause a famine. This is just one way that decreasing biodiversity can affect us. Some experts worry that the mass extinction may be even more problematic to humankind than climate disruption [25].

#### **6. What can we do?**

I have several suggestions. Perhaps my strongest recommendation is to support people and organizations that work in the field of reproductive health. This might mean making donations to organizations and clinics that provide FP services. It could mean lobbying politicians who recognize the importance of FP—and it certainly means remembering the importance of FP when it is time to vote.

For those of us in the field of family planning, here is encouragement:

*"As family planning specialists, we should devote part of our effort to educating policy leaders and the public about the importance of our work from an environmental standpoint" [1].*

#### *Family Planning Helps the World DOI: http://dx.doi.org/10.5772/intechopen.111801*

Although an individual cannot cure the ills of the world single-handedly, supporting access to family planning is one way that each of us can work to help with climate disruption and also with loss of biodiversity.

#### **Summary**

Most of the readers of this chapter are already aware of the advantages of modern family planning—the ability to have sexual intercourse with little fear of an unintended pregnancy. Contraception and abortion have slowed the growth of the human population. Nevertheless, the human numbers are currently 2 or 3 times what would be sustainable. It is important to recognize the important role that family planning plays in helping the non-human portion of the world, in addition to the how it serves people.

#### **Author details**

Richard Grossman Department of Biology, Fort Lewis College, Bayfield, Colorado, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[2] Hicks-Courant K, Schwartz AL. Local access to family planning services and female high school dropout rates. Obstetrics and Gynecology. 2016;**127**(4):699-705. DOI: 10.1097/ aog.0000000000001344

[3] Adongo PB, Phillips JF, Kajihara B, Fayorsey C, Debpuur C, Binka FN. Cultural factors constraining the introduction of family planning among the Kassena-Nankana of northern Ghana. Social Science & Medicine. 1997;**45**(12):1789-1804. DOI: 10.1016/ s0277-9536(97)00110-x

[4] Center for Disease Control and Prevention. Ten great public health achievements--United States, 1900-1999. MMWR. 1999;**48**(12):241-243

[5] Dethier D, Qasba N, Kaneshiro B. Society of Family Planning clinical recommendation: Extended use of long-acting reversible contraception. Contraception. 2022;**113**:13-18. DOI: 10.1016/j.contraception.2022.06.003

[6] Turok DK, Gero A, Simmons RG, Kaiser JE, Stoddard GJ, Sexsmith CD, et al. Levonorgestrel vs. copper intrauterine devices for emergency contraception. New England Journal of Medicine. 2021;**384**:335-344. DOI: 10.1056/NEJMoa2022141

[7] Bearak J et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019. Lancet Global Health.

#### 2020;**8**(9):E1152-E1161. DOI: 10.1016/ S2214-109X(20)30315-6

[8] O'Sullivan, J. The Overpopulation Project. History was rewritten to delegitimize population concerns: we need to reassert the truth. 2022. Available from: https://overpopulationproject.com/history-was-rewritten-todelegitimize-population-concerns-weneed-to-reassert-the-truth/ [Accessed: April 26, 2023]

[9] Center for Biological Diversity. How to Bring Anti-racism Into the Population Conversation. Available from: https:// www.biologicaldiversity.org/programs/ population\_and\_sustainability/ population/anti\_racism\_in\_ population\_conversations.html?utm\_ source=popx&utm\_medium=email&utm\_ campaign=popx140&emci=6d767997 c60d-ed11-b47a-281878b83d8a& emdi=5de2fa2f-cd0e-ed11-b47a-281878b83d8a&ceid=209594 [Accessed: April 26, 2023]

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[11] Footprint Network. 2023. National Footprint and Biocapacity Accounts. Available from: https:// data.footprintnetwork.org/?\_ ga=2.164379580.263543584.1682351781- 264756723.1682351781#/ [Accessed: April 24, 2023]

[12] Ehrlich PR, Holdren JP. Impact of population growth: Complacency concerning this component of man's predicament is unjustified

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and counterproductive. Science. 1971;**171**:1212-1217

[13] Centers for Disease Control and Prevention. Abortion Surveillance— Findings and Reports. 2020. Available from: https://www.cdc.gov/ reproductivehealth/data\_stats/abortion. htm [Accessed: April 24, 2023]

[14] Sully EA, Biddlecom A, Darroch JE, Riley T, Ashford LS, Lince-Deroche N, et al. Adding it up: Investing in Sexual and Reproductive Health. New York: Guttmacher Institute 2019. 2020. Available from: https://www.guttmacher. org/report/adding-it-up-investingin-sexual-reproductive-health-2019 [Accessed: April 24, 2023]

[15] O'Neill BC, Liddle B, Jiang L, Smith KR, Pachauri S, Dalton M, et al. Demographic change and carbon dioxide emissions. Lancet. 2012;**380**:157-164. DOI: 10.1016/S0140-6736(12)60958-1

[16] Bongaarts J, O'Neill BC. Global warming policy: Is population left out in the cold? Population policies offer options to lessen climate risks Science. 2018;**361**(6403):650-652. DOI: 10.1126/ science.aat8680

