Experiences and Determinants of Contraceptive Use among On-Street Women in Shashemene Town, West Arsi Zone, Ethiopia

Women living on the streets are vulnerable to various social, psychological, economic, and health related problems. Girls who work and live on the streets are exposed to the street subculture such as smoking, drug, alcohol, substance and sexual abuse, engaging in sexual activities or selling sex for survival that all put them at a higher risk of unintended pregnancies [1]. Homeless women are far more likely to experience violence of all sorts than women in general, ranging from two to four times more likely, depending on the violence type [2]. Researches reveal that women living on the streets are less likely to benefit from basic reproductive health services as living in the poorest segment, delivering and caring their children out of streets life [3]. 90% of maternal deaths could be pre vented with timely medical intervention [4]; therefore, the chances of death decrease considerably if women receive skilled maternal health care during delivery [5]. Being the poorest and marginalized segments of the society, pregnant women and infants living on the streets seem more vulnerable to maternal and child mortality and morbidity. Hence, it is important to assess the reproductive health seeking behavior of street women to understand access and use of antenatal and neonatal health care services.


Introduction
Women living on the streets are vulnerable to various social, psychological, economic, and health related problems. Girls who work and live on the streets are exposed to the street subculture such as smoking, drug, alcohol, substance and sexual abuse, engaging in sexual activities or selling sex for survival that all put them at a higher risk of unintended pregnancies [1]. Homeless women are far more likely to experience violence of all sorts than women in general, ranging from two to four times more likely, depending on the violence type [2]. Researches reveal that women living on the streets are less likely to benefit from basic reproductive health services as living in the poorest segment, delivering and caring their children out of streets life [3]. 90% of maternal deaths could be pre vented with timely medical intervention [4]; therefore, the chances of death decrease considerably if women receive skilled maternal health care during delivery [5]. Being the poorest and marginalized segments of the society, pregnant women and infants living on the streets seem more vulnerable to maternal and child mortality and morbidity. Hence, it is important to assess the reproductive health seeking behavior of street women to understand access and use of antenatal and neonatal health care services.
Homeless women are the most marginalized segments of the society in terms of getting access to modern family planning services.
Although Shashemene has plenty of NGOs working on improving the reproductive health situations of the town's population, their services have always been limited to serving the 'bar ladies', street females, long distance drivers, and people living with HIV/AIDS. The public sector, on the other hand, serves the 'mainstream' society. Provision of family planning service to the homeless women is, therefore, by far the most neglected issue for years. There is a widely held stereotype that these sections of the society do not have a need to the contraceptive methods by the NGOs, the public sector, and the wider society at large. The family planning needs of the target population has not been adequately researched which demands attention. Therefore, the present research attempted to assess the prevalence and determinants of contraceptive methods use among on-street women in the reproductive age ranges living on the streets of Shashemene, West Arsi zone, Oromia, Ethiopia.

Study Design
A cross-sectional study design was used in which the overall processes of data collection, analysis and write-up all were taken place at a point of time between December, 2018 and February, 2019. Both descriptive and analytical research designs were intensively employed in order to effectively answer the proposed research questions. In its descriptive dimension, the research expressed existing realities and facts among the study's participants as revealed by them. On the other hand, the analytical part of the research considered the relationship between dependent and independent variables in order to seek responses for why things happened the way they appeared in the field.
Methods and data sources: Primary data were collected using survey, depth interview, case history, and non-participant observation methods (methodical triangulation). The survey method was used mainly to gather quantifiable data regarding the frequency of cases occurring and their patterns of distribution among the various segments of the study population. For this purpose, quantitative data were collected through a well-prepared interviewer-administered questionnaire. In addition, non-participant observation and case history methods were also used in order to enrich the qualitative data. Furthermore, existing literatures were intensively reviewed to supplement first-hand data sources. In addition, non-participant observation and case history methods were also used in order to enrich the qualitative data. Furthermore, existing literatures were intensively reviewed to supplement first-hand data sources. Data collectors were trained about the objectives and overall purpose of the research were made to be familiar with the data collection instruments and have been guided about how to best approach respondents and collect quality data. First, Shashemene town was purposively selected due to the fact that homeless women prefer more of urban areas expecting better access to livelihood (getting more money by begging from densely populated area) and shelter. The survey purposively targeted homeless women within reproductive age range, including women that were either pregnant or carried one or more babies during the time of data collection. 148 respondents participated in the survey based on availability/judgmental selection criterion. For the in-depth interview and case history methods, data saturation determined the number of women to be participated in the interview. Therefore, sample size has not been predetermined and the researcher stopped as more redundant responses appeared and at a point where no more new data could be discovered.
Accordingly, 15 women were participated. Consequently, data were collected from a total of 163 on-street women in the study area.

