Modern Contraception Use in
Ethiopia: Does Involving Husbands
Make a Difference?
..
Almaz Terefe, BSc, MPH, and Charles P. Larson, MD, MSc, FRCPC
Introduction
Rapid population growth, which in
many instances far outstrips economic
growth and environmental sustainability,
is the reality in most developing countries
of sub-Saharan Africa.'-3 Within this re-
gion, annual population growth rates over
the past 2 decades have continued to in-
crease, and the contraception prevalence
rate has remained under 10%.1.2
In Ethiopia the overall contraception
prevalence rate among women of childbear-
ing age (15 to 49 years) is less than 2%, and
the crude birth rate is estimated to be 49 per
1000 population.' Most women in Ethiopia
marny by the age of 15, and less than 6%
remain single by the age of 24.4 On average,
Ethiopian wives experience seven pregnan-
cies during their lifetime, each pregnancy
carrying about a 1 % risk of death.1'3'5'6
These figures are associated with an annual
rate of population growth of approximately
3%.1,2 Applying the lower end of national
fertility projections, the current Ethiopian
population of 50 million is expected to reach
90 million by 2010 and 165 million by 2035.
The aim of the program was to initiate
and sustain modern contraceptive use
among married couples. Because the lim-
ited research on male roles in Ethiopia and
sub-Saharan Africa has consistently found
that decisions regarding family size and
contraception are dominated by husbands,
who expect to have large families,7-'2 this
field trial was undertaken to determine
what effect involving husbands in a com-
munity-based, home visitation, health ed-
ucation program would have on the use of
modem contraception in Ethiopia.
Methods
Study Design
This was an experimental, random-
ized field trial comparing the relative ef-
fectiveness of a modem contraception
educational intervention program in Ethi-
opia with and without husband participa-
tion. The general architecture of the study
and enrollment are found in Figure 1. The
interventions were carried out between
August 1990 and January 1991, and mod-
em contraceptive use was verified at 2 and
12 months following intervention.
The study was conducted in the semi-
urban, peripheral Kotebe District, one of
18 districts in Addis Ababa. Kotebe is lo-
cated at about 12 kilometers northeast of
the city center. Approximately 80% of its
population of 43 000 is urban. The source
population for the field trial was any urban
Kotebe female resident between the ages
of 15 and 49 years who was married and
living with her husband. It was estimated
that there were approximately 1214
women eligible for this study residing
within the 12 randomly selected zones.
Excluded from eligibility were women
currently using modern contraception,
pregnant women, and women with a
chronic physical or mental illness. Prior to
this study, no family planning outreach
program was or had been in existence.
Local, trained traditional birth atten-
dants who were currently working in the
district and had, on average, more than 10
years experience in the community were
paired with a female interviewer having a
12th-grade education. The pairs were pro-
Almaz Terefe is with the Department of Com-
munity Health, Addis Ababa University, Addis
Ababa, Ethiopia. Charles P. Larson is with the
Departments of Pediatrics and of Epidemiology
and Biostatistics at McGill University, Mon-
treal, Canada.
Requests for reprints should be sent to
Charles P. Larson, MD, MSc, FRCPC, Mon-
treal Children's Hospital, Gilman Pavilion,
2300 Tupper St, Montreal, Quebec, Canada
H3H 1P3.
This paper was accepted May 11, 1993.
American Journal of Public Health 1567
Terefe and larson
12 of 22 Urban Zones Randomly Selected
N * 1,123 Married Women 15-49
systematic sampling
N* 818
Interviewed
N * 615 Assessed as Eligible
randomization
n
I
I
Experimental
N * 266 enrolled
N X 244 12 month
(9 1.7%) follow-up
FIGURE I-Stucture of trial and enrollment
vided with the names ofmarried women of
childbearing age who resided in their re-
spective zones and were systematically
selected on a 2:1 basis from a census list.
The birth attendants identified these
women, confirmed their eligibility for en-
rollment (203 of 818 were excluded), and
arranged a date and time for a home visit.
The interviewer completed a baseline
questionnaire, which in all instances, was
conducted with the wife only. The inter-
viewers were unaware of the research ob-
jectives and group assignments. Follow-
ing completion of the questionnaire, one
of the principal investigators (AT) col-
lected blocks of eight names and assigned
them as control or experimental subjects
based on random assignment schedules
for each home visitor. At the time of the
follow-up home visit, a further 88 subjects
were excluded: 42 had moved or could not
be found, 43 were ineligible (24 were preg-
nant, 13 postmenopausal, 6 on contracep-
tion), and 3 had husbands who refused
the visit. The final enrollment figures were
261 control and 266 experimental sub-
jects. There was no loss of subjects at the
2-month follow-up, but 29 control (11.1%)
and 22 experimental (8.3%) subjects were
lost to follow-up after 12 months.
