ABSTRACT Background: Unintended pregnancy is an important public health issue in both developing and devel-oped countries because of its serious consequences for women and their families, which include the pos-sibility of unsafe abortion, delayed prenatal care, poor maternal mental health and poor child health out-comes. Objective: The major objective of this study was to identify the magnitude and factors associated with unintended pregnancy among pregnant women attending antenatal care in Cheliya Woreda. Methods: A facility based cross-sectional study was conducted on 320 women attending antenatal care clinic at Cheliya Woreda in four public health centers from March to May 2017. A convenient sampling technique was used until the estimated sample size was reached. Data was collected by trained data col-lectors using Pre-tested structured questionnaires. The collected data was checked for completeness, consistency, coded and entered in to computer and analyzed. The association between variables was ana-lyzed. Result: The magnitude of unintended pregnancy was found to be 37.2%. As chi-square calculation: Age, Marital status, Age at first marriage, Educational background , Occupation, Gravidity, Awareness about contraceptives, methods ever used, Autonomy of women in health care, in deciding the contracep-tion method used and Spousal communication on family planning were among the factors associated with the current pregnancy to be classified as Unintended pregnancy. Conclusion: According to this study, women age, marital status, education, occupation, gravidity, Awareness about family planning and methods ever used, Autonomy of women in health care and deciding the contraception method used and spousal communication on family planning was significantly associated with unintended pregnancy. 1. INTRODUCTION 1.1 BACKGROUND Unintended pregnancy is either unwanted or miss-timed at the time of conception [1-3].It has a great impact on the health of all fecund sexually active women in both developed and developing countries. Unintended pregnancy (UP) can lead to unwanted birth or abortion which could be unsafe. It might af-fect the mother, child and the society at large in different circumstances. For instance, there may be un-safe abortion, delayed or no prenatal care, poor maternal mental health, reduced mother/child relation-ship quality, physical abuse and violence against women, poor developmental outcomes for children, increased risk of low birth weight as well as increased morbidity and mortality [2, 3]. Globally, in 2012 out of 213 million pregnancies, 85 million were unintended, in which 50% ended with abortion, 13% miscarriage and 38% unplanned births [4]. In 2008, out of 210 million pregnancies, 80 million were un-intended, in which 21.6 million were completed by unsafe abortion causing the death of 47,000 women [5]. This indicates that the incidence of 1 in 10 pregnancies end in unsafe abortion [5]. Generally, the number of abortion increased from 19.7 million in 2003 to 21.6 million in 2008; which occurs almost in all developing countries [5]. For instance, according to the study by WHO in 2008, in Africa about 5.5 million unsafe abortions were performed each year and 36,000 of them died [6]. In the same year, in Ethiopia, the study made by Guttmacher Institute, showed that 101 unintended pregnancies occurred per 1000 women aged 15–44, and 42% of all pregnancies were unintended; 382,500 induced abortions were performed in which the annual rate was 23 abortions per 1,000 women [6]. Regarding the capital City Addis Ababa, the situation was more severe than the national level which was 49 per 1000 on average [6]. World Population Reference Bureau 2008 also showed that Ethiopia had the fifth highest number of maternal deaths in the world, one in 27 women died from complications of pregnancy or childbirth annually [7]. As per the study of the Ethiopian Demographic and Health Survey (EDHS) 2011, the prevalence of unintended pregnancy was 29 % of which, 20% were mistimed and 9 % unwanted [8]. Those women had a chance to develop complications, like acute trauma, organ failure, infection and fu-ture reproductive problems due to unsafe abortion [6]. In Ethiopia, unmarried women and teenagers face UP, since it is an ignominy on the societies they become obliged to perform clandestine unsafe abortions which causes, physical abuse, thrown out of home, exposed to prostitution, infected with HIV or un-planned child bearing, morbidity and mortality [9, 10]. The factors for UP vary in different areas and situations some of those were; nonuse of contraceptive, incorrect use of contraceptive, failure of contra-ceptives, unmet need for family planning, lower income, and less autonomy of women [2,11,12]. 1.2 STATEMENT OF PROBLEM Unintended pregnancy is an important public health issue in both developed and developing countries because of its negative association with social and health outcomes for both mothers and children. Unin-tended pregnancy is a pregnancy that is either mistimed or unwanted at the time of conception. It is one of the leading factor contributing to high level of maternal and child morbidity and mortality (37). Al-though several international declarations were passed to address the problem, many women in sub-Saharan Africa are still suffering from unwanted pregnancies and result in unsafe abortion (38). Even though, Goal 5 of the Millennium Development is targeted to reduce maternal deaths by three-fourth by 2015, Ethiopia has the fifth largest number of maternal deaths in the world (39) and the maternal mortal-ity was estimated to be 676 deaths per 100,000 in the year 2011(40). The Ethiopian, DHS 2011 report showed that 16.2% and 18.7% of women reported that their last preg-nancy was unwanted and mistimed, respectively (41). In another study it is showed that more than 40% of pregnancies are unintended and only 14 % of Ethiopian women of reproductive age use birth control methods (42). Unintended pregnancies is higher among women who were unmarried, lower economic status, at an early or late age of reproductive life, among those not using contraceptives consistently and attending formal education(4).Many of the mistimed pregnancies in Ethiopia occurred among women less than 30 years of age (43). Even though, evidences on the prevalence of unwanted pregnancies and identifying factors that are re-sponsible for unintended pregnancies are essential in improving reproductive health service to women information regarding this is hardly available. Therefore it is the purpose of this study to assess the pre-valence of unintended pregnancies and recognizing the determinant factors of unintended pregnancies. 1.3 SIGNIFICANCE OF THE STUDY The aim of this study was to assess the prevalence and associated factors of unintended pregnancy among pregnant women attending antenatal care at Chelia woreda. Understanding the magnitude of unintended pregnancy as well as identifying the factors that are asso-ciated with it is very crucial in designing and implementing interventions that could be tailored to their needs and there by contributing to the attainment of MDG 5( Reduction in maternal mortality). In addi-tion, the results of this study will help in developing or reviewing national policy and guidelines regard-ing the prevention of unwanted pregnancies and induced abortion. 2. LITERATURE REVIEW 2.1 UNINTENDED PREGNANCY In the entire world, pregnancy is wanted and a happy event for women, their husbands/partners, families and the community in general. But this is not always the case, because millions of women around the world become pregnant unintended [5, 16]. This contributes greatly to the increase in maternal and in-fant mortalities. In 2008, out of 210 million pregnancies, 80 million were unintended in which 21.6 mil-lion were ended by unsafe abortion causing the death of 47,000 women [5]. This indicates that of 1 in 10 pregnancies end in unsafe abortion [5]. As a result, significant proportions of women turn to induced abortions to avoid unwanted or unplanned births. A facility based study done in 2011 at selected health centers in Addis Ababa, showed that 38.7% pregnant women attending ANC report that their current pregnancy were unintended [17]. Similar study in Bahir Dar in one facility was 26% [18]. A community based study done in 2014 at Oromia Region, Ethiopia showed that 36.5% of sexually active women re-ported that their most recent pregnancies were unintended [19]. Similarly, a study conducted in Hosanna Town, southern Ethiopia shows that among pregnant married women, 34% of pregnancies were unin-tended [20]. 