[17] O'Neill BC, Dalton M, Fuchs R, Jiang L, Pachauric S, Zigovad K. Global demographic trends and future carbon emissions. PNAS. 2010;**107**(41):17521-17526

[18] Yan Feng et al. Data Analysis of Reducing CO2 Emissions by Investing in Family Planning. 2015. Available from: https://populationmatters.org/resources/ data-analysis-of-reducing-co2-emissionsby-investing-in-family-planning/ [Accessed: April 26, 2023]

[19] Mora C, Tittensor DP, Adl S, Simpson AGB, Worm B. How many species are there on earth and in the ocean? PLoS Biology. 2011;**9**(8):e1001127. DOI: 10.1371/journal.pbio.1001127

[20] Ceballos G, Ehrlich PR, Barnosky AD, García A, Pringle RM, Palmer TM. Accelerated modern human– induced species losses: Entering the sixth mass extinction. Science Advances. 2015;**1**(5):e1400253. DOI: 10.1126/ sciadv.1400253

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### **Chapter 11**

Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive Provision in Southern Ethiopia: An Interpretive Phenomenological Exploration

*Abraham Alano and Lori Hanson*

#### **Abstract**

Albeit the government efforts improving access to contraception through health extension programs in Ethiopia, gaps exhibited on experiences of the stakeholder about the basis on services provision. Therefore, perceptions about the enablers and rationale for contraceptive service were explored. Interpretative phenomenological design was employed to explore the lived experiences of stakeholders. Focus group discussions, individual in-depth interviews, and key informant interviews were employed for data collection. Data were analyzed using interpretive phenomenological analysis. The finding indicated that contraceptive service provision from the socio-economic perspectives was understood adequately, but the human rights-based rationale was shadowed. The contribution of the health extension program for contraceptive use has been remarkable. The improvement is attributed to the alignment of primary health care with the community organizations such as women development armies. The health extension program accelerated contraceptive service and given momentum for PHC. Women revealed encouraging involvement in the process of contraceptive service access and use. However, the bigger picture, and rationale for providing contraceptive services, the human rights approach, remained elusive at lower hierarchy. Hence, the study recommends that the disconnect in the broader premises of providing contraceptive services must be properly communicated across the stakeholders.

**Keywords:** health extension program, human rights, contraception, phenomenology, rationale

#### **1. Introduction**

The provision of modern contraceptive services in developing nations began because of the strong push from developed nations in the 1960s [1–4]. However, the lack of strong governments commitments along with limited resources and the underlying socio-cultural factors remain major impediments to the expansion of the services in many developing nations [5]. Among the notable challenges to be mentioned in the process of service provision is the access to contraceptive services affected by a lack of well-structured institutions in terms of the availability of health professionals and material inputs [6].

To narrow the gap between developed and developing nations toward contraceptive service access and use, the Primary Health Care Declaration (PHC) provides guidance that played a significant role [7, 8]. PHC has clarified a meaningful health strategy for reducing maternal and child morbidities and mortalities in developing nations [9]. Moreover, PHC has bridged the gap between institutional health service delivery and community demands through a community-based service delivery modality [10].

Ethiopia has realized that health issues require the involvement of multiple sectors and collective undertakings. Based on this understanding, the country revitalized the primary healthcare approach by identifying key stakeholders and sectors to involve in the implementation of health-related activities and actions [11, 12]. Guided by the health policy of the transitional government, the Federal Ministry of Health of Ethiopia (FMOH) has taken numerous measures to improve the health status of its population. Among the major steps that have been taken in designing and development of A 24 Health Sector Development Plan (HSDP) with its five successive five-year phases is among the several steps the government actions. After a critical evaluation of the health-based initiatives, the MOH revised its approach and incorporated government-paid community-based health service delivery, the health extension program (HEP) in 2003 [13–15].

The HEP is an innovative approach constituting a paradigm shift in Ethiopia's health service delivery creating strong links between the mainstream institutional health service and community-based health service expansion [16]. The peculiar aspect of the health extension program is that the service providers are all women except in a few pastoral villages and permanent employees of the government. They serve in the rural villages where they grew up, live and, are permanent employees of the government. This was different from the former practice which was based on volunteerism.

The HEP is expected to improve access to health care through increased availability and acceptance as workers largely share similar cultural backgrounds and speak the same language as the community they serve [17–19].

In spite of half a century or more contraceptive services in Ethiopia and encouraging engagements of the government and health workers, there are limited research outputs that reveal the depth of the lived experiences of service users, health workers, and health leaders about how service organizations and extension affect the outcome. This study sought to explore the ways that leaders in the health system, health care providers, and service users attempt to create an enabling environment for contraceptive service provision and its use. The study was conducted by aiming to describe patterns of a provision of contraceptive services and capture the perspectives of health care providers, leaders, and service users' and their lived experiences on enabling conditions of the contraceptive service organization, provision, and use.

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

#### **2. Materials and methods**

#### **2.1 The research context**

This study was conducted in three districts of Sidama Zone designated by Hawassa University as technology villages for research and technology transfer. The three districts were selected for accessibility. Hawassa University is located in the Sidama Zone, one of the 13 zones in the Southern Nations Nationalities and People's Regional state (SNNPRG) of Ethiopia. Sidama Zone is located in the south-eastern part of the region and is bordered by Oromia Regional state on the south, east and north and with Wolaita Zone in the west [20]. Projected from the 2007 national population census, the zone has a total of 3,471,568 people of which 1,753,142 (50.5%) are men and 1,718,426 (49.5%) are women. Close to 24% of the total population of the zone are estimated to be women of reproductive age. Household family size is estimated to be 4.7 and the annual population growth of the zone is estimated to increase 2.9% [21].

