This study showed that more than nine out of ten 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 (29–31). Such practices have a direct impact on girls' education and future carrier (32). It has also a negative consequence on the economic development of nations in addition to causing a significant health risk both to a girl, and her baby (33). 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 the marriage union, the frequency of sexual activity is higher than in those who are not, hence in the absence of contraception there is a greater likelihood of occurrence of pregnancy (29).
During the last two decades, a growing trend was observed in the use of contraceptives by adolescent girls in Ethiopia. Contraceptive use among sexually active girls increased by six-folds between 2005 to 2016 EDHS. This may be contributed to the implementation of several interventions such as youth-friendly health services and innovative health extension program that brings health services including FP to the communities’ home (34, 35). There is also a national political commitment to FP in Ethiopia, governments and nongovernmental organizations have increased resource allocations for contraceptive security and delivery (29). Further, the provision of short-term contraception methods by the private sectors may have 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 because starting from 2009 insertion of the implant was cascaded to the health post level, and training was given to the health extension workers on the provision of the service (36). 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, misconceptions, and provider bias on the provision of long-acting methods for adolescents (37, 38).
Trends of injection methods of contraception 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 injectable contraceptives. This finding is comparable with a study from Kenya and Rwanda, where, injectable contraceptives have been consistently dominant among women aged 15-24 years (39). A possible reason could be due to their fertility intention. Adolescent girl intends to delay or space births for a short period which might explain their preference for short-acting methods that are easier to start and stop as needed (40).
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. This finding was slightly lower than the report from LMICs 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 (40). 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% (40). This finding was also slightly higher than Zimbabwe and Malawi's study, where 35% and 33% of adolescents use a contraceptive, respectively (39). Hence, ensuring access and choice of family planning to improve maternal and neonatal health is crucial.
There were significant variations in the use of contraception by background characteristics of adolescent girls in Ethiopia. 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 who attended secondary/above education was higher than those who had completed primary education (28). Similarly, in Ghana, the odds of contraceptive use were higher among educated female adolescents (41). Further, low contraceptive use among illiterate female adolescents was reported in Bangladesh (42). This may be because educated girls are more likely to appreciate the dividend that contraceptive use has on their lives. Also, they 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 a 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 the wealth status (28). Likewise, another study in Ethiopia showed that women from richer households were more likely to use contraception (27). 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, women from poor households refused the service as they encountered difficulties to cover direct and indirect costs incurred in seeking the services (43).
Further, adolescents who had been told about FP during a health facility visit used contraception more than those who were not told about FP. The existing literature indicated that female adolescent's access to family planning information via different sources increases the use of modern contraceptive methods. For instance, in Nigeria hearing about family planning on mass media was associated with the use of modern contraceptives (44). Also, being visited by a community health worker resulted in an inclination for modern contraceptive methods (45). Access to information plays a significant role in the use of contraception as it can raise an individual’s awareness, and influence their attitude, and could guide them 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 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 (35). However, several factors were identified as barriers to the delivery of effective contraceptive counseling and care for adolescents. For instance, in Latin America, many consider adolescent use of contraception to be socially unacceptable (46). As there were significant associations between FP counseling with contraceptive initiation and continuation, health care provider skills in the counseling, and provision of contraception for an adolescent is, therefore, needed to be emphasized (47).
The main strength of this study was the use of nationally representative data. 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 in under-reporting of sexual activity. The information was self-reported and it may not indicate the true picture of contraceptive practice by an 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.