2.2 SAFE ABORTION Safe abortion is the termination of pregnancy by a skilled health care provider with proper equipment and in an environment with required medical standards. In countries where women have access to safe services, their likelihood of dying from complications of unsafe abortion is very minimal. In developing countries, the risk of death following complications of unsafe abortion procedures is several hundred times higher than that of an abortion performed professionally under safe conditions [5]. An estimation of 103,000 abortions performed in health facilities legally per year in Ethiopia [13]. 2.3 UNSAFE ABORTION This is the termination of unwanted pregnancy either by a person lacking the necessary skills or in an environment lacking minimal medical standards or both [5, 16]. Unsafe abortion causes a significant proportion of maternal deaths and morbidity. Abortion causes the death of 47,000 women each year, and that shows close to 13% of all maternal deaths are due to the complications of unsafe abortion [1, 5, 21]. 2.4 CONTRACEPTIVE METHODS The use of modern contraceptive methods has greatly reduced the incidence of unintended pregnancy, particularly in more developed countries and provision of family planning services and modern contra-ceptives to those who do not have access to them would prevent large proportion of unintended preg-nancies and abortions, as well as many maternal and infant deaths [1, 22]. In 2012, an estimated 645 million women in the developing world were using modern methods, 42 million more than in 2008; The proportion of married women using modern contraceptives in the developing world as a whole barely changed between 2008 (56%) and 2012 (57%). Larger-than-average increases were seen in Eastern Africa and Southeast Asia [23]. Current contraceptive use prevented 218 million unintended pregnancies in developing countries in 2012, and, in turn, averted 55 million unplanned births, 138 million abortions (of which 40 million are unsafe), 25 million miscarriages and 118,000 maternal deaths [23]. Serving all women in developing countries that currently have an unmet need for modern contraceptive methods would prevent an additional 54 million unintended pregnancies, including 21 million unplanned births, 26 million abortions (of which 16 million would be unsafe) and 7 million miscarriages; that would also prevent 79,000 maternal deaths and 1.1 million infant deaths [23]. In Ethiopia, contraceptive prevalence rate is 29%. Whereas, unmet need for family planning services is 25%; from these 16% have a need for spacing, and9%have a need for limiting as per 2011 EDHS [8]. Facility based Study conducted in Bahir Dar among pregnant women, who were visiting antenatal care clinic; indicate that the awareness of male partners on the utilization of contraceptives is significantly associated with unintended pregnancy [18]. Women whose husbands knew contraceptive utilization were almost six times less likely to have unintended pregnancy compared to their counterparts, women whose partners had no awareness on their contraceptive utilization [18]. 2.5 FACTORS ASSOCIATED WITH UNINTENDED PREGNANCIES The problem of UP pregnancies is worldwide. According to a study done in Bangladesh, 32 % of wom-en reported to have their recent pregnancy unintended [24]. Older women, 30 and above years of ages, were more likely than younger women to have had unwanted pregnancy. However, adolescents were more likely than older women to have had mistimed pregnancy [24]. Also according to studies done in Nepal, 35 % of women reported to have their recent pregnancy unintended and among those pregnan-cies, 77% of the women were aged 35 and above [25]. A community-based study done in Oromia Re-gion, Ethiopia in 2013 revealed that women between ages 35-45 were 6.51 times more likely to expe-rience unintended pregnancy compared to those in age group between 25-29 [19, 25]. Economic factors also play great role to increase UP rate. Study done in US, in 2008, showed that unintended pregnancy rates among low-income and poor women were more than three and four times the rate for women in the highest income group [1, 26, 27]. In Ethiopia, the rates of current UP in poor families were more [28]. The level of education also plays a part in determining the rate of UP. Birth rates among women with low education are higher than those with secondary or tertiary education [24]. This is similar in several studies which have shown that level of education has also an influence on the rate of UP [19, 24, 28]. A study done in Kenya reported that women with no education had first sexual intercourse three years ear-lier than their counter parts with at least a secondary school education [29]. Similarly, the Ethiopia DHS, 2011 showed that woman’s education increases, their desire to have no more children. For example, 41% of women with no education desire to limit child bearing compared with 32% of women with primary education [8]. Age at marriage was also found to be a significant predictor of unintended pregnancy. The risk of expe-riencing unintended pregnancy among women who got married before age 15 is 1.3 times higher than those women who got married in ages 15- 19. Over all, the probability of unintended pregnancy has de-creased as age at first marriage increased [30]. Women who have autonomy on their own health care de-cision and financial right are less susceptible for UP [25, 31]. A population based study in Southern Ethiopia, in 2011, showed that; women who had no autonomy on their health care were 4.3 times more likely to have unintended pregnancy compared with some autonomy on their health care [30]. Similarly, study in Oromia Region in 2013, showed that, physically violated women by their partners were more likely to unintended pregnancy than their counter parts [19]. And partners disagree with their number of family size also more likely to UP [19]. Previous UP is a risk factor for subsequent UP [24]. Women with increased past history of UP have high probability of current UP [19, 28, 32]. 3. OBJECTIVE 3.1 GENERAL OBJECTIVE  To assess the magnitude and factors associated with unintended pregnancy among pregnant women attending Cheliya woreda government health centers, Oromia region, Ethiopia, 2017. 3.2 SPECIFIC OBJECTIVES  To assess the magnitude of unintended pregnancy among pregnant women.  To identify factors associated with unintended pregnancy among pregnant women. 4. METHODS AND MATERIALS 4.1 STUDY AREA The study was conducted in Cheliya woreda, Oromia regional state, which is located 178km to the Western part of Addis Ababa, the capital city of Ethiopia and 65km from zonal capital Ambo town. This district is bounded by Liban Jawi woreda to the East, Ilu Galan woreda to the west, Jibat woreda to the south and Mida Kegn woreda to the northern part. The woreda has 105,818 total populations from which 52,858 are males and 52,960 are females living in twenty kebele administrations. Two of the kebeles are urban and the rest are rural. The expected women of childbearing age and pregnant women are 23,417 and 3,672 respectively. The woreda has one primary hospital, four health centers, eighteen health posts, nine private clinics, four drug stores and one rural drug vender which provide health services for the community. The health service coverage of the woreda is 95%. Almost all health institutions provide preventive and curative health services. All government health facilities are providing ANC, Delivery and Family planning services for the needy populations and the previous year coverage of these services are 84%, 66% and 49% respectively. 