#### **2.2 Study design**

The study employed an interpretive (hermeneutic) phenomenological approach which is appropriate for understanding the life world of contraceptive service users women, health care workers (health professionals), and health leaders. It focuses on describing the meanings given by the individuals and how these meanings (the experiences of health care workers, health leaders, and service user women enable contraceptive services provision and use) influence the access to the service and use [22, 23]. The approach further considers the importance of the expert knowledge of the researcher as a valuable guide to the inquiry. The study aims to explore the life experiences related to the enabling conditions for contraceptive services and use by employing this approach. It offered a unique opportunity to establish a rich and in-depth understanding of sustainable and progressive contraceptive services establishment [24].

#### **2.3 Data collection**

To capture in-depth information about the topic of interest: focus group discussions (FGDs), individual in-depth interviews, and key informant interviews were used. Three female research assistants with educational and professional experience were employed to fit the majority of study participants (the rural women). Recruiting the research assistants helped to bridge the gap in both language and gender. Recruitment of research assistants was done in consultation with the Regional Health Bureau, Zonal Health Department and colleagues. After recruitment and training the research assistants, health extension workers, and local women, the community leaders collaborated in the selection of study participants. A purposive sampling method was used to include well-informed participants in the study as key informants, focus group discussants, and in-depth interviewees to explore the depth of their lived experiences [25, 26].

Participants were enrolled in the study based on criteria set to suit the study requirement. These include: the women's experiences of the contraceptive services use for at least a year, their ability to elaborate on the services and factors affecting the service access in their locality, and health leaders at different hierarchies (health institute, district, zonal, regional, and ministerial level) and the health extension workers.

A total of 82 women of reproductive age group were included and participated in the focus group discussions comprised of 7–12 participants in each FGD. For the individual in-depth interview, 19 women of reproductive age from nine kebeles were involved. A total of 18 key informants were involved in the interview based on the designated position they hold in their respective institutions (Appendix A). Semistructured FGDs and interview guides were developed for the interview and the participants were encouraged to speak up about their experiences. This type of interview guide is assumed to be in line with the interpretive phenomenological approach that gives reasonable freedom for the participants to express their experiences of the phenomenon of interest in their ways. It further deepened discussions and reflections on the life experiences of the study participants [27, 28].

Discussions were arranged in consideration of the time and regularity and viability of rural women. All the discussions were conducted outside of market days and from 10:00 A.M. to 11:30 A.M. Data collection schedule was arranged with the study participants through the community health workers (the health extension workers and women development army leader). Consideration was given by the study team on time management as such arriving at the data collection site in time and arranging the setup in a convenient way. The seating arrangement was organized circularly so that everybody could have ample opportunity to properly see one another.

Once the study discussants took their seats, the health extension worker carried out greetings and introduced the research team. Informed consent was obtained to audio-tape and take notes during the discussion. Moderation of the discussion was done primarily by the principal investigator. The research assistant aided by translating to the women and back to the PI and taking the note. A discussion was conducted by giving adequate time that was apportioned for the women to raise issues related to the guiding questions. Care was taken to involve all participants equally so each could discuss their lived experiences. The discussion was managed by considering the standard time for the qualitative data collection and women's busy schedules. Each session lasted 60–90 minutes on average. Discussion sessions concluded with due care about the completeness of the collected data, if there were any queries from the participants and acknowledging their commitment. Participants were informed about the need to attend a subsequent meeting following the preliminary analysis of the first discussion.

The discussion session was recorded using two digital recorders to ensure accuracy and prevent equipment failure. A unique identifier was given to each focus group discussion to differentiate it from subsequent discussions and avoid confusion during transcription. Written notes were taken by a research assistant simultaneously.

Following the focus group discussion, the individual in-depth interviews were conducted with women participants by the research team in the woman's home or at the health post based on the preferences of the interviewee. For those who were interviewed at their home, the research team was guided by the health extension worker or the community leader. A signed consent was obtained from the participants by reading the form out loud to continue the interview. The study team managed the session by providing an even chance to all participants and encouraging all to talk about their life experience in detail without any fear or reservations. In such ways, the interview continued for 40 to 60 minutes until the study team agreed on the emerging ideas as

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

repetitions [29]. Handwritten notes were taken and an audio-tape of the interview was recorded.

Lastly, key informant interviews were conducted in the following manner. Flexible interview dates were arranged as almost all the key informants were busy with their official routines. Once the key informants were identified, an interview schedule was arranged with each interviewer either calling via phone or visiting the office in person. The key informants' interviews were arranged in the informant's office or working unit at a convenient time. The study team managed the interview reaching the site in time to ensure the functionality of materials and give adequate time for the key informants to read the consent form and sign it.

