Modern contraceptive use among sexually active female adolescent: Trends and determinants insight from National Demographic and health survey

The sexual and reproductive health of young people is a global priority. Access to sexual and reproductive health information and services will determine, the burden of adolescent pregnancies and unwanted pregnancies. Teenage pregnancy that has profound effects on the health and wellbeing of young women across their life course is a burning public health and a demographic challenge in Ethiopia. Contraceptive use allows girls to postpone motherhood and space births. However, little is known about the trends in contraceptive use and its determinant among girls aged 15 to 19 in Ethiopia. Therefore, this study was designed to identify factors associated with modern contraceptive methods use among sexually active adolescent girls in Ethiopia. Four Ethiopian demographic and health survey data were used to examine trends of contraceptive methods use among sexually active adolescent girls. To identify factors associated with contraceptive use, the 2016 Ethiopian demographic and health survey data was used. The data was accessed from the demographic and health survey program data base and data for sexually active adolescent girls were extracted. Data analysis was done using SPSS version 21. Data were weighted for analysis. Descriptive analysis was used to describe independent variables of the study participants. And design effect was considered during analysis. Multivariable logistic regression model was used to identify factors associated with contraceptive use. and Health Surveys , HIV/AIDS: Human immunodeciency virus infection and acquired immune deciency syndrome , IUCD: Intra-Uterine Contraceptive Device, SPSS: Statistical Package for the Social Sciences, STIs: Sexual transmitted infections , TV: Television


