Effect of women autonomy on family planning service use among married women in Ethiopia: a systematic review and meta-analysis protocol

*Niguss Cherie 1, Teklemariam Gultie2, Zeleke Dutamo3, Kunuz Haji 4and Aleme Mekuria5

1 Wollo University, College of Medicine and Health Sciences, School of Public Health, Ethiopia 2 Arba Minch University, College of Medicine and Health Sciences, Ethiopia 3 Wachamo University, College of Medicine and Health Sciences, Ethiopia 4 Jimma Zone Health Office, Jimma, Ethiopia 5 Arba Minch College of Health Sciences, Arba Minch, Ethiopia

* Corresponding author E-mail: [email protected]

Review question/objective The objective of this review is to estimate the effect of women autonomy on family planning service use among married women in Ethiopia.

1 Background The Universal Declaration of Human Rights states that everyone has the right to take part in the Government of his/her country. The empowerment and autonomy of women and the improvement of women’s social, economic and political status is essential for the achievement of both transparent and accountable government and administration and sustainable development in all areas of life(1).

Similarly, women’s autonomy is defined as the capacity and freedom to act independently, for example, the ability to go places, such as health facilities or the market, or to make decisions regarding contraceptive use or household purchases alone and without asking anyone’s permission(2). Women’s autonomy in health care decision-making is very crucial for better maternal and child health outcomes. It is also considered essential for decision- making in a range of situations, from health care seeking and utilization to choosing among treatment options. Gender-based power inequalities can restrict open communication between partners about reproductive health decisions as well as women's access to reproductive health services. This in turn can contribute to poor health outcomes (3, 4).

Evidence from Africa and South-East Asian countries has shown that women usually have less power and often have limited autonomy and control over their health decisions regarding issues related to their own health care. Moreover, they usually have unequal access to nutrition, education, and health care, as well as a limited opportunity to earn income and have control over resources, as well as few effective legal rights (2).

A growing body of studies suggests that women with greater autonomy are more likely to seek health care for themselves and use different forms of health care services available to them. Studies have also shown that increased female autonomy confers benefits such as long-term reduction in fertility, higher child survival rates, and allocation of resources in favor of children in the household (5-8). Women’s participation in health care decisions increased with her age, number of living children, education, and wealth. Rural and poor women were less likely to be involved in decision making than urban or rich women (9). Involvement of husband alone or family members or others in decisions particularly maternal health care seeking is associated with lower contraceptive use compared to joint decision-making(10-14) .The lower women’s autonomy limits their reproductive health care seeking behavior including family planning because of socio cultural influence in poor settings such as Ethiopia. In contrast, some studies report that women’s autonomy has no effect on reproductive health care seeking (15).

2 Ethiopian men are dominant decision-makers in most family matters, including fertility and family planning. Women are either under collective decision-making with their partners or completely rely on the male partner’s decision on issues that affect their reproductive health need (16).

Studies conducted in Ethiopia indicate that there is a diverse relationship between women autonomy and contraceptive use. Moreover, women in urban areas are much more likely to use family planning service independently as compared to those from rural women (17-18).

The national reproductive health strategy endorsed by federal ministry of health of Ethiopia had given due emphasis to family planning aiming to reduce unwanted pregnancies and enable individuals to achieve their desired family size, but still the country is one of the highest fertility with the total fertility rate (TFR) of 4.6 and modern contraceptive utilization rate is only 35%(20). Because of low contraceptive use and high fertility status among married women, the pregnancy related mortality ratio is 412 maternal deaths per 100,000 live births. It is attributed to the little autonomy on decision making to use fertility controls (19-21). Therefore, the aim of this review is to synthesize the relevant studies conducted in the country and summarize what is known about women autonomy towards family planning use so that the information obtained will be used for advocacy purpose to policy makers to take action up on the identified problems.

Keywords: women autonomy, family planning, utilization, married women, Ethiopia

3 Methods/Protocol design Inclusion criteria Types of participants This study review will consider published and unpublished studies that include women participants who are in reproductive age group and married. Types of exposure This study review will include studies examining the autonomy of married women on family planning utilization in Ethiopia.

Types of outcomes This study review will consider studies that include family planning service utilization as an outcome measure.

Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies if randomized-controlled trials are not available for inclusion.

Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be employed; an initial limited search of PubMed, Google Scholar, Scopus, CINHAL, HINARI, JBI and Cochrane Library will be undertaken followed by analysis of text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will be undertaken across PubMed, Google Scholar, CINHAL, HINARI, JBI and Cochrane Library. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Full-text articles will be retrieved after review of the title and abstract.

