This study examined the trend and correlates of contraceptive use among sexually active female adolescents in Ethiopia using national demographic and health survey.
Finding from this study indicated that more than nine in ten of adolescents were married. About half, 225 (47.3%) of were cohabited at age 15 years and less than which is more than three years earlier compared to the recommended age at marriage in Ethiopia. This finding was showing the practice of very early marriage and early sexual activities among adolescent girls. These types of sexual practices have a direct impact on their education and future carrier particularly subsequent to childbirth (27).
Early marriage often results from the traditional and cultural family values that justifies control over women’s sexuality and fertility(28–30). Due to increased fertility and population growth as a result of the extended time that the girls spend in childbearing years, early marriage has a negative consequence on the economic development of nations in addition to causing a significant health risk to both the girl and her baby(31). Evidence indicated that in marriage union the frequency of sexual activity is higher than in those who are not, hence in the absence of contraception there is the greater likelihood of occurrence of pregnancy(28).
According to the finding from this study, the rates of use of contraception by adolescents are increasing from time to time over the last decade in Ethiopia. Improvements in contraceptive prevalence trends were more pronounced between 2005 and 2011 survey years. Possible explanations for this increment in contraceptive prevalence may be related to implementation of several interventions aimed at increasing demand for and access to sexual and reproductive health services among adolescents and youths by providing youth-friendly health services and innovative health extension worker program that brings health services including family planning to the communities home(20,32)
There is also a national political commitment to family planning in Ethiopia, by governments and nongovernmental organizations has increased resource allocations for contraceptive security and deliver(33). The private sector also played an important role in increasing young women’s access to contraceptive services in Ethiopia (34).
The present study revealed that the Knowledge of contraceptives was almost universal. However, with this intense knowledge there exists a huge gap between the knowledge and practice of contraceptive methods. The possible explanation for this gap was seen in our context where husband is the household decision makers in most of the cases; hence it may be difficult for adolescent girls to decide by themselves on using or non-using of contraception even though they have the knowledge about the contraception. This is because the adolescent is not matured enough to planned their fertility intension. Also fear of side effect and disapproval from husband may be the reason for not using contraception.
According to this study, there is visible change in trend of contraceptive use, yet, more than three fifth of the sexually active female adolescents are still not using the contraceptive according 2016 EDHS report. This finding was slight lower than the report on patterns and trends in adolescents’ contraceptive use in developing countries where 42–68% of 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, it is higher than the results among the African countries where contraceptive prevalence was 20–35% except in Namibia in which it reached at least 40% (35).
Also, this finding was slightly higher than the study from Zimbabwe and Malawi where 35% and 33% of adolescents use contraceptive respectively (36). Further, it was higher compared to figures from Nepal. In Nepal only 23.1% of married women age 15-19 are currently uses any method of contraception, (14.5% modern contraceptive use and 8.6% traditional method (37). The association between poor contraceptive use and teenage pregnancy is supported by studies and nonuse of contraceptive could put adolescent in risks for teenage pregnancy, unintended birth, adverse birth and health outcome. (36,38,39). Hence, ensuring access and choice to family planning to improve maternal and neonatal health is crucial.
The proportion of sexually active female adolescent contraceptive users relying on the IUD and implants increased substantially from no reported users in 2000 to 1.1% and 6.3% respectively in 2016. The share of injection methods of contraceptive rose from 1.6% to 29.1%, while the patterns observed in condoms and pill as the method of contraception declined from 1.1% to 0.1% and 3.2% to 1.8% respectively. This finding indicated that adolescent girls appear to be shifting away from condoms and pills and choosing for injectable contraceptives.
This finding is comparable with evidence from Kenya and Rwanda showed that injectable contraceptives have been consistently dominant method among women aged 15-24 years(40). Possible reason for this could be due to the age of the participants, being young. The fertility intension for these young population is to delay or space births for two or more years which might explain their preference for short acting methods that are easier to start and stop as needed(35). However, evidence from developing country indicate that, in Sub-Saharan Africa the low use of condoms and the increasing dominance of injectables have challenges for family planning efforts and may have significant programmatic and public health implications(41).
Despite the progress that has been achieved, a substantial number of sexually active adolescent girl uses short acting methods especially injectable method which have high failure rate compared to long acting and reversible contraceptive methods. Low uptake of long acting and reversible contraceptive method may be due to barriers such as lack of availability, fear and misconceptions and providers bias on provision of long acting methods for adolescents(42).
There were significant variations in the use of contraception by demographic and socioeconomic characteristics of adolescent girls in Ethiopia. According to this study, there is significant inequality among sexually active adolescent regarding contraception use by their education, partner’s occupation, wealth status and access to information about family planning at health facility. Adolescents who have secondary and higher educational level, who had information about family planning at health facility, and adolescent from are in the highest wealthy families use significantly more contraception as compared to their counterpart who have not attended formal education, did not have information about family planning at the health facility, or who belong to the poor families.
This study revealed that respondent education was an independent predictor for contraceptive use among sexually active female adolescent. This finding was similar with a study from Nigeria and Burkina Faso that stated 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(43). Similarly, the study conducted in Ghana identified 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 (44). Educational status was also a significant predictor of contraceptive use in Bangladesh- low contraceptive use among illiterate female adolescents was reported (45). 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 significantly 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 finding was in line with DHS analysis from three African countries: Nigeria, Burkina Faso and Ethiopia, across all three countries, there is a significant equity gap in modern contraception use because of wealth index (43). 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(46). 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 difficulties to cover direct and indirect costs incurred in seeking the services(47)
Further, those had been told about family planning during health facility visit was a significant 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 findings strongly indicated that, female adolescent access to family planning information via different sources increases their use of modern contraceptive methods. For instance, study from Nigeria found that hearing about family planning on mass media was associated with the use of modern contraceptives (48). In addition, in Bangladesh it was highlighted that being frequently visited by family planning worker resulted in responding positively to their use of contraception(20).
Access to information play a significant role in the use of contraception as it has the capacity to raise an individual’s awareness, and influence their attitude and could guide adolescents to make an informed decision to use the services. However, in the present study only 15% of those who visit health facilities are told about contraception that indicated many sexually active adolescent girls miss out on this information. A systematic review that conducted in 2011 and updated in 2016 on youth-friendly family planning services for young people indicated the importance young people place on receiving comprehensive, client centered family planning counseling(32). However, there are a number of factors that identified as barriers to the delivery of effective contraceptive counselling and care for adolescents at these different levels. For instance, in Latin America, many consider adolescent use of contraception to be socially unacceptable (49).
Since there were significant associations between FP counseling with contraceptive initiation as well as and continuation, health care provider skills in the counselling and provision of contraception services for adolescent are therefore need be emphasized (50)
Our study has some limitations, the small sample sizes that contributed to a bit wide confidence level for some variables. Possibility of social desirability bias that may resulted to underreporting of sexual activity. Since the information was self-reported it may not indicate the true picture of contraceptive practice by adolescent. 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.