Introduction
Adolescents, individuals in the age range 15-19 years, who are central to sustainable development. This age group contributes up 16 per cent of the world's population and is one of the fastest growing cohorts.
Adolescence is a critical phase in life for achieving human potential. It is a time of social and biological transition between childhood and adulthood that entails numerous milestones and opportunities, roles, and responsibilities (1)(2)(3)(4)(5). Given their demography, challenges during life transition and their importance in developmental goals, an explicit attention does not given to adolescent during millennium development goals (6) Though, sustainable development goals recognized adolescents as a previously neglected group who must be addressed. In addition, the importance of adolescent's health was emphasized in the global strategy for women's, children's and adolescent's health (5,7). Also, the 2016 lancet commission report on adolescent repeated the triple dividend of investing on adolescent. The investments will lead to high bene ts that enable adolescents to become healthy adults who are equipped to contribute positive to societies (5,8).
The sexual and reproductive health of young people is a global priority as the reproductive choices made by them have a massive impact on their health, schooling and employment. Access to sexual and reproductive health information and services will determine, the burden of adolescent pregnancies and unwanted pregnancies (3,5,9). In developing regions, about half of all pregnancies among girls aged [15][16][17][18][19] years are estimated to be unintended, and more than half of these unintended pregnancies result in abortion. Worldwide, about 15% unsafe abortions occur among girls under the age of 20 years annually.
Early pregnancy and childbearing typically denote the end of formal education, and restricts opportunities for employment (10). Further, children born to adolescent girls are more likely to have low birth weight (11).
Available evidence suggests that, sexually active unmarried adolescents are not seeking to become pregnant, and married wish not to become pregnant at a young age or wish to delay a second pregnancy (12). All adolescents who want to prevent pregnancy are able to obtain and use modern contraceptives, that they are given their choice of a wide range of methods (13).
Despite having clear needs, adolescents and young adults often fail to access sexual and reproductive health care (5). Effective access and use of modern contraceptives can reduce a substantial number of adolescent girls experience the negative health consequences as a result of not using contraceptives (6).
In Ethiopia teen pregnancy is a burning public health and a demographic challenge. The proportion varies with geographical location, 15% in rural and 5% in urban. Teenage pregnancy has profound effects on the health and wellbeing of young women across the life course as a result, preventing teen pregnancies and fertility is among the priority issues of the Ethiopian Federal Ministry of Health. Reproductive choices among young women are especially important, as early childbearing can impair their health and limit their prospects for productive participation in society. Yet, unplanned pregnancies among adolescents happen despite the best of contraceptive intentions (6,14).
Allowing girls to postpone motherhood, and space births, contraceptive use reduce unwanted pregnancies and the demand for abortion. However, little is known about the trends in modern contraceptive use and its correlates among girls aged 15 to 19 in Ethiopia. Understanding the contraceptive use status of such a large part of the population can provide meaningful evidence for health programming of the country. Hence, the objective of this further analysis is to examine trends and correlates of contraceptive use among sexually active adolescents to generate comprehensive evidence that will be useful to planners, policymakers, program managers, researchers, and all other stakeholders who are working to improve the health of adolescents in Ethiopia. Furthermore, it will assist in designing strategies and programs to better address coverage, quality, and equity issues at the country level as this paper sought to examine the trends of contraceptive using four Ethiopian DHS. typically adopt a two-stage sample design. Each region was strati ed into urban and rural areas, which yielded 21 sampling strata. Samples of Enumeration areas [EAs] were selected independently in each stratum in two stages. The rst stage involves randomly selecting clusters, EAs. Two hundred two, 202 urban and 443 rural clusters were selected. At the second stage a systematic sample of households is drawn from a listing of households in each of the sampled clusters-28 households per each cluster were selected. All women age 15-49 and men age 15-59 who are the usual members of the selected households are eligible to be interviewed in the survey.
The EDHS questionnaire covers topics related to sexual and reproductive health, including marriage, pregnancy, fertility, family planning, sexual behavior, maternal health, and STIs and HIV/AIDS, and etc. The information about contraceptive use was collected from all non-pregnant, fecund reproductive age women using pretested questionnaire (www.measuredhs.com). Among total interviewed women, 6401 of them were youth; 15-19 girls account 3498(22.3%) while 20-24 age groups were 2903(18.5%). Data for sexually active adolescent girls were extracted from the data set. Of the total adolescent girls participated in the study, 518 them were sexually active in the last four weeks before data collection. The data set was requested from the Measure DHS program on April 1, 2019. An approval was then granted to download the data.
This report examines one of the important indicators for adolescent female, contraceptive use by sexually active adolescent, regardless of their marital status as denominator. Some of the selected independent variables include: age, educational status, religion, ethnicity, marital status, working currently, wealth status, visiting of health facility, hearing about family planning information from radio, TV, newspaper, place of residence and region of residence, told of family planning at the health facility. Some of these study variables were re-coded to suit the purpose of the study while some were used as they are in the original data set. For instance, religious a liation was re-coded into orthodox Christian, other Christian and Muslim. Wealth status was also recoded into poor, average and rich by combining "poorer" and "poor" for poor and "rich" and "richer" for rich. Highest educational level status was recoded into No education, Primary, and second /higher by combining secondary and higher.
The data were analyzed using SPSS version 21. Descriptive analysis was used to describe background characteristics of the study participants. Binary and multiple logistic regressions were employed to identify candidate variable and examine the determinants of sexually active adolescent contraceptive use respectively. Adjusted odds ratios with 95% con dence interval were presented for signi cant variables in the model in order to estimate the likelihood of contraceptive use among the various categories of female adolescents. Standard EDHS sample weights are applied in the data analysis to account for the unequal probability of selection in the sample and nonresponse. Therefore, all gures and tables in the report depict weighted numbers and percentages.

Operational de nition
Adolescent an individual in the age group 15-19

Sexually active
Those respondents who reported that they have had sexual intercourse, irrespective of their marital status in the last four weeks

Contraceptive use
Respondents who at the time of interview said they or their partner are using any contraceptive method to delay or avoid becoming pregnant. It was dichotomous denoting users and nonusers of contraceptive methods.
Current use of modern contraception: Current users of modern contraceptives include women who said that they or their partner are currently using any of the following modern methods of contraception: female sterilization, male sterilization, pill, injectable, intrauterine device, implant, condom, and emergency contraception at the time of survey.