Key informant interviews began by briefly explaining the purpose of the study, the procedures for selecting the informants, and the overall process of the study. Once the research team obtained a final signed consent form from the participant, the interview was conducted. The convenience of the room and the sitting arrangement for the interview was ensured before directly embarking into the interview. By using a semi-structured interview guide, the interview was conducted flexibly and systematically.

The interview process was done by following a qualitative study data collection approach suiting this specific (interpretive phenomenology) design. The interview session was conducted as guided by the study guide questions and opportunities to probe more issues as they emerged. Adequate time was given to capture the necessary information and to ensure the documentation of both handwritten notes and recording the audio-tape. Finally, the research team thanked the informants for their time and information before departing and told them about the possibility of returning for further discussion after the preliminary analysis. All key informant interviews were conducted in similar procedures. Data collection was conducted from September 2013 to May 2014.

#### **2.4 Data analysis**

This study used the guiding principles of interpretive phenomenological methodology. It enables viewing the phenomenon along the way that reflects the significant interaction of both the data sources (participants) and the researchers as part of their "being in the world" rather than only "being' itself [30, 31]. Thus, the interinfluence and connections of the two sources are reflected in the interpretive analysis. An adapted flow diagram from the interpretive phenomenological analysis (IPA) was used to guide the analysis (Appendix B).

Data analysis was conducted in two languages. The following steps describe the process: transcriptions were carried out on all the audio-taped materials verbatim, first in Amharic and then in English (Appendix C). Materials were also translated back to Amharic by a professional linguist. After that, the Amharic translation was given to the principal investigator to check for consistency.

Summary finding in the form of shortened transcripts incorporating the field notes was presented to the key informants for their further input and comments. Data immersion by the researcher immersed into the data several times through repeated reading to find out emerging codes. The analysis process utilized several rounds of indulging in the transcripts, reading and rereading, consultation with the key informants, and soliciting their inputs for the emerging descriptive codes. Inputs from the informants were incorporated into the second round of data analysis with remarks. Side notes and descriptive coding were then completed for all the materials. Data

reduction was done in a step-by-step approach, beginning with the transcripts, followed by descriptive coding, and then distilling this material into themes by bringing similar ideas and concepts together.

The overall analysis process made use of the hermeneutic circle, which means iterative back-and-forth linkage of data from both the researcher's and participants' perspectives. Guided by the study questions, the side notes, linked to the descriptive codes, themes were identified These steps were done by re-visiting the transcripts after major themes had been identified to interpret connections between the initial data and our later refinements [29, 30, 32]. Summarized reports were presented to study participants about the phenomena derived from their shared experiences. Discussions were held with participants based on the study guide questions and core concepts. Their feedback was incorporated in line with the experience of the researcher. This increased the confidence in interpretations and further enriched the understanding of the phenomena.

Data quality was assured using the steps of qualitative data quality assurance approaches generally called trustworthiness. The four closely resembling criteria for ensuring trustworthiness are credibility (truth value), transferability (applicability), dependability (consistency), and conformability (neutrality) suggested in the literature [33]. Actions carried out to ensure the trustworthiness were: (1) presenting the summary of transcripts to the study participants to give them an opportunity for further comment; (2) reviewing of the preliminary findings to ensure the early findings reflect what they know and experience; (3) sharing the preliminary summary findings with the health managers and service providers to check interpretations.

#### **3. Results**

The findings of this study are organized under the respective questions relating to health provider efforts in creating an environment conducive to contraceptive uptake and use. The aim was a better understanding of the issues of service delivery organization, processes, and content related to service availability, accessibility, convenience, trends, and the current status of contraceptive services. Moreover, the pattern of service integration, linkage among the primary health care units and the community organizations, and anticipated challenges related to services sustainability and ensuring quality were also explicated.

#### **3.1 Trends and patterns of contraceptive service provision in connection to the HEP**

#### *3.1.1 Health managers and service providers' perspectives*

Despite more than half a decade of longevity of the contraceptive service provision in Ethiopia and the study area, the progress in reaching all segments of the population was sluggish. Voluntary non-governmental organizations mainly, the Family Guidance Association of Ethiopia, started this service provision at an early age. Integration of the contraceptive services into health systems took place gradually but service expansion and increment in method mix remained low until 2005, where sharp increment took place since then. All study participants in three data collection methods expressed frankly that the current level of contraceptive services expansion and improvement in the availability of method mix was attributed to the health extension program.

#### *Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

As pointed out by study participants that the health extension program has brought contraceptive services closer to residents living and working places. In doing so, it has improved unconditional access to the service.

The extraordinary contribution of the health extension program in enhancing the contraceptive service access unlike the previous approach, is its propensity to extend the services to the household level through home visits and other community-based distribution options using community-based organizations such as women development armies. Another merit of the health extension workers is that they are female and recruited from the same *kebeles* where they offer service. This created a conducive environment for service-seeker women to feel comfortable when visiting the health post to access contraceptive service and when the female HEW visits their home; they express their needs without reservation. Moreover, the service-providing health extension workers share a similar culture and speak the same language and being female creates a favorable environment for women to ask whatever questions they desire. Study participants substantiated these conclusions:

*The health extension program has improved access and utilization to communities and households. Gender parity of the health extension workers with plenty of health service users, the women is another important issue received attention. The program played incredible role that averted several barriers of contraceptive service use. These were evidenced by the convenience the program created for women in terms of time, distance language and cultural harmony. On top of the above, the program also created gender parity between the service providers and users. In the nutshell, the health extension program improved access to the services*

*The health extension program is therefore a reason for the rapid increment in contraceptive prevalence and service coverage in the district as of the last seven years. This is so because the health extension workers provide the service both institutional and outreach models (at health posts but also house to house visitation). The health extension program significantly reduced the former distance of more than 5–10 KM to 2–3 KM walk and stretched it to the household level.*

The finding of the study has justified that the establishment of the health extension program created a strong services link within the primary health care units and the community. This further contributed to the current state of contraceptive use progress. More specifically, community mobilization using women development armies, and a one-to-five network [1] through model households are notable experiences to learn from.

