Geographical variation and factor associated with modern contraceptive utilization among Young married women aged between 15-24 years: Spatial and multilevel analysis of EDHS 2016.

Introduction: Despite increase in trend of contraceptive utilization in worldwide it was still low in developing country. In Ethiopia modern contraceptive utilization among young married women was low which shows gaps between women reproductive desire to avoid pregnancy and contraceptive behavior. This study shows varation in modern contraceptive utilization and factor associated with it among young merried age group between 15-24 years in Ethiopia. Objective: The aim of the study was to assess the geographical varation of modern contraceptive utilization and associated factor among young married women aged between 15- 24 year in Ethiopia. Methods: Cross-sectional study design was applied using Ethiopia demographic and health survey 2016 data. The sample size was 2298 young married women aged between 15-24 years. Spatial analysis was done using spatial autocorrelation Moran’s I, Gettis-OrdGi* and spatial scan statics to identify signicant clusters of modern contraceptive utilization. The data were analyzed using a two level-mixed-effects logistic regression model to determine the individual and community level factors associated with modern contraceptive utilization. Result: In Ethiopia, prevalence of modern contraceptive utilization among young married women age group 15-24 years was 36.7 %. Spatial scan statistics identied primary clusters of modern contraceptive utilization were all zone of Amhara, Addis Ababa and Shewa. In other hand, Gettis-OrdGi* analysis indicated zone 1 of Afar region, Borena zone of Oromia region and all zone of Somalia regions were low prevalence spot region. In this study religion, wealth index, religious, health facility visits within 12 months, husband desire more children, perception of distance from health facility, region, Community access to health services and community educational level were statically signicant variables for modern contraceptive utilization. Conclusions: There is low prevalence of modern contraceptive utilization and it was varied across zone of Ethiopia. High and low prevalence spot area, most likely cluster, community and individual level factor associated with modern contraceptive utilization is identied which is important to prioritize family planning strategy. Therefore, exerting much effort on this area is supreme important as it has signicant public health contributions.