Socio demographic characteristics of the adolescents
This section describes the distribution of young, sexually active adolescent girls (N = 504) by their selected background characteristics by using 2016 EDHS data set. The mean age of the respondents was 17.73(± 1.124). The mean ages at rst cohabitation and rst sexual intercourse were 15.59 (± 1.734) and 15.63 (± 1.751) years respectively. Among sexually active adolescents in the study, about half, 225 (47.3%) of the cohabited at age 15 years and less Three fth (60.6%) of the sexually active adolescent girls were attained primary education. Most, 87.3% (440) of them were from rural residents, almost nine in ten [91.0%] of them were married, 125 (24.8%) of them were from poorer socioeconomic group, 211(41.9%) were Muslim by religion and 199 (39.5%) were Oromo by Ethnicity. More than three fourth (79.7%) of girls were not working at the time of the survey ( Table 1)

Currently Used Modern Methods Mix
According to Ethiopian DHS of 2016, more than one in four (42.2%) of adolescent girls started sexual intercourse at and before age 15 and knowledge about contraceptive among sexually active adolescent girls is almost universal (98percent). However, the report showed that only 199 (39.6%) of adolescents who enter into a sexual relationship are currently using any form of contraceptive method. Also, among those who use contraceptives, a signi cant proportion 198 (39.3%) of them use modern contraceptive methods and more than one fourth, 147 (29.1%) of them were using injectable method. Injectable contraceptives have become very popular among young women and methods such as condoms and pills are less popular. Regarding long acting method, less than ten percent (6.8%) of them use implants/Norplant. (Fig. 3) Figure 4 shows the different types of contraceptives among users of any modern method of contraception for 2000 and 2016. There is a slight change in the pattern of use over time. The trends in mix of currently used modern methods indicated promising improvement. The share of long acting reversible contraceptive method, Norplant/implants among sexually active adolescent girls has signi cantly increased by more than 6 percentage points between 2000 and 2016 and more than three times between 2011 and 2016 (from 1.9 to 6.3 percent). Regarding the observed shifts in the prevalence of short-term methods, the share of injectable methods of contraception has signi cantly increased by more than 25 percentage points from 2000 to 2016.

Factors Associated With Contraceptive Use Among Sexually Active Adolescents
In bivariable logistic regression eleven variables had signi cant relationship with female adolescent contraceptive use. These include respondent and partner educational and occupational status, currently working status, wealth status, visited by eld worker in the last 12 months, told about Family planning at a health facility, place of residence, heard family planning messages on radio on the last few months, and heard family planning messages on TV on last few months. However, in the multivariable logistic regression there is no signi cant relationship between adolescent contraceptive use and type of place of residence, respondent occupation, heard family planning message on radio on last few months, heard family planning messages on TV on last few months and visit of health facility.