4.2 STUDY DESIGN AND PERIOD A facility based cross-sectional study was conducted from March to May 2017, at four public health centers in Cheliya woreda, Oromia, Ethiopia. 4.3 SOURCE POPULATION All pregnant women who live in Cheliya woreda 4.4 STUDY POPULATION Pregnant women who were attending antenatal care (ANC) during the study period were included in the study . 4.5 INCLUSION AND EXCLUSION CRITERIA 4.5.1 Inclusion Criteria All pregnant women who were attending antenatal care at public health centers. 4.5.2 Exclusion Criteria Unable to communicate:-Women who are seriously ill at the time of data collection or woman who don’t hear or speak and mentally disabled was excluded. 4.6 SAMPLE SIZE DETERMINATION Sample size was calculated using the formula for single proportion by considering the proportion of un-intended pregnancy taken from EDHS 2011 which is 29% (8), and 95% confidence interval was used with a marginal error of 5% and by taking the non-response rate as 10% due to sensitivity of the issue. n = ((Zα/2)2P(1-p)), d2 Where: n=Sample size Zα/2 for CI of 95% = 1.96, P = 29% of prevalence of unintended pregnancy taken from EDHS, 2011 d = Desired precision (Margin of error) = 0.05 Since the source population is less than 10,000 finite population correction formula is used (N=3672(Pregnant women who live in the district)). nf= N((Zα/2)2 P(1-p)_______ d2(N-1)+ (Zα/2)2 P(1-p) nf = 3672((1.96)2 x 0.29x 0.71)______________ (0.05)2 x (3672-1) + ((1.96)2 x 0.29 x 0.71 = 291 The non-response rate of 10%, the estimated sample size is 320. 4.7 SAMPLING TECHNIQUES All public health centers found in Cheliya woreda are served as the sampling frame. For each health cen-ter the estimated sample size is calculated as follows:- Table 1: Total number of sample size collected from each health centers of Cheliya Woreda, Oromia, Ethiopia, March to May, 2017 SN Health center Expected number of Pregnant women Sample size required and collected 1 Ale Hula Dabi 1016 88 2 Ale Soyema 700 61 3 Gedo 1043 91 4 Tulu Kosoru 913 80 Woreda 3672 320 Figure 1: Schematic presentation of sampling procedure of selected public health centers in Cheliya Woreda , Ethiopia, March to May, 2017 NB: The shaded boxes are the kebele where Health Centers are located. 4.8 STUDY VARIABLES 4.8.1 Dependent Variables Unintended pregnancy 4.8.2 Independent Variables Age, Educational status, Occupation, Marital status, Gravidity, Parity, Use of contraceptive, Type of contraceptive used, Awareness about contraceptive, Use of emergency contraceptive 4.9 OPERATIONAL DEFINITION Intended pregnancy: – A pregnancy that was desired at the time it occurred or sooner. Unintended pregnancy:- Is either unwanted or miss-timed at the time of conception Miss timed pregnancy:-If a woman did not want to become pregnant at the time of conception, but did want to become pregnant in the future. Unwanted pregnancy:-If a woman did not want to become pregnant at conception or at any time in the future. Parity: – The number of times a women has given birth. Pregnant woman: A woman who is positive in urine pregnancy test. Women autonomy: The ability to decide independently about type of contraceptive use, self-health care, and their income management. 4.10 DATA COLLECTION INSTRUMENT AND PROCEDURE Data was collected by interviewer administered structured questionnaire, composed of socio demographic va-riables, economic factors and reproductive history of pregnant women including awareness and practice of family planning and unintended pregnancy as well as birth and induced abortions. Four Midwifery nurses who are work-ing in the health center were recruited for data collection. They received a one day intensive training. The training was given on how to ask and fill the question, selection criteria of ANC attending pregnant women, and how to approach the mothers. Before the actual data collection days 4.11 DATA QUALITY CONTROL The questionnaire was initially prepared in English and translated in to local language which is Afan Oromo and again back translated to English by another expert to check for its consistencies. And the questionnaire was pre-tested prior to data collection on pregnant women who were attend ANC at Gedo hospital for about16 (5%) of the sample and modifications were done accordingly. Moreover, during data collection, the investigator checked how the data collection process is going on. At the end of data collection, the investigator checked the completeness of filled questionnaires. Every questionnaire was checked before data analysis by the investigator. 4.12 DATA PROCESSING AND ANALYSIS All collected data were checked for completeness; coded and entered in to computer. Summary statistics such as frequency and percentage were computed, table and graphical techniques were used. Data was analyzed manually by using scientific calculator to provide frequencies and percentages for categorical variables and means and standard deviations for numerical variables. Assessment of factors associated with unintended pregnancy among pregnant women and the result was presented using tables, figures and other means of presenting data. 4.13 ETHICAL CONSIDERATIONS Ethical clearance was obtained from the Ethics Review committee of the Haramaya University School of Nursing and Midwifery and letter of permission was also obtained from the Cheliya woreda Administration, Cheliya Wo-reda health Office and health institutions. The study participants were informed of the purpose of the study, their right to participate or refuse to participate in the study was explained. Informed consent was obtained from every respondent; strict confidentiality of information was also maintained through anonymous recording and coding of the questionnaires. 4.14 LIMITATIONS OF THE STUDY Interviewer administrated questionnaire related social desirability bias might not be eliminated, under reporting first unwanted pregnancy, later reported as wanted if the pregnancy has continued. Current pregnant women at-tending antenatal clinic may not be representative to all pregnant women in the district. 4.15. PLAN FOR DISSEMINATION AND UTILIZATION OF RESULTS The final report of the study will be submitted to the Haramaya University School of Nursing and Midwifery. The result will be presented during thesis defense, as a partial fulfillment of the degree of Bachelor Science in Midwi-fery. Moreover, the findings of the study will be disseminated through publication in local and international jour-nals if possible. 5. RESULT 5.1. RESULT SOCIO-DEMOGRAPHIC AND ECONOMIC CHARACTERISTICS A total of 320 pregnant women were responded to the questionnaire with 100% response rate. Majority of the respondents 120(37.5%) were between age 25-29 years. One hundred three (32.2%) were between 20-24 years, fifty two (16.3%) were between 30-34 years, twenty seven (8.4%) were between 35-39 years and eighteen (5.6%) of them were between 15-19 years of age. The median age of the participants was 26.5 years. Among the respon-dents the majority, 280 (87.5%) were married, 26 (8.1%) were single and never married, whereas widowed and divorced respondents were 8(2.5%) and 6(1.9%) respectively. Concerning age at first marriage, 155 (48.4%) of respondents had got married at the age of 20-24 years, 88(27.5%) were 15-19 years, 73 (22.8%) were 25-29 years and 4 (1.3%) were got first marriage at 30-34 year of age, with a median age of 21.9 years. In terms of educational backgrounds, majority of the respondents, 121 (37.8 %) were attend primary school and followed by respondents who were never read and write which is 101 (31.6%) and 65(20.3%) were attend sec-ondary school while only 33(10.3%) of the respondents were graduated from College/University. At about three forth of the respondents, 235 (73.4%) are rural residents while 85(26.6%) of them are urban residents. Concerning the religion, 154 (48.1%) were Protestant, followed by 132 (41.3%) Orthodox and 20(6.3%) were Wakefata while 9 (2.8%) and 5(1.6%) of the respondents were Muslims and Catholic followers respectively. Ethnically almost all of the respondents, 303(94.7%) are Oromo, while only 10(3.1%) and 