1568 American Journal of Public Health
42 not found
43 ineligible
I
Control
N * 261
N a 232
(88.9%)
Intervention
Eight female health assistants, accom-
panied by the traditional birth attendants in-
volved in the initial contact, conducted the
home visits. These health assistants were
employed at the local district health station
and were known to the community. They
worked on this project in the early evenings
and on weekends, which facilitated sched-
uling the husbands in the experimental
group. The health assistants were trained to
maintain an informal atnmosphere and to per-
mit spontaneous communication.
After briefly explaining the purpose
of the study, the health assistants re-
quested the consent of the participants.
Next, they provided health education on
family planning and modern contraceptive
methods to either the wife alone (control
group) or the wife and husband (experi-
mental group). (The eight health assistants
had an almost equal number of control and
experimental subjects.) The sessions gen-
erally started with a discussion of the
health of the family, which is a culturally
acceptable manner in which to initiate a
conversation. Questions on the woman's
reproductive historywere then used as the
entry point into the actual family planning
education. The content of the education
focused on the advantages of family plan-
ning as a means of preventing unwanted
pregnancy and birth, of spacing births,
and of controlling family size. Health as-
sistants discussed the advantages of birth
spacing for the mother, children, and fam-
ilywith respect to both promotive and pre-
ventive aspects of health. Additionally
they stressed the ill effects of a large family
on all family members and on the nation as
a whole. This was followed by an expla-
nation of altemative contraceptive meth-
ods-the birth control pill, the intrauterine
device (IUD), and the condom-and a dis-
cussion of the relative efficacy of modern
contraception versus traditional methods.
A maximum of two visits were made.
Couples intending to initiate modem con-
traception were allowed their choice of
method and provided with the appropriate
explanations and information about follow-
up. The contraceptive method was pro-
vided at the conclusion of the home visit, if
requested. This included either two cycles
of birth control pills, two dozen condoms,
or a copper-T TUD set to be brought to the
local health center for insertion.
The hypothesis to be tested was as fol-
lows: those couples in which husband and
wife receive family planning education in
the home will have a signiScantlyhigher rate
of modern contraceptive use at 2 and 12
months following the intervention than
those couples in which the wife alone re-
ceives such education (P < .05, two-sided).
Measurement
Baseline sociodemographic and re-
productive histories as well as knowledge
about and attitudes toward modern con-
traception were obtained prior to random-
ized assignment and a home visit. Initia-
tion of contraception was recorded as yes
on the basis of stated intent following the
home visit. At 2 and 12 months, the use of
modern contraception was verified on the
basis of current birth control pill use and
refills, condom refiDls, or proof of TUD in-
sertion. In all instances, this information
was obtained from the wife.
Analysis
All questionnaires were checked by
one of the principal investigators for ac-
curacy, and the data were coded. Data
were entered, edited, and analyzed using
EPI-INFO version 5.01B (USD, Inc.,
Stone Mountain, Ga).
Results
Ninety-five percent of the study
groupwere Orthodox Christians, and 85%
November 1993, Vol. 83, No. 11

of the women were housewives. The lan-
guage of origin in two thirds of the partic-
ipants was Amharic while that of the rest
was mostly Oromigna. Two thirds of the
husbands were government employees,
which includes local factory workers.
There were no between-group differences
in these characteristics. Complete fol-
low-up through 12 months was achieved
in 91.7% of the experimental and 88.9% of
the control subjects.
Table 1 summarizes the between-
group comparison of demographic and re-
productive histories. There were no sig-
nificant differences between control and
experimental subjects found at enroll-
ment, except that control group women
had a slightly higher number of siblings
(P < .05). The level of education of 70%
of the women was 6th grade or below,
while 70% of the men had completed 5th
grade or higher. Husbands in this study
were also older than theirwives. The num-
ber of women having one to two children,
three to four children, and five or more
children ranged between 25% and 30% for
each category and was evenly and uni-
formly distributed across both groups.
Only 6.6% of the women had no living
children.
There were no significant group dif-
ferences in family planning knowledge or
attitudes. The majority of the women
(65%) wished to have four children. Fif-
November 1993, Vol. 83, No. 11
teen percent of the women had not heard
of modem contraceptive methods while
about 40% knew of only one such method:
mainly the birth control pill. Husbands
were generally supportive of the need for
family planning (57% and 69% in control
and experimental subjects, respectively).