Discussion
The risks of pregnancy are greater at young maternal ages. The association between poor contraceptive use and teenage pregnancy is supported by studies suggesting that contraceptive use can prevent unintended pregnancy and early childbearing and their consequences. (15)(16)(17). Ensuring access and choice to family planning to improve maternal and neonatal health is crucial.
This paper examined the trend and correlates of contraceptive use among female adolescents aged 15 to 19 in Ethiopia, using national demographic and health survey. We found that the number of young women using contraception is increasing from time to time over the last decade and knowledge about contraceptive method among adolescents is almost universal in Ethiopia. However, more than three fth of the sexually active female adolescents are still not using the contraceptive, which could put them in risks for teenage pregnancy, unintended birth, adverse birth outcomes and health outcomes. This gure was slight lower than the report on patterns and trends in adolescents' contraceptive use in developing countries, 42-68% of married and unmarried sexually active adolescent females in all the Latin American countries (except Guatemala and Haiti) and in Bangladesh, Indonesia, Kazakhstan and Turkey were currently using contraceptives. However, among the African countries, contraceptive prevalence was 20-35% except Namibia in which it reached at least 40% (18).
Finding from the current study was slightly higher compared to gures from Nepal. In Nepal 23.1 % of married women age 15-19 currently uses any method of contraception, (14.5% modern contraceptive use and 8.6% traditional method (19) There were signi cant variations in the use of modern contraception by demographic and socioeconomic characteristics of adolescent girls in Ethiopia. According to this study, there is signi cant inequality among sexually active adolescent regarding modern contraception use by their education, partner's occupation, wealth status and had been told information about family planning at health facility.
Adolescents who have secondary and higher educational level, who had told about Family planning at health facility, and who are in the highest wealth quintiles use signi cantly more modern contraception as compared to their peers who have not attended formal education, had not told about Family planning at the health facility, or who belong to the lowest wealth quintiles.
This study revealed that respondent education was an independent predictor for contraceptive use among sexually active female adolescent. This nding was similar with a study from Nigeria and Burkina Faso that stated that, prevalence of contraceptive use among adolescents with a secondary-level education or above was 5.9 and 2.4 times higher in Nigeria and Burkina Faso respectively than those who had completed only primary-level education (4). Similarly, the study conducted in Ghana identi ed education as a determinant for contraceptive use, the odds of contraceptive use were 7.39 and 11.53 times among female adolescents who had primary and secondary or higher education respectively compared to their counterparts who had no formal education [prevalence and correlates of (20). Educational status was also a signi cant predictor of contraceptive use in Bangladesh-low contraceptive use among illiterate female adolescents was reported (21). This may be due to the fact that educated women are more likely to appreciate the returns/dividend that contraceptives use has on their lives. Also educated women may have a plan to pursue highest career with in their education as a result they want to delay their childbearing time.
The likelihood of contraceptive use among the female adolescents increased signi cantly with the increase in their household economic status. As a result, female adolescents in the household with highest wealth index were more likely to use contraceptives than their poor counterparts. This nding was in line with DHS analysis from three African countries: Nigeria, Burkina Faso and Ethiopia, across all three countries, there is a signi cant equity gap in modern contraception use because of wealth index (4).
Similarly, the analysis conducted using the 2016 Ethiopian demographic and health survey to identify factors associated with long acting and permanent contraceptive methods use showed that women in the richer wealth index were more likely use long acting and permanent contraceptive methods compared to those in poor wealth index (22). This may be for the reason that most of the small resources obtained from the petty jobs done by women and their spouses in poor households are diverted to take care of the family and less is shifted to the health of the mothers themselves. As a result, poor household preferred not to use the service as they encountered di culties to cover direct and indirect costs incurred in seeking the services (23) This study also identi ed that the occupation of husbands was determining the use of contraception. Sexually active adolescent women whose husbands' occupation is sales workers practice less contraception methods than those husbands are not working. The possible reason for this is that, if the husband has no work, the possibility of being at home is there as a result; during home to home visit health extension workers may inform him to support his wife for contraceptive use. This access to information from eldworkers offers the opportunity to for the husband to in uence his wife to use family planning. In another way round due to economic insecurity, husband did not work, women may motivate to use contraceptive to space or limit the birth because there are inadequate resources at home.
Further, those had been told about family planning during health facility visit was a signi cant predictor for contraceptive use. Contraceptive use among respondents who had told about family planning information was 3.7 times compared to their counterparts who had not told about family planning information at the health facility. The existing body of literature, considered in parallel with our own ndings, strongly indicated that, adolescents' girls' access to family planning information via different sources increases use of modern contraceptive methods. For instance, study from Nigeria were found that hearing about family planning on mass media was associated with the use of modern contraceptives among these adolescents(24). In addition, Bangladesh it was highlighted that being frequently visited by Family planning worker resulted the more they respond favorably to their use of contraception (20). Access to information play a signi cant role in the use of contraception as it has the capacity to raise an individual's awareness, and in uence their attitude. In addition, the information could guide people to make an informed decision to use the services. Our study has limitations, the data is from a cross-sectional survey and unable to establish any causal relationship between our outcome of interest (contraceptive use) and the covariates of interest.

Conclusion And Recommendation
There is an increment in trend of modern contraceptive use among sexually active female adolescents during the 2000 to 2016 EDHS. With nearly doubled between 2005 and 2011. Almost all of the girls know about modern contraceptives, but this high knowledge did not translate into its use as only two fth uses it. Injectable was the most widely used contraceptive method. Respondent education, partner's occupation, wealth status and had been told information about family planning at health facility were signi cant determinants for contraceptive use.
As adolescent populations continue to grow, governments must develop more targeted strategies for improving socioeconomic and adolescents' education which might be contribute to enabling them to use contraceptive and prevents related complications. Considering the fact that contraceptive knowledge does not necessarily translate into usable, qualitative studies, are needed to understand why high knowledge levels are not associated with high usage patterns Trends in method mix contraceptive use among sexually active adolescent, Ethiopia DHS 2000-2016