7(2.2%) are Amhara and Guragie respec-tively. Concerning an occupational status, 224 (70%) were housewives, followed by, 46(14.4%) government employees, and 27(8.4%) were students, 8 (2.5%) were private employed. Concerning the household monthly income, ma-jority of the respondents, 198(61.9%) reported less than 500 ETB monthly income, followed by 83(25.9%) were earning 501-1000 ETB, 19(5.9%) were earning 1001-2000 ETB, while only 14(4.4%) and 6(1.9%) were earning 2001-3000 ETB and, above 3001 ETB monthly income. (See Table 2, Figures 2 and 3 below Table 2.Socio demographic characteristics of pregnant women attending ANC clinic at public health centers in Cheliya district, Oromia region, Ethiopia, March to May, 2017(n=320) Variables Character Frequency Percentage Remark Age (n=320) 15-19 years 18 5.6 Mean Age 26.5Years 20-24 years 103 32.2 25-29 years 120 37.5 30-34 years 52 16.3 35-39 years 27 8.4 Marital status (n=320) Married 280 87.5 Single 26 8.1 Divorced 6 1.9 Widowed 8 2.5 Age at first marriage (n=320) 15-19 years 88 27.5 Mean Age 21.9Years 20-24 years 155 48.4 25-29 years 73 22.8 30-34 years 4 1.3 Educational status (n=320) No formal education 101 31.6 Primary school 121 37.8 Secondary school 65 20.3 College/university 33 10.3 Residence (n=320) Urban 85 26.6 Rural 235 73.4 If Urban duration (n=85) Less than 12 months 17 20.0 Above 12 months 68 80.0 Religion (n=320) Orthodox 132 41.3 Muslim 9 2.8 Catholics 5 1.6 Protestant 154 48.1 Other(Wakefata) 20 6.3 Ethnicity (n=320) Oromo 303 94.7 Amhara 10 3.1 Guragie 7 2.2 Occupation (n=320) Housewife 224 70.0 Student 27 8.4 Government employee 46 14.4 Private employee 8 2.5 Other(Daily laborer) 15 4.7 Household monthly income (n=320) Less than 500 198 61.9 501-1000 Birr 83 25.9 1001-2000 Birr 19 5.9 2001-3000 Birr 14 4.4 Above 3001 Birr 6 1.9 Figure 2: Age of the study participants in Cheliya Woreda, Oromia region, Ethiopia, May 2017 Figure 3: Household Monthly Income of the study participants, Cheliya woreda, Oromia region, Ethiopia, May 2017 5.2. REPRODUCTIVE HISTORY OF THE RESPONDENTS The following table shows the previous intensions of the respondents about their reproductive histories. Majority of the respondents, 206(64.4%) were experienced previous pregnancy and 114(35.6%) of them were become pregnant for the first time. Among the respondents with history of previous pregnancy, 90(43.7%) of them had 1-2 pregnancy, 81(39.3%) had 3-4 pregnancy and 35(17%) of them had greater or equal to 5 pregnancy history. Majority of the respondents with history of previous pregnancy, 133(64.6%) had 1-2 alive children. the rest of them, 49(23.8%) nulliparous and 24(11.7%) had greater or equal to 3 alive children. About 68(33%) of the res-pondents were experienced previous abortion history. Almost all respondents ever experienced abortion, 66(97.1) of it was only one times and 2(2.9%) was two times from which 44(64.7%) was induced and the rest, 24 35(35.3%) was spontaneous. Seventy two (35.0%) of the respondents experienced previous unintended pregnancy from which 40(55.6%) was taken place within the last three years. Thirty one (43.1%) the previous unintended pregnancy was continued even mistimed and/or unwanted and 39(54.2%) of it was attempted to stop pregnancy and succeeded, but 2(2.8%) of the pregnancy was continued even attempted to stop it. Majority of the respon-dents need to have any more child/children in the future but only 29(9.1%) of them didn’t. Among the current pregnant women attended ANC clinic, 72(22.5%) them mentioned that they wanted their current pregnancies later (Mistimed) and 47 (14.7%) of them reported that they did not want their current pregnancies at all (Unwanted). When summing up these two, 119(37.2%) of respondents reported their current pregnancies were unintended (that is, mistimed or unwanted pregnancy). (See table 3 and Figure 4 below) Table 3: Reproductive History of pregnant women’s attending ANC clinic public health centers in Cheliya wore-da, Oromia region, Ethiopia, May, 2017 Variables Character Frequency Percentage Past pregnancy history (n=320) Yes 206 64.4 No 114 35.6 No. of previous pregnancy (n=206) 1-2 pregnancy 90 43.7 3-4 pregnancy 81 39.3 > 5pregnancy 35 17.0 Parity category (n=206) Nulliparous 49 23.8 Times 133 64.6 >3 times 24 11.7 Previous history of abortion (n=206) Yes 68 33.0 No 138 67.0 No. of previous abortions (n=68) 1 66 97.1 2 2 2.9 3 0 0.0 >4 0 0.0 Previous abortions type (n=68) Induced 44 64.7 Spontaneous 24 35.3 History of UP (n=206) Yes 72 35.0 No 134 65.0 Not sure 0 0.0 Previous UP time (n=72) Within last three years 40 55.6 Before three years ago 32 44.4 Frequency of previous UP within the last three years (n=40) 1-2 times 39 97.5 3-4 times 1 2.5 Previous UP action (n=72) Nothing the UP continue 31 43.1 Attempt to stop pregnancy but failed 2 2.8 Attempted to stop pregnancy & succeeded 39 54.2 Need to have any more child/children in the future? (n=320) Yes 291 90.9 No 29 9.1 Yes, this current pregnancy is at the right time (n=320) Yes 248 77.5 No 72 22.5 No, not to have any child /children/ in the future (n=320) Yes 47 14.7 No 273 85.3 Is the current pregnancy planned (n=320) Yes 201 62.8 No 119 37.2 Type of UP (n=320) Mistimed 72 22.5 Unwanted 47 14.7 Figure 4: Reproductive History of pregnant women attending ANC clinic in Cheliya woreda, Oromia region, Ethiopia, May 2017 5.3 FAMILY PLANNING HISTORY OF PREGNANT WOMEN ATTENDING ANTENATAL CLINIC As indicated in Table 4 below majority of the respondents, 309(96.6%) heard of modern contraceptives. They had got source of information as follows. About 203(65.7%) of them from Radio, 79 (25.6%) from Television, 224 (72.5%) from their friends and 245 (79.3%) of them had got information from health facilities. Majority of the study participants heard about modern contraceptive from more than one sources of information. Regarding the awareness on family planning, Injectables and Pills were the most familiar methods known by participants as 309 (100%) and 307(99.4%), respectively followed by Implant for 203(65.7%) and IUCD 130(42.1%). Although ma-jority of the respondents were aware of more than one contraceptive methods, few numbers of them didn’t aware of Condoms 17(5.5%), Emergency contraceptives 11(3.6%) and Calendar methods 4(1.3%). Regarding the utili-zation of contraceptive methods, 225(63.4%) of the study participants had ever used any type of contraceptives. About 205(64.1%) of the respondents were used contraceptives to delay or avoid this current pregnancy. The widely used contraceptives were Injectables 107(52.2%) and Implants 68(33.2%). Even Pills was popularly known by majority of the respondents, they didn’t prefer to use it since the high rate of forgetting to take as in-structed. About 187(91.2%) of the study participants were reported that they had taken their contraceptive me-thods as instructed. (See Table 4 below) Table 4.Awareness and source of information about modern FP methods among ANC attending women in Cheliya district health centers, Oromia region, Ethiopia, March to May 2017 Variables Character Frequency Percentage Have you heard about FP (n=320) Yes 309 96.6 No 11 3.4 Source of information on Radio (n=309) Yes 203 65.7 No 106 34.3 Source of information on TV (n=309) Yes 79 25.6 No 230 74.4 Source of information on Friends (n=309) Yes 224 72.5 No 85 27.5 Source of information on Health facilities (n=309) Yes 245 79.3 No 64 20.7 Which modern contraceptive methods do you aware -pills (n=309) Yes 307 99.4 No 2 0.6 Which modern contraceptive methods do you aware- Condom (n=309) Yes 17 5.5 No 292 94.5 Which modern contraceptive methods do you aware -Injectables (n=309) Yes 309 100.0 No 0 0.0 Which modern contraceptive methods do you aware -IUCD (n=309) Yes 130 42.1 No 179 57.9 Which modern contraceptive methods do you aware- Implant (n=309) Yes 203 65.7 No 106 34.3 Which modern contraceptive methods do you aware- Calendar (n=309) Yes 4 1.3 No 305 98.7 Which modern contraceptive methods do you aware -EC (n=309) Yes 11 3.6 No 298 96.4 Ever used any type of contraceptives (n=320) Yes 225 63.4 No 95 36.6 Attempt to delay or avoid current pregnancy (n=320) Yes 