The trends of contraceptive use by the adolescent girls were increasing in the last two decades in Ethiopia. Contraceptive use among sexually active girls was increased by 6-folds between 2005 to 2016 EDHS. Possible explanations for this increment 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 program that brings health services including family planning to the communities’ home (27, 28). There is also a national political commitment to family planning in Ethiopia, governments and nongovernmental organizations have increased resource allocations for contraceptive security and deliver (29). Further, although much of contraception services are provided by government, provision of short term contraception methods by the private sectors can also played an important role in increasing young women’s access to contraceptive services in Ethiopia (30).
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% in 2016 respectively. However, IUD use did not increase compared to implants. This may be due to the fact that, starting from 2009 insertion of implant was cascaded to the health post level and training was given to the health extension workers on the provision of the service.
Despite the progress that has been achieved, a considerable number of sexually active adolescent girls use short acting methods, especially injectable which has a high failure rate compared to long acting and reversible contraceptive methods. The low uptake of long acting and reversible contraceptive methods may be due to barriers such as lack of availability, fear and misconceptions and provider bias on the provision of long acting methods for adolescents (31, 32).
The share of injection methods rose from 1.6% to 29.1%, while the patterns observed in condoms and pill declined from 1.1% to 0.1% and 3.2% to 1.8% respectively between 2000 and 2016. 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 study from Kenya and Rwanda where, injectable contraceptives have been consistently dominant among women aged 15-24 years (33). Possible reason could be due to the age of the participants. The fertility intention for 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 (34). However, 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 (35).
Although there are visible changes in the trend of contraceptive use and knowledge of contraception was almost universal, still more than three fifths of sexually active female adolescents are not using the contraception according to 2016 EDHS data. This finding was slightly lower than the report from 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 (34).
However, it is higher than the results from the African countries where contraceptive prevalence was 20–35%, except in Namibia in which it reached at least 40% (34). 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 girls age 15-19 are currently using any method of contraception (37). Non-use of contraception could put adolescent in risks for teenage pregnancy, unintended birth, adverse birth and health outcome (36,38,39). Hence, ensuring access and choice of family planning to improve maternal and neonatal health is crucial.
With a high level of contraception methods knowledge, a huge gap exists between the knowledge and practice of contraceptive methods. This gap may be happened because of contraceptive related side effects. Adolescent may fear side effects associated with using contraception and this could in turn interfere with their practice. Additionally, even though young women’s have knowledge about contraception, due to disapproval from their sexual partner, they may not use family planning (40).
There were significant variations in the use of contraception by background characteristics of adolescent girls in Ethiopia. Adolescents who have secondary and higher educational level, who had information about family planning at health facility, and those 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, and who belong to the poor families.
This study revealed that respondent’s education was an independent predictor for contraceptive use. This was similar to a study conducted in Nigeria and Burkina Faso where contraceptive use among adolescents attended secondary/above level education were higher than those who had completed only primary-level education (41). Similarly, in Ghana, the odds of contraceptive use was higher among educated female adolescents (42). Further, low contraceptive use among illiterate female adolescents was reported in Bangladesh (43). This may be because educated women are more likely to appreciate the dividend that contraceptive use has on their lives. Also educated women may have a plan to pursue the highest career within their education as a result; they want to delay their childbearing time.
The likelihood of contraceptive use increased significantly with the increase in household economic status. This finding was in line with report from three African countries: Nigeria, Burkina Faso and Ethiopia. Across all these countries, there is a significant equity gap in modern contraception use because of wealth index (41). Likewise, another study in Ethiopian showed that women in the richer household were more likely to use contraception (44). This could be because, most of the small resources obtained from the petty jobs done by women, and their spouses in poor households are diverted for taking care of the family and less is shifted to the health of the mothers. Hence, poor household preferred not to use the service as they encountered difficulties to cover direct and indirect costs incurred in seeking the services (45).
Further, adolescents, those had been told about family planning during a health facility visit used contraception more than those who were not told about family planning. The existing body of literatures indicated that female adolescent access to family planning information via different sources increases use of modern contraceptive methods. For instance, in Nigeria hearing about family planning on mass media was associated with the use of modern contraceptives (46). Also, being visited by a community health worker resulted in more likely to use modern contraceptive methods (47). 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 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.
Systematic review conducted in 2011 and updated in 2016, on youth-friendly family planning services for young people indicated the importance that young people place on receiving comprehensive, client centered family planning counseling (27). However, there are a number of factors that was identified as barriers to the delivery of effective contraceptive counselling and care for adolescents. For instance, in Latin America, many consider adolescent use of contraception to be socially unacceptable (48). Since there were significant associations between FP counseling with contraceptive initiation, as well as continuation, health care provider skills in the counselling, and provision of contraception for adolescent are therefore needed be emphasized (49).
This study showed that, more than nine in the ten of adolescents were married and about half were cohabiting at age 15 years and less than; more than three years earlier compared to the recommended age at marriage in Ethiopia. This showed the practice of very early marriage and early sexual activities among adolescent girls.
Early marriage often results from the traditional, and cultural family values that justify control over women’s sexuality and fertility (50–52). These types of practices have a direct impact on girls' education and future carrier (53). It has also a negative consequence of the economic development of nations in addition to causing a significant health risk both to a girl, and her baby (54). This was due to an extended time that the girls spend in childbearing years that cause an increase in fertility and population growth. The evidence also 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 greater likelihood of occurrence of a pregnancy (50).
The main strength of this study was the use of a nationally representative data set. The study has also some limitations, the small sample sizes that contributed to a bit wider confidence level for some variables. Possibility of social desirability bias that may result to underreporting of sexual activity. The information was self-reported and it may not indicate the true picture of contraceptive practice by adolescent. The data are from a cross-sectional survey and unable to establish any causal relationship between a response variable (contraceptive use) and the covariates of interest.