All the study participants consensually remarked that the health extension program and the service organization have functional linkages manifested through collaborative undertakings at the community level. The strong collaborative undertakings between the health extension workers, the women development armies, and a one-to-five community network ensured the expansion of contraceptive service within their catchment area. Such interlinks or collaboration among stakeholders not only improves access to services but also is a clear indication for female empowerment as the service providers, advocators, and community leaders lead contraceptive service programs. This was further substantiated by citations from the study participants and a district-level manager explained the issue as follows:

*Health system organization in the study area is a witness for the observed strong linkage and collaborative undertakings. The health professionals from the health center provide supportive supervision to the health post and in a similar passion the health extension worker do so for the women development army. The supportive supervision is for all the health extension packages including the family planning services.*

#### Similarly, another experienced health extension worker has given her experience in this regard by clearly indicating:

*By its very nature the health extension program is from the 'community to the community', that has strong linkage between the service providers, users and leaders. The relationship is eventually took a shape of strong family and created mutual trust. We, the health extension worker provide service with a sense of serving our fellow women. A woman being the first contact point in the household has been another ease condition for the expansion of services both in the household and the community. On top of the women development army a one-to-five network system, we also use other community organizations such as 'edir' and 'kuteba mehiber [2]'. We work collaboratively with all these organizations, networks and systems. Generally, we have established a strong working relationship starting from an individual woman to the community level.*

#### *3.1.2 Service user women's perspectives*

Experiences of service user women toward contraceptive service availability and accessibility in the era of health extension programs are congruent with the health service manager and service providers' articulations.

Women explained that, unlike the previous high-level health institutions, now they comfortably express their feelings and get services including advice easily through understanding. They never fear or feel ashamed of telling their feelings as the health extension workers are from the same localities. When the health extension workers visit clients' houses, women easily talk to them and even invite them to have coffee or food. Because of such interaction, the extension workers feel at home and well-acquainted with the service users. This was not the case before the inception of the health extension program.

Daname, a woman in the focus group discussion who has used contraceptive services from various sources elaborated on the service access difference and the convenience now and previously:

*I paid 270 ETB for contraceptive service (surgical implant) at Yirgalem hospital before the access to contraceptive service improved. I also waited for five days to get service in addition to paying a service charge as stated above. Now the situation is different. Service accessibility was greatly improved. As the former discussants mentioned, we got service here at our kebele by our children. This is a big change. We share our feelings without hiding anything from the health extension workers. We don't have a problem with waiting for long hours for services, no need to go daily to queue up for services, no one tells us to bring your card from the card room. We receive services at one stop shot.*

#### Similarly, another woman in one of the focus group discussions vented:

*More specifically, the establishment of a health post in our kebele has created a better chance to access health services both for ourselves and our children. We were troubled*

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

*to access the health services for our children before the establishment of this health post. It was customary to move here and there looking for health services previously. We were forced to take them to medically unproven services and exposed them to unsanitary/unhygienic services. Past years were known for us for the huge deaths of our young children others remained disabled. Appreciation should be paid to the government and our God who brought this time. We got relief and our children are growing well and healthy (Baliessie, a mother of 5 children and 30 years old).*

Loetie, a 25-year-old woman who used contraceptive service for 5 years explained her lived experience as how she has benefited from the service as:

*Remarkable change is seen here when compared to the earlier time. Instead of waking far distance to access contraceptive service, this time I am accessing contraceptive service here in my kebele with a short walk distance. Before the health extension program, one was experienced walking long distances and required to pay for contraceptive service. Thus, the long-distance walk, time and financial barriers hampered from service users in the pre-health extension era. Grace be to the Almighty God and appreciation to the government; we receive health information daily. The health extension workers provide services and information in all the packages, with due focus on how to keep our hygiene, different types of contraceptive methods available in the health posts and elsewhere, inform the benefits of contraceptive use about spacing pregnancies thereby improving the health status of both mothers and children.*

Furthermore, women expressed their views on the contribution of the health extension workers in creating health services demand and access in their respective kebele. They are the first to bring contraceptive information and services; by the way, this remains the reason for the improved prevalence of service use in their kebele. Women further witnessed that their know-how and skills for health service use are improved since the establishment of the health extension program.