205 64.1 No 115 35.9 Method ever used (n=205) Pills 16 7.8 Injectables 107 52.2 IUCD 14 6.8 Implants 68 33.2 Methods used appropriately as instructed (n=205) Yes 187 91.2 No 13 6.3 Not sure 5 2.4 5.4 REASONS OF UNINTENDED PREGNANCY The following table shows the reason of Unintended Pregnancy among currently pregnant women attending ANC clinic. The major reason of unintended pregnancy was don’t have enough money to take care of the baby 63(52.9%) followed by 26(21.8%) were since in school, 12(10.1%) not in a marriage, 7(5.9%) had short gap from previous pregnancy, 5(4.2%) were encounter lack of support (objection) from their partner, 4 (3.4%) were di-vorced and 2(1.7%) of them were raped. Majority of the reason not using contraceptive to prevent unintended pregnancy were fear of side effects 36(37.9%) followed by forgetting to take at right time 25(26.3%) , lack of awareness 11(11.6%), religion and moral reason 7(7.4%) , lack of contraceptive of their choice 6(6.3%), method failure which accounts 5(5.3%), thought they were too young to attend family planning 5 (5.3%). Only 24(7.5%) of the study participants were aware of emergency contraceptives. Concerning the women’s Autonomy, 116 (36.3%) of the respondents had autonomy on their family planning decision 199 (62.2%) decided with their hus-band jointly and 5(1.6%) were husband/partner. Decision in autonomy of income management, 108(33.8%) were women and 212(66.3%) were women and their husband jointly. Regarding spousal communication, 190(59.4%) discussed their spousal on family planning methods. (See Table 5, Figures 5 and 6 below). Table 5.Reasons of unintended pregnancy among women’s attending ANC clinic public health centers in Cheliya woreda, Oromia region, February to May, 2017 Variables Character Frequency Percentage Reason of unintended pregnancy (n=119) Since in school 26 21.8 Don’t have enough money to take care of the baby 63 52.9 Raped 2 1.7 Divorced 4 3.4 Not married 12 10.1 Short gap on between previous pregnancy 7 5.9 Not supported by partner 5 4.2 I don’t like pregnancy at all 0 0.0 Other (mention) 0 0.0 Reason of not using contraceptives (n=95) Too young to attend FP clinics 5 5.3 No awareness on contraceptives 11 11.6 Contraceptive not available 6 6.3 Religious and moral reasons 7 7.4 Method failure 5 5.3 Fear of side effect 36 37.9 Forget it 25 26.3 Emergency contraceptives awareness (n=320) Yes 24 7.5 No 296 92.5 Emergency contraceptives awareness-methods (n=24) Emergency contraceptive pills Yes 24 100.0 No 0 0.0 IUCD Yes 2 8.3 No 22 91.7 Autonomy of women health care (n=320) She 116 36.3 Her husband/partner 5 1.6 She and her husband/partner jointly 199 62.2 Autonomy of women in deciding the contraception method used. (n=320) She 110 34.4 Her husband/partner 5 1.6 She and her husband/partner jointly 189 59.1 Other(Health professionals) 16 5.0 Autonomy of women in deciding the utilization of income the household earns. (n=320) She 108 33.8 Her husband/partner 212 66.3 Spousal communication on fami-ly planning (n=320) Yes 190 59.4 No 130 40.6 Figure 5: Reasons of Unintended Pregnancy among Pregnant Women attending ANC clinic in Cheliya Woreda public health centers, Oromia, Ethiopia, March to May 2017 Figure 6: Reasons of not using Family planning methods among Pregnant Women attending ANC clinic in Che-liya Woreda public health centers, Oromia, Ethiopia, March to May 2017 5.5 CHI-SQUARE TEST FOR FACTORS ASSOCIATED WITH UNINTENDED PREGNANCY 5.5.1. CHI-SQUARE TEST FOR SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PREGNANT WOMEN As indicated in the following table; Age, marital status, age at first marriage, educational background and occupa-tion of the study participants were significantly associated with unintended pregnancy while residence and house-hold monthly income were not a factor for their current pregnancy was said to be Unintended.(See Table 6 below) Table 6: Chi-square Test Socio-demographic characteristics of pregnant women’s attending ANC clinic public health centers in Cheliya woreda, Oromia region, Ethiopia, May, 2017 Variables Character Frequency History of current pregnancy Intended Unintended (95%CI) X2 calculated X2 tabulated Age (n=320) 15-19 years 18 1 17 26.32 9.488, df=4 20-24 years 103 69 34 25-29 years 120 79 41 30-34 years 52 36 16 35-39 years 27 16 11 Marital status (n=320) Married 280 198 82 60.99 9.488, df=3 Single 26 2 24 Divorced 6 0 6 Widowed 8 1 7 Age at first marriage (n=320) 15-19 years 88 30 58 45.2 7.815, df=3 20-24 years 155 109 46 25-29 years 73 59 14 30-34 years 4 3 1 Educational status (n=320) No formal education 101 53 48 14.269 7.815, df=3 Primary school 121 91 30 Secondary school 65 36 29 College/university 33 21 12 Residence (n=320) Urban 85 53 32 0.011 3.841, df=1 Rural 235 149 87 Occupation (n=320) Housewife 224 160 64 60.573 9.488, df=4 Student 27 1 26 Government employee 46 32 14 Private employee 8 5 3 Other 15 3 12 Household monthly income (n=320) Less than 500 198 115 83 8.602 9.488, df=4 501-1000 Birr 83 58 27 1001-2000 Birr 19 13 6 2001-3000 Birr 14 11 3 Above 3001 Birr 6 6 0 5.5.2. CHI-SQUARE TEST FOR REPRODUCTIVE HISTORY OF PREGNANT WOMEN As indicated in the following table, gravidity of the study participants was significantly associated with the preva-lence of unintended while previous history of pregnancy and parity of the study participants were not be consi-dered as an associated factor. (See table 7 below) Table 7: Chi-square Test for Reproductive History of pregnant women’s attending ANC clinic public health cen-ters in Cheliya woreda, Oromia region, Ethiopia, May, 2017 Variables Character Frequency History of current pregnancy Intended Unintended (95%CI) X2 calculated X2 tabulated Past pregnancy history (n=320) Yes 206 133 73 0.760 3.841 No 114 68 46 Gravidity (n=206) 1-2 pregnancy 90 70 20 16.695 5.991 3-4 pregnancy 81 49 32 > 5pregnancy 35 14 21 Parity category (n=206) Nulliparous 49 32 17 5.035 5.991 1-2 times 133 75 58 >3 times 24 9 15 5.5.3. CHI-SQUARE TEST ON AWARENESS AND SOURCE OF INFORMATION ABOUT MODERN FAMILY PLAN-NING METHODS Regarding the of an awareness and source of information about modern family planning methods, history of con-traceptive use and methods ever used were highly associated with the prevalence of the current pregnancy to be said unintended. (See Table 8 below) Table 8: Chi-square Test on Awareness and source of information about modern FP methods among ANC attending women in Cheliya district health centers, Oromia region, Ethiopia, March to May 2017 Variables Character Frequency History of current pregnancy Intended Unintended (95%CI) X2 calculated X2 tabulated Awareness about family planning (n=320) Yes 309 199 110 9.669 3.841, df=1 No 11 2 9 Ever used Contraceptives (n=320) Yes 225 156 69 13.778 3.841, df=1 No 95 45 50 Methods ever used (n=225) Pills 16 6 10 24.639 7.815, df=3 Injectables 107 83 24 IUCD 34 32 2 Implants 68 59 9 5.5.4. CHI-SQUARE TEST FOR REASONS OF UNINTENDED PREGNANCY As indicate in the following table, Reasons for not using contraceptives, Autonomy of women in health care and deciding the contraception method used and spousal communication on family planning were among the factors associated with unintended pregnancy. (See table 9 below) Table 9: Chi-square Test regarding Reasons of Unintended Pregnancy regarding Autonomy of women among women’s attending ANC clinic public health centers in Cheliya woreda, Oromia region, February to May, 2017 Variables Fre-quency History of current pregnancy Intended Unintended (95%CI) X2 calculated X2 tabulated Reasons of not using contracep-tives (n=95) Too young to attend FP clinics 5 1 4 13.768 12.592, df=6 No awareness on contraceptives 11 2 9 Contraceptive not available 6 2 4 Religious and moral reasons 7 4 3 Method failure 5 1 4 Fear of side effect 36 24 12 Forget it 25 11 14 Autonomy of women health care (n=320) She 116 82 34 7.855 5.991, df=2 Her husband/partner 5 1 4 She and her husband/partner jointly 199 118 81 Autonomy of women in decid-ing the contraception method used. (n=320) She 110 70 30 12.018 7.815, df=3 Her husband/partner 5 1 4 She and her husband/partner jointly 189 106 83 