The literature search will be restricted to the English language and human study group. The literature records will be managed using the EndNote X9 reference manager. All the articles published from January 1/2010 to March 1/2020 will be included in this review.

4 A Medical Subject Headings (MeSH) thesaurus and keyword terms will be used both in separation and in combination using the Boolean operator like “OR”, “AND” or “NOT” to search for eligible articles to include in the analysis. A sample search strategy, for PUBMED, is shown below and a similar strategy was adapted for the other databases. (“women autonomy” OR “women decision making” OR “female autonomy” OR “household decision making power” OR “autonomy” OR “health care decision making” AND “family planning utilization” OR “family planning use” OR “family planning uptake” OR “contraceptive utilization” OR “contraceptive use” OR “contraceptive uptake” OR “birth control” OR “fertility control” OR “contraception” AND “married women” OR “women” OR “women in union” AND “Ethiopia OR federal democratic republic of Ethiopia”). Advanced search was done by Mesh term and all fields in PubMed. Study selection All studies retrieved through search strategy will be imported to EndNote X9 to exclude duplicates. After excluding the duplicated articles, title, abstract and full-text reading will be used independently to select study and data extraction accordingly by five reviewers. The disagreement will be solved by consensus. The PRISMA flow diagram will be applied to summarize and synthesize the selection procedure and process of the articles (22-23). Quality appraisal Five reviewers independently will assess the risk of bias. Because JBI has substantial inter-rater reliability and validity (24), The JBI quality appraisal tool (Review Instrument (JBI-MAStARI) (Appendix I) will be used to assess the quality of evidence and risk of bias in studies. Those articles with a scale of ≥7 out of 10 will be considered as high quality. Taking the mean score of the five reviewers, differences in their assessment results will be determine. The JBI tool emphasized on three main issues; the principal component of the tool graded from five stars and mainly emphasized on the methodological quality of each primary study. The other component of the tool graded from two stars and mainly concerns about the comparability of each study. The last component of the tool graded from three stars and used to assess the outcomes and statistical analysis of each original study. Participants Studies reported the effect of women autonomy on family planning service use among married women in Ethiopia.

5 Outcomes of the study: The primary outcome of this systematic review is to determine the effect of women autonomy on family planning service use among married women in Ethiopia. In this review, articles defined family planning use as women who were using any modern family planning methods to prevent unintended pregnancy will be included. Data extraction and management: Data will be extracted from papers included in the review using a standardized data extraction format from JBI-MAStARI (Appendix II); (24). Data will be extracted by five reviewers. The extraction form will be pre-tested on 5 eligible studies. The data extraction format included primary author, publication year, region, study area, study design, sample size, measurement type, proportion and the quality score of each study. Data analysis, publication bias and heterogeneity Data will be entered into Microsoft Excel and then exported to Rev Man software for further analysis. The descriptive data will be presented using a table to describe the characteristics of each primary study. Besides, the point effect size of each study, as well as the overall effect size, will be described using a forest plot graph. Statistical heterogeneity will be determined and quantified using Cochran’s Q statistic and the I2 test statistic respectively. A p-value less than 0.10 of Cochran’s Q statistic will be used to declare heterogeneity and the I2 test statistics of 25%, 50% and 75% will be declared as low, moderate and high heterogeneity respectively as cited (25). Effect sizes expressed as OR for categorical data and their 95% CIs will be calculated for each associated factor of family planning use and forest plot will be used to present the effect size. The possible risk of publication bias will be examined by using funnel plot inspection as well as Begg’s and Egger’s test and p-value less than 0.05 will be used to declare the statistical significance of publication bias as cited(26). Subgroup analysis, meta-regression and sensitivity analysis Subgroup analysis will be conducted by region of the country, study setting and residence to compare the finding among these variables and to minimize random variation among included studies. Meta- regression will be also conducted by considering publication year, region and study setting as covariates to identify the possible source of heterogeneity. Lastly, a sensitivity analysis will be performed to examine the influence of a single study on the overall estimate.

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Conflicts of interest There are no conflicts of interests to declare

Acknowledgments We would like to thank Jimma University, institute of Health for their overall support.

Contributions of authors

All the authors contributed in the conceptualization, development of this protocol and searching of available studies.

7 References

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Appendix 1: Appraisal instruments

MAStARI appraisal instrument

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