Data analysis:
After all sorts of data were collected, data cleaning and organization was undertaken in order to check for completeness. The quantifiable data gathered through intervieweradministered questionnaire were then coded and entered into SPSS version 20 for further processing. Descriptive statistical tools, including frequency tables, Figures and percentages were utilized to present frequencies and differential distribution of cases across the various sub-groups within the survey participants.
Furthermore, inferential statistical techniques such as correlations and multivariate linear regression were used in order to analyse the relationship between the dependent variable and the independent variables. In addition, qualitative data collected through depth interview and case history methods were first transcribed word for word (verbatim) and organized. Following this, themes were searched and identified in the data in order to analyze it against the specific research objectives. Finally, findings were presented in a narrative manner showing patterns in the analysis.

Ethical Considerations
The researcher has obtained ethical approval from the concerned body of Wolaita Sodo University. An informed consent was gained by informing the research participants about the objectives and rationale of undertaking the research. Furthermore, up on collecting data, the names of the research participants have not been written on the interviewer administered questionnaire and other checklists in order to keep their personal identity anonymous.
The researcher further ensured this by not indicating the exact names of any of the respondents. Above all, each respondent was informed about the level of freedom that is provided in case one wants to withdraw from the research.

Operational definitions:
a.
On-street women: women who make a living by begging on street sides, religious centers, and other mass concentration sites as a full time activity, those that have no formal homes instead use these sites as a shelter. In this document, both on-street women and homeless women have been frequently used interchangeably just to convey the same meaning.

b.
Rape: is defined as any act of penile penetration of the vagina or anal by force or by threat of harm, made when the victim/ woman is incapable of giving consent due to drug or intoxication of alcohol, mental illness, physical impairment or any other form disability to defend oneself.  respondents were asked to report how many years they stayed on the street and 50.1% revealed to have stayed for 1-5 years, followed by 24.3% who stayed 6-10 years. Only 3 respondents answered that they have stayed for more than 21 years on the street.

Figure 2.
Data presented in table above furnished us with an interesting insight in that the experience of using family planning methods among the target population in the study area is low which might have emanated from the fact that there is a very low level of awareness regarding the subject. Table 3   The Need to Use Family Planning Methods Findings of depth interview also revealed low level of awareness about contraceptive methods and the experience of using one.
Few assume that family planning exists only in the form of needle injection. Hence, this created a sense of fear that it might be painful.
Many also revealed that they are not currently using contraceptive methods. One factor has been identified to be the higher prevalence

Case
Meseret is a 34 years old adult woman using the street both as a shelter and a means of making a living. She came from Wolaita and had been on the street since her early childhood. She has never had a child nor she ever been pregnant. She used to date a boy from  [6] showed that the use of modern conraceptive among the homeless women in Addis Ababa was good.

Conclusion and Recommendation
Awareness regarding contraceptive methods among on-street women is low in Shashemene town, west Arsi zone, Ethiopia. This low level of awareness is accompanied by the lower experiences of using one or more types of contraceptive methods among the study's population. Furthermore, the problem has been aggravated by the unprecedently high prevalence rate of HIV/AIDS and almost a negligible level of basic literacy among the target groups. Unless immediate remedial action is taken by the concerned governmental and non-governmental organizations, on-street women in Shashemene town will continue with their high fertility rates, making the vicious cycle of poverty to sustain.