Other(Health professionals) 16 14 2 Spousal commu-nication on family planning (n=320) Yes 190 128 62 4.328 3.841, df=1 No 130 73 57 6. DISCUSSION This study was conducted with the main objective of assessing the magnitude and factors associated with unin-tended pregnancy based on a sample of 320 pregnant women attending ANC clinic at four government health centers in Cheliya woreda. This study showed that 37.2%( 95% CI, 5% margin of error) of the study participants were reported that their current pregnancy was unintended and among all unintended pregnancies, 22.5% of women wanted a child if it had been after some times or years in the future and 14.7% of women reported that their current pregnancy was totally unwanted. Even though, there is an introduction of modern family planning and increase information and awareness on family planning; many studies including this current study showed that unintended pregnancy is common problem in Ethiopia [8, 9, 13, 18, 19, 28, 30, 34 ]. In the Chi-square test, women age, marital status, education, occupation, gravidity, Awareness about family planning and methods ever used, Autonomy of women in health care and deciding the contraception method used and spousal communica-tion on family planning were significantly associated with unintended pregnancy. This study result is slightly smaller than the facility based study done in Addis Ababa with prevalence of 38.7% [17]. But it is higher than the facility based study done in Bahir Dar 26% [18] and EDHS 2011, The prevalence of unintended pregnancy which was 29% [8].This study is slightly comparable with other community based study done in West Wollega with prevalence of 36.5% [19], and figuratively higher in study done at Hossana town in 2011 with the prevalence of unintended pregnancy was 34% [20]. In contrast the study conducted in Damote Gale Woreda in Southern Ethi-opia in 2011 showed that the prevalence of unintended pregnancy among married women was 42.2% [30], which was much higher than the current study. This variation was due to the difference in socio-demographic characte-ristic, awareness about modern contraceptives, history of contraceptive use and related reasons if they didn’t ever used it. Several studies showed that as the education level increases the rate of unintended pregnancy decrease and reduc-es the chance of discontinuity of contraceptive. [8, 19, 24, 28-30]. In the current study, women’s educational sta-tus had a significant association in experiencing unintended pregnancy. Even little advance in education improves women’s decision making power leading to avoidance of unintended pregnancy [30]. Occupational status of the study participants has a significant influence on the prevalence of un-intended pregnancy. The Chi-square test calculation among pregnant women attending ANC clinic was 60.573 (at 95% CI, 1 degree of freedom). Similar to the study done by Guttmacher Institute in 2010 Which is the proportion of married women using modern contraceptives in the developing world as a whole greatly increased and reduced the experience of unintended pregnancy[24]. This study result supports the hypothesis that if a woman has higher awareness of methods, she is more likely to be aware of the benefits of those method which in turn will motivate her to use the methods and less likely to have unintended pregnancy. The similar result was found in the result done at Ganji Woreda, West Wollega, Oromia Region, Ethiopia [19]. In contrast with other studies, this study showed that there was no significant association between place of residence, household monthly income, past pregnancy & parity history and the prevalence of unintended pregnancy. This study result may contradict with other studies ever done on the correlates of unintended pregnancy. However, judging by results of the Chi-square calculation, it is difficult to entirely dismiss the influence of residence place, household monthly income, past pregnancy and parity history on the prevalence of unintended pregnancy among reproductive age group women. 7. CONCLUSION According to this study, women age, marital status, education, occupation, gravidity, Awareness about family planning and methods ever used, Autonomy of women in health care and deciding the contraception method used and spousal communication on family planning was significantly associated with unintended pregnancy. 8. RECOMMENDATIONS  Based on the findings of this study, the following recommendations were forwarded. I. Policy and Program Level  Federal MOH should plan and work hard on the prevention of unintended pregnancy II. Health Worker  All health workers and health extension workers should work hard to address all reproductive age women in educating them and serve them as per the national reproductive health service package. III. NGO and Other Stakeholders  The woreda health office should work hard with influential stakeholders, community leaders, religious leaders, CBOs, other influential persons and woreda women’s& children’s affairs office to decrease the prevalence of unintended pregnancy and rumors related to the services intended to prevent unintended pregnancy. IV. Researcher  Further qualitative study is recommended to study in-depth the prevalence of unintended pregnancy and asso-ciated factors.

1. Introduction1.1. BackgroundFamily planning (FP) saves lives of women and children and improves the quality of life for all. It isone of the best investments that can be made to ensure the health and well-being of women, children,and communities (1) by decreasing maternal mortality and improves women’s health throughpreventing unwanted and high-risk pregnancies and reducing the need for unsafe abortions. Somecontraceptives also improve women’s health by reducing the likelihood of disease transmission andprotecting against certain cancers and health problems(2).One principal determinant of uptake and continued utilization of family planning services is overallclient satisfaction with those services(3). It is one of the factors that influences the use of FP and otherreproductive health services (4) . Women who reported having received contraceptive counseling weremore satisfied with their method.(5)World Health Organization (WHO) recommend to offer evidence-based, comprehensive contraceptiveinformation, education and counselling to ensure informed choice for all women who need theservices(6)According to Turkish Demographic health survey (DHS) 2013, 33% of all women use a moderncontraceptive method(7). United nation population fund agency (UNFPA) DHS analysis from 24countries in 2016,showed contraceptive prevalence and side effect counseling in Honduras, Senegal,Kenya and Ethiopia was 64& 49, 22&81, 53&60 and 27&33 respectively(8) which is low especiallyin EthiopiaTo increase modern contraceptive prevalence rate and decrease discontinuation rate, contraceptivecounseling is crucial. Contraceptive counseling is a type of client-provider interaction that involvestwo-way communication between a health care staff member and a client for the purpose ofconfirming or facilitating informed decision by the client, or helping the client address problems orconcerns (9)i. It also helps clients to obtain the information they need to use contraceptive methodscorrectly (10) and thereby decrease the likelihood that they will discontinue use of the method (11)and decrease unmet need of family planning.2Effective contraceptive counseling is one of the cornerstones for increasing family planningacceptance. The best decisions about family planning are those that people make for themselves basedon accurate information and a range of contraceptive options. Otherwise they can either deny theservice or discontinue the method if they are not properly counseled on minor side effects and mythsrelated to the method. It empowers people to exercise their right to good quality family planning care(12).Providing quality education, counseling and medical services related to family planning can lead toimproved reproductive health outcomes (13). Counseling clients properly during family planningservices was found to improve both long term