Background
Family planning de ned as "the capability of individuals and couples to anticipate and attain their desired number of children, and the spacing and timing of their birth, which is achieved through the use of contraceptive methods" (1). It is cost-a effective way to reduce maternal mortality by reducing the number of pregnancies, abortions, proportion of at high-risk births, improve health related outcome, and social and economic bene ts (2).
Globally, 28% of young women living in developing regions are married .In sub-Saharan Africa, more than 20% of 15-19-year-old adolescents and 60% of 20-24-year-old young adult women are estimated to be in marital union (3,4) .Young adulthood is an important period for physical and mental development, and behaviors during this time can have long term implications. Young married women face many challenge to overcome this challenge it is critical to access comprehensive reproductive health services that focus on safe, healthy sexual and reproductive lives (5,6).
Modern contraceptive utilization among younger married women was low when compared to older women (7). It is higher amongst sexually active unmarried women age 15-24 than married women age [15][16][17][18][19][20][21][22][23][24]. These young married women had higher risk of unintended pregnancies because of repeated pregnancy, lower educational attainment, higher rates of contraceptive failure and more likely to abandon contraception (8,9). Unwanted pregnancy would have consequences of unsafe abortion, maternal and infant morbidity, dropping out of school, unemployment opportunities and increase the risk of poverty (10). Barriers to use modern contraceptive among young married women include poor understanding of pregnancy risks, gendered social norms, and concerns about the effect of contraceptives on health or fertility, opposition from partners, cost and disapproving attitudes from providers (11,12).
In developing country little published evidence about married young women and their partners to address the social and behavioral constraints to contraceptive use. So it is important to learn from the few rigorously documented and evaluated projects that have worked with married young women (13). Overall, only 52.9% of the women were using a modern contraceptive method, but coverage varied greatly. West & Central Africa showed the lowest coverage; whereas South Asia and Latin America & the Caribbean had the highest coverage (14).
In Ethiopia young aged 10-24 comprise 35% of the country, 28% of adolescents aged 15-19 and 24% of young women aged 20-24 have had unintended pregnancies (27,28). One in 10 young women age 15-24 have a unmet need for family planning, compared to 23% of adult women age 25-49 (1). Among young married women, modern contraceptive prevalence increased from 6% in 2000 to 36% in 2011 (15) Women are part of their community, and do not live in isolation so every decision in uenced by those around her. While women may receive accurate health information from facility and health providers but health-seeking decisions are in uenced by community. Especial younger married women were challenged by partner and family involvement in decision making on using of FP method (16).
Young sexual and reproductive health is affected by a country's cultural, religious, legal, political and economic contexts. Utilization of family planning methods is determined by factors at the individual, household, and community level, but the geographic pattern of contraceptive use may be associated with in uences at zonal level such as the availability and accessibility of health services in these areas (17). In responding, health actions are needed at each level, from structural, through community settings including schools and health services (18)(19)(20)(21).
Global effort has been implement to increase modern contraceptive utilization which can contribute to achievement of national and global goals and priorities, such as Family Planning 2020 and the Sustainable Development Goals. Access to sexual and reproductive health services for youth and improving availability, affordability, and youth-friendliness of service may critical for this achievement. But it is not enough which need to include provide service in different location by private and governmental provider to offer quality of service but also emphasized the important of policymakers concerned with youth FP programs (21)(22)(23).
Ethiopia actively developing strategies to expand family planning (FP) access for young people as all Family Planning 2020 (FP2020) commitment-making countries have a focus on youth, including through provision of youth-friendly services, free contraceptives for adolescents, and ensuring consistent commodity supplies to youth-speci c facilities (23). But the growing number of young people, renewed interest in FP service, multi-component programming by engaging parents and community leaders and training health care providers were continuous issue need to focus by policy maker. In addition, more evidence is needed on other approaches designed to reach young people, including providing services outside of health facilities, such as pharmacies and drug shops, determining how to reach the most vulnerable adolescent groups, and developing standardized (6,24,25).
To implement this there is need to have evidence about distribution modern contraceptive utilization across zone of country among young married women and individual and community level factor association with it. So this study assessed the geographical variation of modern contraceptive utilization, and individual and community level factor association with it among Young married women aged between 15-24 years evidence from Ethiopia demographic and health survey 2016. Additionally this research focuses on young married women because young married women are under intense pressure to demonstrate their fecundity.

Study Design
A population based cross-sectional study design was conducted using data analysis from the Ethiopia demographic health survey (EDHS) 2016. EDHS data obtained from the nine regions and two administrative cities were used. The data was collection from January 18-June 27, 2016 (26).

Study area
The study was conducted in Ethiopia (3 0 -4 0 N and 33 0 -48 0 E, situated at the eastern tip of Africa which is located at the horn of Africa and one of the tenth largest countries in Africa. The projections for the 2007 population and housing census estimate the population of nation 108,805,142 in 2018. In the country, there are nine regional states and two city administrations subdivided into 68 zones, 817 districts and 16,253 kebeles. In Ethiopia majority of the population (83.6%) are living in rural areas and the average household size is 4.7 persons. In addition, women in the reproductive ages constitute 24% of the population and 7,685 health posts, 392 hospitals and 3,962 health centers have been giving health care services. In all health facilities, FP service is provided at least ve days a week (27,28).