Following the home visit interven-
tion, 47.0% (n = 125) of the experimental
versus 33.0% (n = 86) of the control
women decided to start using modem con-
traception (relative risk [RR] = 1.42, 95%
confidence interval [CI] = 1.15, 1.76). In
more than 90% of cases, the birth control
pill was chosen. At 2 months following the
home visit intervention, it was confirmed
that approximately one-half of all couples
who had stated their intention to initiate
modem contraception were not using it.
The practice of contraception at 2 months
was verified in only 24.7% (n = 66) exper-
imental and 15.3% (n = 40) control sub-
jects (RR = 1.61, 95% CI = 1.13, 2.30).
This analysis was further stratified by the
presence or absence of husband support
for family planning. Relative risk esti-
mates and 95% confidence intervals re-
mained above 1 and favored the experi-
mental subjects with and without husband
support. No significant interaction was
found (Woolf's x2 0.14, P = .71).
Table 2 summarizes the modem con-
traceptive practices of those subjects who
were successfully followed through 12
months after home visitation. From these
figures, one can subgroup subjects into
those who practiced modem contracep-
tion throughout the year (yes at 2 and 12
months), those who defaulted by 12
months (yes at 2, no at 12 months), those
who delayed starting (no at 2, yes at 12
months), and those who never used it (no
at 2 and 12 months). Experimental sub-
jects were less likely to have defaulted
Contraception in Etbiopia
from modem contraceptive use by 12
months (RR = 0.55,95% CI = 0.37,0.81)
and more likely to have delayed starting it
(RR = 1.58, 95% CI = 1.01, 2.46). At 12
months, twice as many experimental cou-
ples were using modem contraception as
were control subjects (RR = 1.90, 95%
CI = 1.36, 2.66). Overall, 25.2% of cou-
ples were using it at 12 months, and the
majority of these (55.8%) initiated the
practice 2 or more months after the home
visit intervention.
Discussion
This randomized field trial of family
planning education in the home with or
without husband participation has demon-
strated that, as hypothesized, providing a
family planning educational intervention
program in the home to the husband and
wife significantly improves modem con-
traception use up to 12 months following
the intervention. Usage as measured by
early or late initiation, overall use at 12
months, and default rates was better in all
instances among couples with husband
participation than among those couples
without husband participation. Given the
favorable quality of the randomization, it
is concluded that the differences can be
attributed to husband involvement in the
intervention program and have not been
confounded by demographic, reproduc-
tive, or knowledge and attitude disparities
between the two study groups.
Several investigators have found that
Ethiopian and East African husbands ex-
pect to have large families and thus play a
dominant role in a couple's decision to
initiate modem contraception.7-12 Given
that most Ethiopian women will not ini-
tiate contraception without their hus-
band's knowledge, a husband's disap-
American Journal of Public Health 1569
Terefe and Larson
proval can be expected to be a major
deterrent to use. Unfortunately, favorable
husband attitudes do not appear to be suf-
ficient. For example, among the couples
enrolled in this study, none of whom were
practicing modem contraception at the
outset, more than 60% of husbands sup-
ported the need for family planning. This
high baseline level of husband support for
family planning was unexpected and may
explain the generally successful response
to the two interventions. It maybe that the
husbands were providing the expected an-
swer out of respect for the interviewer.
Similar unpublished findings of high sup-
port but low practice have been found in
the north-central Ethiopian district of Yi-
fatna Timuga. While husbands may ac-
knowledge the need for family planning,
practice tends to be influenced by the high
levels ofmisinformation regarding the side
effects of modem contraception, particu-
larly oral contraceptives.7 This includes
fears ofsterility, arthritis, loss of weight or
strength, and skin changes.
Of particular interest is the finding
that most of the women initiated modem
contraceptive use more than 2 months fol-
lowing the intervention. This delayed or
"sleeper" effect was first described 40
years ago by Hovland and Weiss,13 who
attributed the delay in communication ef-
fect to the low credibility of the source of
information. Over time, the inhibiting in-
fluence of the source diminishes and the
message leads to change. It has been as-
sumed, but unconfirmed, that health as-
sistants and trained traditional birth atten-
dants enjoy a relatively high status in
Ethiopian communities; this may not be
the case. Altematively, the delays ob-
served may be explained in terms of the
time required to undergo a change in atti-
tude and the degree of personal commit-
ment required. Given that the use of mod-
em contraception is contrary to past
practices and familial expectations, the
home visit may have shifted couples from
a position of uncertainty or ambivalence
to one of an acknowledged, positive desire
to initiate modem contraception. Such a
change in attitude and, subsequently, in
actual practice is a process that, in a large
subset of couples, may unfold over sev-
eral weeks. The delays identified in this
study suggest that family planning inter-
vention programs should interpret early
results cautiously.