outcomes, such as increased birth spacing and continueduse of modern contraception methods, as well as short term outcomes such as increased knowledgeand satisfaction with family planning services (14).These all facts suggest the need to reorient and refocus the contraceptive counseling to offer a tailoredapproach to meet individual needs of clients. Therefore, the study intended to examine clientsatisfaction with contraceptive counseling and client provider -interactions as related to familyplanning services and bring into focus the relevance of counseling and effective human relations tofamily planning in public health facilities in Asella town.1.2 .Statements of the problemsUnintended pregnancies and unplanned births can have serious health, economic, and socialconsequences for women and their families. One immediate outcome of unintended pregnancies—induced abortion—is unsafe in many countries .In these countries, abortion often damages women’shealth and sometimes results in their death (15). According to WHO 2010 report, nearly 99% abortiondeaths were caused by unsafe abortion secondary to unintended pregnancy(16)Unintended pregnancy is experienced by many women and remained high in all parts of the world. InUnited states for example, approximately 50% of pregnancies are unintended (17). A cross sectionalstudy conducted in Kenya in 2013 showed 24% of all the women had unintended pregnancy (18).According to Ethiopian demographic health survey (EDHS) 2016, 17% of pregnancies were mistimed(19). 3Research by Teshale Mulatu in 2014 also indicate, 50% respondents had had unwanted pregnancy andinduced abortion at some point in their livesUses of FP which is the best intervention to reduce rates ofunintended pregnancy is enhanced by contraceptive counseling.Numerous professional associations (including the American College of Obstetricians andGynecologists, American Academy of Family Physicians, and American Academy of Pediatrics)recommend counseling as part of clients service for preventing unplanned pregnancy (20).Helping women to achieve their reproductive goals, including assisting them in choosing how toprevent undesired pregnancies (contraceptive counseling), is essential to optimize the health of womenand their families (17). The role of FP counselling is to support a woman and her partner in choosingthe contraceptive that best suits them and to support them in solving any problems that may arise withthe selected method.Improving and optimizing the quality of contraceptive counseling is one approach to help women ofall race/ethnicities and socioeconomic status to improve their ability to plan pregnancies and preventthese unintended pregnancy and maternal death. In line with this, improving the quality ofcontraceptive counseling is key strategy to prevent unintended pregnancy(21).However nowadays, unintended pregnancy is not only a major health problem, but are also a greatsocial and financial burden on societies and countries. There are about 75 million unwantedpregnancies per year according to WHO statistics. When abortions were included, unintendedpregnancies increased to 49% of all pregnancies. Counseling prior contraception is a mandatory or amust to prevent these unintended pregnancies and their related risks. Unfortunately counseling is adeficient process in third world countries and sometimes not present at all. (22)Contraceptive counseling can also help in reducing unmet need of contraceptive utilization. Studydone in India in 2015 reveal receiving contraceptive counseling led to 3.1 % reduction in unmet need(12).According to research conducted in USA in 2016 entitled the role of contraceptive attributes inwomen’s contraceptive decision making, 60% of respondents discontinued contraceptive methodbecause of the side effect and it clearly play an important role in satisfaction and continuation. 4So, anticipatory counseling about method side effects can help increase the likelihood that thecharacteristics of the method and the woman’s preferences are aligned and minimize contraceptivediscontinuation (23).Causes and consequences of contraceptive discontinuation evidenced from 60 demographic and healthsurveys at three months after discontinuation reveal, 40% or more women were at risk of conception:in Egypt (40%), Ethiopia (42%), Kenya (51%), Malawi (73%), United Republic of Tanzania (56%)and Zimbabwe (47%). These high rates of discontinuation stress the need to improve service quality,particularly counselling(24).Study conducted in Egypt showed that family planning consultations in are predominantly physiciancentered and that client participation was to a large extent passive, mostly serving the doctor’s agenda,which is gathering information about the client(25)Although contraceptive counseling is acknowledged to be cornerstones for increasing acceptance anduse of family planning and addressing the unmet need, much has not been written about it by region orstate, less is known in our country specially the contraceptive counseling is not clearly known orevidenced by research still now as far as my search is concerned.Considering this gap, this study aims at identifying what client satisfaction with contraceptivecounseling and factors associated with it looks like in women attending family planning clinic inAsella public health institutions, 2018.2. Literature reviewFamily planning represents an urgent global health priority for the twenty-first century. It helpswomen and men make informed decisions about the number and spacing of their children, which makenewborn, child, maternal, and family healthy. The economic well-being of families, communities, andeven countries is improved by access and uses of FP services(26).Quality contraceptive counseling is the key interventions to promote family planning and helps toimprove the quality of care and reduce maternal deaths (12).5It is an important principle in the delivery of FP services(11) for confirming or facilitating a decisionby the client, helping the client address problems or concerns(9),improve patient outcomes(27),increase patient satisfaction, decrease contraceptive discontinuation rate and increase contraceptiveacceptance rate. It is one of the fundamental right of human being (the right to information andeducation) (28).2.1. Prevalence of contraceptive counselingContraceptive counseling is not provided for most women worldwide. Its quality and content greatlyvaries from country to country. Counseling is very important before women initiate drug for chronicdiseases. More than 45% of all Americans have chronic disease, and almost all women anticipate anunexpected illness that requires medication. These medications can be teratogenic which can affect thenewborn. This indicates as there is gap in contraceptive counseling to prevent this congenitalabnormality by using different contraceptive methods (29)According to evidence from 24 countries by UNFPA in 2016, recent changes in current use ofcontraception have not been accompanied by corresponding increases in contraceptive counselingregarding side effects and availability of other methods at the time of initiating use of moderncontraception. Thus, two of five women that started using any of the methods during the five yearsbefore the study did not receive counseling about possible side effects from the selected method, andnearly 50% did not hear about side effects or other methods (8).During contraceptive counseling, health care provider should stress on benefits of the contraceptivethan its adverse effects. But According to research in San Francisco Bay Area in 2009–2012, providersmore often discussed potential adverse effects of Intra uterine device (IUD ) use than benefits;counseling often was non interactive and did not address how patient preferences related tocharacteristics of IUDs. Counseling was frequently fragmented by the need for return visits or referralelsewhere for insertion (30). Similarly, according to qualitative descriptive study done in Pakistan in2013, IUCD was not discussed during participant’s visits, and they often had to request theinformationContraceptive counseling should be start from most effective contraceptive method and proceed to lesseffective so that the woman is encouraged to use the most effective contraceptive methods. 