Does proximity of women to facilities with better choice of contraceptives affect their contraceptive utilization in rural Ethiopia?

BACKGROUND There is limited evidence of the linkage between contraceptive use, the range of methods available and level of contraceptive stocks at health facilities and distance to facility in developing countries. The present analysis aims at examining the influence of contraceptive method availability and distance to the nearby facilities on modern contraceptive utilization among married women in rural areas in Ethiopia using geo-referenced data. METHODS We used data from the first round of surveys of the Performance Monitoring & Accountability 2020 project in Ethiopia (PMA2020/Ethiopia-2014). The survey was conducted in a sample of 200 enumeration areas (EAs) where for each EA, 35 households and up to 3 public or private health service delivery points (SDPs) were selected. The main outcome variable was individual use of a contraceptive method for married women in rural Ethiopia. Correlates of interest include distance to nearby health facilities, range of contraceptives available in facilities, household wealth index, and the woman's educational status, age, and parity and whether she recently visited a health facility. This analysis primarily focuses on stock provision at public SDPs. RESULTS Overall complete information was collected from 1763 married rural women ages 15-49 years and 198 SDPs in rural areas (97.1% public). Most rural women (93.9%) live within 5 kilometers of their nearest health post while a much lower proportion (52.2%) live within the same distance to the nearest health centers and hospital (0.8%), respectively. The main sources of modern contraceptive methods for married rural women were health posts (48.8%) and health centers (39.0%). The mean number of the types of contraceptive methods offered by hospitals, health centers and health posts was 6.2, 5.4 and 3.7 respectively. Modern contraceptive use (mCPR) among rural married women was 27.3% (95% CI: 25.3, 29.5). The percentage of rural married women who use modern contraceptives decreased as distance from the nearest SDP increased; 41.2%, 27.5%, 22.0%, and 22.6% of women living less than 2 kilometers, 2 to 3.9kilometers, 4 to 5.9 kilometers and 6 or more kilometers, respectively (p-value<0.01). Additionally, women who live close to facilities that offer a wider range of contraceptive methods were significantly more likely to use modern contraceptives. The mCPR ranged from 42.3% among women who live within 2 kilometers of facilities offering 3 or more methods to 22.5% among women living more than 6 kilometers away from the nearest facility with the same number (3 or more methods) available after adjusting for observed covariates. CONCLUSIONS Although the majority of the Ethiopian population lives within a relatively close distance to lower level facilities (health posts), the number and range of methods available (method choice) and proximity are independently associated with contraceptive utilization. By demonstrating the extent to which objective measures of distance (of relatively small magnitude) explain variation in contraceptive use among rural women, the study fills an important planning gap for family planning programs operating in resource limited settings.