Is the intervention package offered in
this trial applicable to and realistic for
other Ethiopian and sub-Saharan commu-
nities? To answer this question, three el-
ements of the intervention require consid-
1570 American Journal of Public Health
eration: home visitation, the visitor, and
the educational content. Home visiting is
a labor-intensive activity that requires
competent organizational skills at the dis-
trict level and reliable transportation facil-
ities. A maximum of two visits-and in
most cases, only one visit-was provided.
Four to six women or couples were seen
in a half-day schedule. The equivalent of
one full-time health assistant can be ex-
pected to serve from 1500 to 2000 couples
per year in an urban community. In a rural
setting, these numbers would be reduced
owing to travel time. The large majority of
the couples visited were not regular health
institution attenders and, in the absence of
home visiting, were unlikely to have ben-
efited from an institution-based program.
Without a community outreach compo-
nent such as home visitation, family plan-
ning services would miss the large major-
ity of their target population.
In this study, husband participation
was high. Although there were a few in-
stances in which the husband refused to
complete the health education session, the
vast majority were tolerant and available
as scheduled. Several factors may explain
this high rate of husband compliance.
First, the visits were carried out by health
workers well known to the community.
These workers shared a common cultural
and social background with the couples
they visited and were aware of how to
approach husbands in an acceptable and
appropriate manner. Second, the educa-
tional message was ordered to respond
first ofall to the couples' main concems or
perceived barriers to use. Third, at the
time this intervention was carried out, the
stability ofthe govemment was very much
in question. Thus, for security reasons,
people tended to return home and stay at
home after working hours. This situation
probably facilitated the task of scheduling
husband participation.
The interventions were provided by
health assistants and trained traditional
birth attendants who were currently work-
ing in the district following a brief period of
training. This level of health professional
is found throughout Ethiopia and most of
Africa. The content of the intervention
was based on the educational outline de-
scribed; as mentioned, however, this con-
tent was modified according to the cou-
ple's family planning knowledge and
attitudes, with which the birth attendants
and health assistants were familiar. Given
appropriate supervision and integration
into existing health services, the interven-
tions provided are considered applicable
to any urban and probably most rural set-
tings in Ethiopia.
At 12 months following the interven-
tion, nearly one quarter of all subjects
were using some form of modem contra-
ception. In a district where the baseline
contraception prevalence rate was 2%, the
rise to 17%, even without husband in-
volvement, is a strong endorsement of
home visitation. With the inclusion of hus-
bands, the program's impact on the use of
modem contraception nearly doubled. If
these results can be repeated in other set-
tings, the benefits would seem to justify
the personnel inputs. The training and su-
pervision requirements are modest and
applicable to districts where a health man-
agement system is in place and functional.
Based on the study's findings, the devel-
opment and evaluation of alternative mod-
els of home visitation and husband in-
volvement that include evaluation of the
intervention elements and costs in relation
to its benefits is recommended.
This investigation does not take into
account the interaction of multiple factors
influencing the desire to have children-in
particular, cultural factors that can vary
widely between regions, districts, and
even communities. Warwickl4 and others
have cautioned against grand conclusions
based on single studies, and we concur.
Involvement of husbands must be linked
to local realities and responsive to the ex-
pressed desires of communities. The in-
tervention described in this study was de-
veloped following extensive consultation
with the community and the national fam-
ily planning program. Furthermore, we
used existing resources and housed the
program within the local health institu-
tions. This provides, at best, a broad
framework upon which to design similar
family planning programs that involve
men in contraception and constructively
expand their family planning responsibil-
ities. E
Acknowledgments
This research was supported in full by the In-
ternational Development Research Centre of
Canada through the McGill-Ethiopia Commu-
nity Health Project.
We wish to thank the staff of the Addis
Ababa Regional Health Department-and, in
particular, Dr Agonefer Tekalegne-for sup-
porting and helping to facilitate the conduct of
this study.
References
1. United Nations Development Programme.
Human Development Report 1992. New
York, NY: Oxford University Press; 1992.
2. World Bank. World Development Report
November 1993, Vol. 83, No. 11
 Contraception in Ediiopia

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