This is further supported by the excerpts from other participants:

*Before the health extension program, I knew nothing about what contraceptive service mean and why it exists. We hardly find health services in our locality until the establishment of the health post in our kebele. Mostly we were ignorant about health services such as contraceptive use and vaccination. Immediately following the establishment of the health post in our kebele, the worker started to inform us about various health extension packages including contraceptive use and related benefits. They showed us the difference between unplanned and planned fertility and mechanisms to control fertility, (Dalbe, a 27 years old used contraceptives for 7 years).*

A one-to-five network means a model woman in one of the five neighboring households: act as a team leader (due to her outstanding performance on the health extension program) for all development-related affairs in that team.

#### **4. Discussion**

#### **4.1 Toward an enabling environment for contraceptive use**

The perception of participants in the study regarding the environment in relation to contraceptive service is discussed in this section and includes: (1) the service organization that includes accessibility, availability, acceptability, and convenience (2) the premises of rights approach for service provision and (3) special contributions of health extension program as an innovative primary health care strategy toward contraceptive service.

#### **4.2 Contraceptive service organizations (content and process)**

The study has indicated that until recently, the access and availability of services were weak in the country. The findings confirmed this claim, as, at the early stages of the health extension program, only oral contraceptive pills were available at health posts. Currently, couples of methods are available including short-term methods and long-term methods at the health posts provided through a health extension program. However, the availability of more methods is not uniform across the health institution. It increases when one goes up in the hierarchy of health services delivery institutions.

Agreement is established among stakeholders (services providers, users, and health managers) of the availability, accessibility, convenience, and use of contraceptive services in the study area. One can conclude that there are some improvements in coordination and communication among stakeholders concerning the service processes and contents. Except for a few, all the participants' experiences showed that contraceptive service availability, accessibility, and quality are improving. Some peculiarities were experienced concerning the injectable contraceptive method availability of specifically injectable contraceptives.

The lack of a particular method, an injectable contraceptive (which is more likely accepted by users), may pose a challenge to further expanding and sustaining contraceptive services [34]. Switching from one method to another ought to be due to defined medical reasons or the choice of the client, but the current shortage-related switching is another hindrance that may overshadow service quality and expansion. The shortage of widely acceptable contraceptive methods could hamper service expansion and negatively affect the good feedback toward the HEP. The irregularity in availing of preferred methods may contrast with the established service norms, which state that the service delivery should provide adequate attention to sociocultural and personal experiences [35–37].

The study examined the processes that support the provision of high-quality contraceptive services and revealed that most contraceptive users' access services from health posts. As indicated, the prime source of contraceptive services in the community is the health extension worker with close supervision from the health center. Therefore, maintaining the quality of such service is dependent on regular updating of the competence of the health extension workers through continuous refresher training and supportive supervision. These must be coupled with the provision of materials that help with spot references such as job aid, guidelines, manuals, and standard operating procedures. The availability and use of reference materials are examined in this study from the perspectives of service providers and managers.

The higher-level health service managers argue that they have prepared and distributed standard supportive documents in the form of manuals, flipcharts, and leaflets as requested by the regions. Similarly, most of the health extension workers indicated the availability of reference materials adequately and useful in guiding their service provisions. However, few of the service providers had shared their feelings that the materials are inadequate or incomplete for fulfilling the level of competency

#### *Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

required for service provision. The study revealed that reference materials (and that the materials are comprehensive and easy to understand and use) by the service providers helped to provide contraceptive services efficiently. Service providers' competency is crucial for initial service start-up and subsequent continuation of service provision. The findings from USAID-Deliver [38], argue that proper method choice and sustained use are dependent on the information clients receive from providers.

Government-sponsored health extension program is one of the significant indicators for the established links to the contraceptive uptake. The establishment of the health extension program remained a unique landmark for the rapid services uptake and quality improvement. This is further evidenced that more than half a decade-long service remained sluggish in its progress but has shown tremendous improvement since the establishment of this program. As has been indicated in much empirical evidence [39, 40], the service coverage showed tremendous improvement in contraceptive prevalence.

From the perspectives of the service providers, health services managers and users, the study scrutinized their view of which factors contributed to the remarkable improvement in contraceptive use and any defined connection to the new innovative community-based health extension program. Their lived experiences indicated that the health extension program has made a unique contribution to rapidly improving access to and convenience of these services for women. As indicated in the participants' experiences the health extension program improved services access by bringing them closer to women where they live, and work compared with the former strictly institutionalized approach of service delivery.

The availability of the services in each *community organizations* created the opportunity for women to easily access the services tackling challenges related to distance and requirements of permission from their husbands. In circumstances when women maintain the secrecy of their service use from their husbands, they go to the health post as if they are going to a neighbor's house. Studies support this finding that any service to be promoted and used by the target group should fulfill certain conditions including physical, financial, and socio-cultural aspects. Bringing services closer to the potential users increases the possibility of actual use [41, 42].

Another peculiarity of the health extension program concerning contraceptive service is that the program has removed many obstacles and barriers that hampered women's potential for service use. When the behavior of health professionals welcomes the service users (cultural and linguistic congruence) clients are more likely to use services [43, 44]. Thus, this study finding is in congruence with the above one as the health extension workers are almost all women recruited from the *community* which they serve and share the same culture and language. This has removed the gender, language, and cultural barriers between service providers and service users.