Data source and extraction
The data for this analysis were extracted from EDHS 2016 and accessed from the Measure DHS website (http://www.dhs program.com). It is a secondary data analysis from nationwide community-based survey. The data sets were downloaded in SPSS format with permission from Measure DHS website (http://www.dhs program.com). Data cleaning and recording were carried out in STATA. The family planning related datasets were joined to Global Positioning System (GPS) coordinates of EDHS using the joining variable as recommended by DHS measure. In the DHS surveys, samples were selected using a strati ed, two-stage cluster design, using enumeration areas (EAs) as a primary sampling units and households as the secondary sampling units (26).
Sample size determination and sampling procedures Ethiopia demographic and health survey 2016 was done by selecting a total of 18,008 households for sample, of which 17,067 were occupied. Of occupied, 16,650 were successfully interviewed, yielding a response rate of 98%. The total household size was 16,650 and from these 16,583 eligible women was identi ed for individual interviews. The interview completed with 15,583 women yields a response rate of 95%. 15, 583 women aged between 15-49 years completed the interview and 10,223 (weighted sample) were married women. Among 10,223 (weighted sample) married women ,2298 young married women (weighted sample) age between 15-24 years were included in this study (26). A two-stage samples technique was employed. The strati ed based on geographic region and urban/rural areas. In the rst stage of selection, the primary sampling units (PSUs) were selected with probability proportional to size (PPS) within each stratum. The PSU forms the survey cluster a total of 645 EAs (202 in urban areas and 443 in rural areas). Then xed number of 28 households (25-30) per cluster was selected with an equal probability systematic selection from the newly created household listing in the second stage of survey. The overall probability of selection of a household was differed from cluster to cluster (26). Population and outcome measurement In EDHS, Women aged 15 to 49 were randomly selected enumeration areas (EAs) were eligible for family planning as part of this those all young married women age 15-24 years were included in this study. Modern contraceptive utilization categorized as modern contraceptive utilization and none modern contraceptive utilization.
Data management, data processing and analysis methods Sampling weight was applied to an individual interview unit of analysis to adjust for differences in probability of selection and interview between cases in a sample due to design, happenstance or corrections for differential response rates. Weighing of individual interview would produce the proper representation of family planning information and related factor. All of these special codes were careful considered when analyzing DHS datasets. The data extraction, descriptive and summary statistics were done by STATA 14. Spatial statics was analyzed by ArcGIS version 10.3 and Sat Scan™ version 9.6 software.

Spatial analysis of unmet need for family planning Spatial Autocorrelation
Moran's I is one of spatial autocorrelation method that assess the extent of clustering of modern contraceptive utilization in the regions. Moran's I test statistic computed to test the null hypothesis, no signi cant clustering of modern contraceptive utilization in the entire study region (29).
Getis OrdGi* statistic (Hot spot analysis) Hotspot statistic was computed to measure how spatial autocorrelation varies over the study location by calculating Gi* statistics for each area. The Z-score is computed to determine the statistical signi cance clustering of modern contraceptive utilization, and the p-value computed for the signi cance. If the zscore is between − 1.96 and + 1.96, the p-value would be larger than 0.05, and could not reject the null hypothesis; the pattern exhibited could very likely be the result of random spatial processes. If the z-score falls outside the range, the observed spatial pattern is probably too unusual to be the result of random chance, and the p-value would be small to re ect this. Therefore, it is possible to reject the null hypothesis and proceed with guring out what might be causing the statistically signi cant spatial pattern in the data. So high Gi* indicates "hotspot" whereas low Gi* means a "cold spot" (30,31). Spatial scan statistic Spatial scan statistic is based on Bernoulli model which applied by Kuldorff methods using the SaTScan™ software to analyze the purely spatial and clusters of modern contraceptive utilization. A Bernoulli-based model was used in which events at particular places analyzed if married women were modern contraceptive utilization or not represented by a 0/1. A spatial scan statistic used a scan window (the population at risk) in the shape of a circle, which moves across the study region. The size of the scan window was adjusted to scan for small clusters up to 50%. It also used to examine a large number of distinct geographical windows to test for the presence of modern contraceptive utilization. For each window Monte Carlo simulation used to test the null hypothesis that there was no statistically cluster of modern contraceptive utilization cases within the window.
The cluster with the greatest maximum likelihood ratio was considered as the primary cluster of modern contraceptive utilization. Other statistically clusters that did not overlap with the primary cluster were identi ed as secondary clusters of modern contraceptive utilization, and ranked according to their likelihood ratio test statistic. (29,32) Multilevel Logistic Regression Analysis The determinants of contraceptive utilization were identi ed by using multilevel logistic regression model. Those variables with P-value < 0.2 in bi-variable logistic regression model were entered into multivariable logistic regression model to measure the effect of each variable after adjusting for the effect of other variables. Variables with p-value < 0.05 were considered as statistically signi cant to identify independent factors for modern contraceptive utilization. To demonstrate the importance of the community level and individual level component multilevel analysis was used candidate variables p-value less than 0.05. were entered into the model and will be checked tted for models (33).
Multilevel analysis is appropriate to measure DHS data since it is hierarchical data therefore two stage multilevel analyses was used to explore factors affect modern contraceptive utilization at individual and community level factor (34). Four models were considered in the multilevel analysis; model one empty without explanatory variable that speci ed only the random intercept and it presents the total variance in modern contraceptive utilization among clusters, model two adjusted for individual variable, model three for adjusted community level variable and model four both adjusted individual and community level variable. The association was measured by odd ratio of individual level variable and community level to identify factors that associate with contraceptive utilization. Measurement of variation was identifying using interclass correlation (ICC) and proportional change in variance (PCV). The model for tness diagnostics was select by using Deviance Information Criteria (DIC) or Alkaile information criteria (AIC).
Model with lowest AIC and highest log likelihood test was selected which better explain modern contraceptive utilization (34,35).

