Rationalization, facilitators, and impediments of fertility transition in Ethiopia: qualitative exploration of the community readiness, willingness, and ability.

Background: High fertility and rapid population growth can threaten human development and increase risks to maternal and child health. The diffusion of the benefits of lower fertility requires readiness to plan, and willingness and ability to adopt and use family planning measures. Objective: This assessment aimed to explore the readiness, willingness, and ability (RWA) among selected Ethiopian communities, and identify the facilitators and impediments of fertility transition. Design: This exploratory phenomenological qualitative study collects data from purposefully selected community members and experts in Addis Ababa, Arbaminch, and Jigjiga. Method: The analysis follows deductive coding and a thematic presentation of findings under the RWA domains. Readiness deals with four themes: (1) the rationalization of the value of children, (2) recognition of the burden of high-risk fertility, (3) readiness to define the ideal number of children, and (4) socio-cultural norms about family size. Willingness contains three themes: (1) the psychosocial legitimacy of contraceptives, (2) the religious legitimacy of contraceptives, and (3) women's power to cope with barriers to family planning. The ability domain contains (1) women's knowledge about contraception and (2) access to and utilization of contraceptives. Results: The communities involved in this study recognized the burden of high-risk fertility behaviors (early-age fertility, and frequent and many births), but they prefer large family sizes. Consequently, they exhibit good family planning willingness and practice for birth spacing but not for birth limitation. Recognizing the socio-economic burden of high-risk fertility, accepting and using contraceptives for the health of mothers and children are possible facilitators of fertility transition. Conversely, the desire for high parity, husbands and religious disapproval of contraceptives, side effects of contraceptives, and limited access to method mix are possible impediments. Conclusion: The RWA to space births are adequately diffused and adopted by the community, but birth limitation is not yet recognized. Beyond promoting birth spacing, Ethiopia's fertility transition requires a shift in societal values from large to small family size. Overcoming barriers to contraceptive use also requires tailored efforts to improve the availability of method mix and involve male and religious leaders.