The contextual similarity between the health extension workers and service user women not only created a unique opportunity for the early services adoption but also for the continuous use. Women evidently expressed their experiences in this regard by comparing their pre-health extension program service inquiries. Formerly, the service was far from their residential area and male-dominated. Moreover, they were requested to pay for services and in most cases looked for a translator to explain their feelings to the health professional. As a result, they were highly discouraged from the health institutions to seek services [17–19].

The peculiarity of health extension programs in improving access is their conformity to the local community context. The contraceptive service extension to the household through home visits by female health extension workers is favorably welcomed by the community. Program. This is connected to cultural aspects and the domestic work patterns in which most rural women stay home doing domestic duties, and thus, are easily accessible for a health extension worker to provide services during their home visits.

The study further showed another crucial perspective of the health extension program the participants' life worlds related to contraceptive service, its alignment to the multidimensional aspects of the health systems from the health principles and philosophical ascertainments. The organizational arrangement of the health extension program shows strong links from the community level to the mainstream health institution. This further indicated and assured the need for close collaboration across the wide dimensions of actors to ensure the success of the program. The health system closely works with partners at various levels to fill gaps either technically or materially. Many study findings show that health service delivery approaches that do not leave room for inter-sectorial cooperation and that do not ensure community involvement is never satisfactorily accessible, acceptable, or sustainable [19, 39, 43, 44].

More so is the trust the health extension program builds at the community level. It is at this time that the health system closely functions with the local community in a sustainable manner. This is in line with the assertion that the health system is being affected and affects other systems. This is evidenced by that the health extension program functions in a network at the *kebele* level. The health extension workers participate in the *kebele* affairs and receive support from the *kebele* administration. They are members of the *kebele* command post, which is responsible for overall affairs. Furthermore, the health extension workers closely function with the women development armies, one-to-five networks, and model household women. This has established strong linkages between the health extension program and the community members at a basic level. Thus, it is through such channels that information and services flow until they reach the households and target women.

The trust and strong collaboration established between the health extension workers and the current women users of contraception has created a circular passion for the information dissemination to the current non-user women in the community. The platform of current service-user women in the community through the women development army and the one-to-five network in their neighborhood helped initiation of discussion about contraceptive use and its benefits with the current non-user counterparts by sharing their life experiences. Perry and Roger (2014) argue that if the health service delivery approach offers attention to the multiple dimensions of health determinants and involves all stakeholders, the service uptake increases tremendously. Gulzar and Ali [45] also agree that the client's family planning service use behavior is largely influenced by the relationship between the service provider and the client. This study has proved that female health extension workers have greatly improved contraceptive service uptake by extending service to households through home visitation.

The basic premise of contraceptive service provision was reemphasized that the health extension program packages were designed based on fundamental human and reproductive rights. The human rights dimension for reproductive health received little attention at its earliest time. Through the persistent struggle of the advocacy

#### *Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

groups coupled with a series of UN conferences, meetings, and treaties have produced an agreed-upon approach to ensure the reproductive health rights of service users. The essence that human beings have a right to enjoy the highest level of attainable health, including sexual and reproductive health, received increased attention. Women and men have the right to have means to do so without any discrimination and coercion. Such ascertainments ensure that women have the right to choose a method best suited to their condition and to withdraw from the method when it fails to do so. In the contrary to the human rights principle, failure to provide adequate information and limiting service access is an indication that the contraceptive service is not in line with the ICPD plan of action. Hardee et al. [46] argue that any family planning program must respect the ICPD plan of action and must guarantee freedom of contraceptive choice and respect, protect, and fulfill human rights.

#### **4.3 Strengths and limitations**

The study was conducted in three districts of the Sidama zone and considered only the married women currently using the services may be considered as the limitations of the. Sexual and reproductive matters are usually sensitive and considered as taboo in most rural communities, thus might have limited the depth of response during data collection. Another possible limitation is that the study has not considered current non-users' perceptions of the benefits of contraception. Men are also not considered in this study as the prime purpose of the study is to explore the experiences of women.

The study was carried out to explore the experiences of women contraceptive service users in the Hawassa University research villages, which were established to observe the impact of university-based research in knowledge generation, technology transfer, and the livelihood of the residents. The scope and patterns of this study have taken such shape with the assumption to strengthen the university-community linkage. These are some of the delimitations of this study.

#### **4.4 Conclusion and recommendation**

Based on the findings of this study, it can be concluded that the contraceptive service organizations' process and content, are encouraging and improvements made in service quantity and quality. HEP symbolized the effectiveness of communitybased health services provision as the backbone of primary health care. Moreover, HEP amicably expressed the functionality of intersectoral collaboration and various community-based organizations networks hand-in-hand for the betterment of the most needy segment of the society. Women revealed encouraging involvement in the process of contraceptive service access and use in their organizations such as development armies and the one-to-five network.

#### **4.5 Recommendations**

Identifying successful strategies for the sustainable use of reproductive health services from the human and women's rights perspectives is vital not only to ensure the wellbeing of women and their significant others but also toward ensuring the attainment of sustainable development goals. This study, therefore, has come up with the following recommendations to ensure evidence-based service provision and propel contraceptive service use in a way that consistently respects human rights and sustainable use:

#### **5. Declaration**

#### **5.1 Ethical considerations**

Ethical clearance for this study was obtained from all concerned institutions both abroad and in-land. These are: the University of Saskatchewan, Canada, Hawassa, University, Ethiopia and the SNNPR Health Bureau, Ethiopia. Study participants offered their consent in written form ensuring their voluntariness to be part of the study. The study team explained the purpose of the study; its benefits and any risk in case thoroughly to prove the confidence of the study participant. Study participants were informed about communication of the study finding in various meetings, workshops and publications and verbal consents were obtained.