Ethical consideration
The data was accessed by registration on the DHS website (www.dhsprogram.com) and getting approval from the measure DHS. Prior to the actual interview, informed consent was obtained from the participants, their guardian or household heads. Data was used only for the purpose of statistical reporting and analysis, and for the proposed research project. The data treated as con dential, and no effort should be made to identify any household or individual respondent interviewed in the survey. Ethical clearance was obtained from the institutional ethical review board of the Institute of Ethiopia public health association, Ethiopia.

Socio Demographic Characteristics
A total of (n = 2298) young married women were interviewed in 2016 EDHS. Among these Young married women 1815 (79.47%) were cohabitation before age of 18 years. About half of the respondent 1158 (50%) were not educated. About 1424 (62%) of respondents had more than one or two children. Large proportion of respondents 1745(76%) hadn't any work. Regarding to partner's education level, 1355(59%) were not educated (Table 1).

Regional Prevalence Of Modern Contraceptive Utilization
The prevalence of modern contraceptive utilization varied across the regions of the country. The highest modern contraceptive utilization (63%) was found in Addis Ababa region but lowest modern contraceptive utilization (2%) was in Somalia region ( Fig. 1).

Spatial Distribution Of Modern Contraceptive Utilization
The analysis of spatial autocorrelation indicated that the spatial distribution of modern contraceptive utilization was non-random in the Ethiopia. The Global Moran's I values were 0.45 (p value < 0.0001) that pointed out signi cant clustering of modern contraceptive utilization in the study area (Fig. 2).
Gettis-OrdGi* analysis indicated high and low prevalence spot areas of modern contraceptive utilization.
The highest prevalence spot areas for modern contraceptive utilization were detected in Addis Ababa, West and East Gojam. One the other hand, zone 1 of Afar region, Borena zone of Oromia region and all zone of Somalia regions were lowest prevalence spot area (Fig. 3).
Spatial scan statistics identi ed signi cant primary (LLR = 113.3, P < 0.001) and secondary (LLR = 19.1, P < 0.001) clusters of modern contraceptive utilization (  Fig. 4).  (Tables 6 and 7). Finally, multivariable logistic regression of model four indicated that religion wealth index, religious, family size, health facility visits within 12 months, husband desire more children, perception of distance from health facility, region, Community access to health services and community educational level were statically signi cant variables for modern contraceptive utilization in this study (Table 6). Model one: empty model no variable. CI: Con dence interval, AOR: adjusted odds ratio, 1: Reference category * P < 0.05; **P < 0.01; ***P < 0.001  Community level factor showed up with higher PCV, 43% variance of modern contraceptive utilization explained by community levels factor. Additionally 20% and 27% variance of modern contraceptive utilization explained by individual level factor, and both individual and community level factors respectively (Table 7).