6Research conducted in Texas in 2014 show rates of postpartum counseling are higher, but even amongwomen who did report counseling, discussion of LARC, sterilization and vasectomy was infrequent,and very few women reported feeling encouraged to use these highly effective methods(20)A cross sectional study conducted in Northern Iran, Urmia in 2008 revealed 51.3% of participantscompletely satisfied by easiness and understandability of consultation from health care provider andonly 21.7% of participants was completely satisfied by the use of counseling tool duringconsultation(31)A result of research conducted in Ibrid Jordan in 2013 showed, 87% of respondents reported that theprovider had helped them choose a method and 70% of respondents chose a method that day. Of thosewho chose a method, 81% said that the provider had discussed how to manage the side effectsassociated with that method (32). Another research conducted in Australia in 2017 reported, doctorsdid not fully discuss the potential side-effects of contraceptives and they were unsupportive orjudgmental (33). According to research done in Egypt in 2016 ,none of the nurses introducingthemselves to clients (34).Ideally all women should be informed everything about the contraceptivethey use during counseling session. But UNFPA research analysis in 2016 from 24 countries reportedproportion of women counseled about side effects and other available contraceptive methods were25% and 80% in Ethiopia and Zambia respectively (8).Similarly in EDHS 2016, only 30% of all women currently using modern contraceptives werecounseled at the time they started the current episode of method use about the method’s side effects,what to do if they experience side effects, and other available methods(19).In addition research donein wonji hospital, Ethiopia in 2017 showed, 55% of FP users do not got the service with information(35)According to client and facility level determinants of quality of care in family planning services inEthiopia in 2017 research report, information was not provided about how to use the contraceptivemethod for 26.7% of respondents and information about the contraceptive method’s potential sideeffects was provided for only 53.6% of respondents (36).72.2. Factors associated with contraceptive counselling2.2.1. Socio demographic and client related FactorsAccording to research done in university of Pittsburgh Medical Center in 2010, the most commonperceived patient barrier for contraceptive counseling was patient preference for particularcontraceptive methods (37)Result of assessing women’s satisfaction with family planning services in Mozambique in 2016showed, user had the opportunity to ask questions in only 45.2%(4).Research conducted in University of Michigan has also shown that, women ages 40–44 were lesslikely than younger women to receive counseling and to use contraception if at risk of unintendedpregnancy (38)If a woman, preferably with her partner, is able to make an informed choice, she is more likely to besatisfied with the method chosen and continue its use(39)2.2.2. Provider related factorsResearch done in 2008 in Uganda showed almost all providers felt that the quality of care they couldoffer was compromised because they were overloaded with work, and managers confirmed someclinics were understaffed. Individual providers take on multiple responsibilities in addition to FPservices. These all compromise contraceptive counseling (40)Nurse working in a primary care facility in Kaduna, Nigeria in 2014 justified her limited counselingtime because of the number of patients she must attend to in one day and she did not talk much aboutimplants because she did not know much about it and how to insert it. She need in-service training(41)According to research in Bangladesh in 2014, though paramedics interviewed in FP clinics knew thebasic principles of counselling, their interpersonal skills were inconsistent and often poor.There remains a non-communicative, hierarchical attitude between clients and paramedics, which maycontribute to poor understanding of potential side effects and incorrect method(42).Qualitative descriptive study done in Pakistan in 2013 showed, health providers were not motivatedand were reluctant to provide the IUCDs because of inadequate counseling skills, lack of competence(43).8Results of qualitative Analysis approaches to contraceptive counseling in Texas showed, shareddecision-making approach counseling technique was the least common approach overall (accountingfor 22% of visits), but patients expressed a preference .In the same study the most common approach(used in 48% of visits) in counseling was foreclosed approach by assuming patient had already madea decision (44).According to research done in University of Colorado in 2014, the majority of faculty and residentsreported that they perceive inadequate time (75.3%) and inadequate knowledge (74.0%) as reasons fornot performing contraceptive counseling (45).According to research in Bahirdar in 2013 ,only 24-37% of respondents were informed about theavailable family planning methods and their utilization(46).Research done in wonji hospital, Ethiopia, showed, 55% of family planning users do not got theservice with information (35).According to assessment of Family Planning Services in Kenya in 2009,the most notable finding isthat only 15% of the providers used visual aids during the consultation and only 12% of staff took inservice training in any family planning topic in past year(47).2.2.3 Facility relatedAccording to research entitled “Counseling and Client Provider-Interactions as Related To FamilyPlanning Services in Nigeria in 2015, 41.18% of the facilities do not have visual and auditoryspace.61.11% do not have good client respectful orientation .Using the language the clients understandwas observed in only 23.53% of family planning centers. Interactive communication between clientsand providers was observed in 42.94% of the centers(48).Research conducted in Ibrid Jordan in 2013 showed ,family planning wall chart was noticed by 85% ofall interviewed women, 96% reported that it was useful (32).According to qualitative descriptive study conducted in Pakistan in 2013, facility had impropersupporting infrastructure(43).A cross sectional study conducted in Northern Iran, Urmia in 2008 revealed , only 21.7% ofparticipants was completely satisfied by the use of counseling tool during consultation(31).92010 Kenyan service provision assessment key finding reveal, only 25% of family planning facilitieshave all the items necessary for counselling(49)A Qualitative Study conducted in Rwanda in 2015 showed limited method choice, and long waitingtimes but short consultations at facilities were barriers to accessing high-quality services and werecommon complaints of respondents(50)2.3. Significance of the studyThere is inadequate study conducted on client satisfaction with contraceptive counseling in Ethiopia ingeneral and Asella town in particular as far as my search is concerned. Thus, this study aims to answerwhether women are satisfied with the contraceptive counseling they receive and what are theindividual correlates of satisfaction with the method. It also used as input for planning andimplementation of FP service in Asella town. Finally, this research finding will be used for universitystudents and health professionals as a reference to build on or generate new knowledge in the area ofcontraceptive counseling which ultimately improves service quality and coverage.2.4. Conceptual frameworkBased on reviewed literatures, client satisfaction with contraceptive counseling can be affected bydifferent factors. These factors can be categorized as Provider related, Facility related, Sociodemographic related interpersonal communication related and Client related. The following figure isconstructed based on reviewed literatures and shows the relationship of contraceptive counseling andassociated factors.

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