#### **5.2 Consent for the publication**

This manuscript is an extract from the PhD dissertation with some addition later on. All ethical issues including communication of the finding to various stakeholders were properly communicated and their consents were obtained. Study participants signed consent forms in the local language are attached under the supporting document Section 7.

#### **5.3 Declaration of funding**

The original PhD dissertation was funded by the joint contribution of Hawassa University, Ethiopia and the University of Saskatchewan, Canada. The funding was only covered fieldwork expenses such as travel cost, perdiem, fuel, and related incidentals. Additional data were gathered at the expense of the authors' personal pockets. No fund was allocated for the communication of finding such as publication. There is no interference of the funding entities in all undertakings of the study work except offering the fund for the accomplishment of the study.

#### **Authors' contribution**

The manuscript is a joint effort of all the authors. AA was responsible for conducting data collection, analysis, and the write up. LH was responsible for revising transcription, analysis, editing, and supervising all steps. MM was involved in designing the study, manuscript preparation, editing of the manuscript.

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

#### **Competing interest**

The manuscript is the efforts of both authors primarily dedicated to academic purposes. The financial support from Hawassa and Saskatchewan universities was in support of a PhD study. The manuscript is partially taken from the PhD dissertation with some addition of data after it. Hence, there were no competing interests either from the funding sources or the authors.

#### **List of abbreviation**

#### **A. Profile of study participants**

#### **A. 1 FGD**

#### **Site 1**

See **Tables A1**–**A9**.

**Table A1.** *Profile extracted from the FGD participants' transcription document of the Waycho site.*

#### **Site 2**

#### **Table A2.**

*Profile of the participants extracted from the FGD participants' transcription document of the Ganie site.*

#### **Site 3**

#### **Table A3.**

*Profile of the participants extracted from the FGD participants' transcription document of the Degara site.*

#### **Site 4**

**Table A4.**

*Profile of the participants extracted from the FGD participants' transcription document of the Korangoge site.*

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

#### **Site 5**

#### **Table A5.**

*Profile of the participants extracted from the FGD participants' transcription document of the Dilarife site.*

#### **Site 6**

#### **Table A6.**

*Profile of the participants extracted from the FGD participants' transcription document of the Konsore Fullasa site.*

#### **Site 7**

#### **Table A7.**

*Profile of the participants extracted from the FGD participants' transcription document of the Gassara Kuwie site.*

#### **Site 8**

#### **Table A8.**

*Profile of the participants extracted from the FGD participants' transcription document of the Wotara Gendo site.*

#### **Site 9**

#### **Table A9.**

*Profile of the participants extracted from the FGD participants' transcription document of the Basha site.*

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

#### **A. 2 Profile of key informants**

*N.B. The Key informants composed of service providers at community and health institution levels, health service managers at district, regional and federal levels indicating the hierarchy.*

#### **Table A10.**

*Key informant profile extracted from the transcription of the informants' document from the study sites such as health institutions (health post and health center) and the health services administrative offices.*

#### **B. Data analysis flow diagram adapted from IPAThe qualitative data analysis steps adapted from IPA (Smith et al., 2009, pp. 82–100) and customized to fit my study taking the following steps as indicated below in flow diagram (Figure B1).**

#### **Figure B1.**

*It can be cited as Fig. B1. Flow diagram of data analysis adapted from the Interpretive Phenomenological Analysis (IPA).*

#### **C. A flow diagram indicating steps in translation**

This study involved several participants in the overall processes with various languages background. In order to establish a common understanding and create

**Figure C1.**

*This can be cited as a flow diagram developed to indicate a translation of transcription from the local language to the working language in the stepwise (developed by the researcher).*

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

closeness in the process of the research, use of language translation from one to another has been a necessary condition. Accordingly, the following steps in translation has been taken until the final text took its recent shape (**Figure C1**).

#### **Author details**

Abraham Alano1 \* and Lori Hanson2

1 SNNPR Policy Research Institute, Hawassa University, College of Medicine and Health Sciences, School of Public Health, SNNPR, Hawassa, Ethiopia

2 Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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*Edited by Panagiotis Tsikouras, Nikolaos Nikolettos, Werner Rath and Friedrich Von Tempelhoff*

This book provides a comprehensive overview of contraception. It provides the most recent evidence to guide clinical practice and management. The chapter topics include general management of contraception, family planning and more specific issues such as hormonal and non-hormonal barrier methods and emergency contraception.

> *Zouhair O. Amarin, Obstetrics and Gynecology Series Editor*

Published in London, UK © 2024 IntechOpen © Md Saiful Islam Khan / iStock

Conception and Family Planning - New Aspects

IntechOpen Series

Obstetrics and Gynecology, Volume 2

Conception

and Family Planning

New Aspects

*Edited by Panagiotis Tsikouras, Nikolaos Nikolettos,*

*Werner Rath and Friedrich Von Tempelhoff*