Discussion
Increase modern contraceptive utilization has a major role of improving health by decrease child and maternal health. To increase utilization of modern contraceptive, knowing its geographical variation and associated factor will bring considerable effect in future improvement.
In this study modern contraceptive utilization among young married women in this study was 36.7% [95% CI: 34.8%, 38.7%]. It was similar with study done in Uganda (7),and the possible reason may be similar emphasizing given by the local health programmers. It was higher than study done in Malawi (36). But it was low when compared to study done in Bangladesh (37), Ghana (5). The possible explanation for this variation might be due to the involvement of health extension workers in awareness creation activity, difference in provision of health service including in school through different club related to reproductive health programmers, availability of youth friendly health service or difference of study population (38)(39)(40).
The spatial distribution of modern contraceptive among young married women across Ethiopia region showed signi cant variation and clustering at zonal level. The Global Moran's I values 0.42 (p value < 0.001) indicated spatial heterogeneity modern contraceptive among young married that need to identify gaps and to prioritize intervention (21). Gettis-OrdGi* statistics indicate highest prevalence zone for modern contraceptive utilization were detected in Addis Ababa, West and East Gojam. One the other hand zone 1 of Afar region, Borena zone of Oromia region and all zone of Somalia regions were lowest prevalence area zone (Figure). It was consistence with study done in Kenya and India which indicate modern contraceptive utilization across districts were signi cant variation and clustering (41,42). Rwanda and Ethiopia (43,44). These s studies explain geography, cultural factors, demographic characteristics of respondents, health service delivery capacity and community awareness about FP is possible explanation for regional variations of modern contraceptive utilization (41)(42)(43)(44) The multilevel analysis shows that there is a big variation in use of modern contraceptive at both at the individual and community level variable. In this study religion wealth index, religious, health facility visits within 12 months, husband desire more children, perception of distance from health facility, region, community health services utilization and community educational level were statically signi cant variables for modern contraceptive utilization ( Table 7).
Religious of respondent were signi cantly associated with modern contraceptive utilization. Muslim followers were less likely to use modern contraceptive .This nding had agreement with study done in Malawi (36), Ethiopia (44) and Bangladesh and (45). This might be due religion is critical sociocultural dimensions that had signi cant impacts on attitudes towards and the uptake of contraceptive methods.
Religious prohibitions hinder the acceptability of contraceptives even in area with adequate FP services despite who perceive FP to be of bene t to their well-being are more likely to use contraceptive methods (46). This condition ultimately has an impact on the successful implementation of FP programs.
High household wealth was positivly associated with modern contraceptive utilization those young women in poorest household were less likely to use modern contraceptive when compared to richest household. It is comparable to study conducted in Tanzania and Nigeria (47,48). The possible explanation could be related to the implicit costs needed to access health care services, mass media and education, as well wealthier background ought to have better decision making power on contraceptive use (44) .
Health facility visits associated factor with women's use of modern contraceptive utilization. Young married women who visit health facility in last 12 month were more likely to use modern contraceptive.
Study revealed in Malawi(36), India and Zambia (49,50). The possible explanation may be related to getting information about family planning and easily accessing contraceptive service (49,51) .Favorable quality of care and opening hours of the family planning facilities was also found to be strongly associated with modern family planning use (52).
Husband desire more children where associated with modern contraceptive utilization those young women whose husband want more children were less likely to use modern contraceptive. This has agreement with study done in Egypt (44) and Ghana (53). The reason may be those decide desire number of children is tendency to access family planning services (54).Women's internal motivations to achieve their child spacing goal could be the possible reason for higher level of contraceptive use.
Perception of distance from health facility positively affected modern contraceptive utilization. Those young married women who have big problem to access health services were less likely to use modern contraceptive. Studies done in Uganda (7), Egypt (44) revealed that those women lived distance to family planning facilities in uenced use of contraceptive methods. Since the group is young they faced di culty to access family planning by traveling long distance. The challenge may be nical, norm and decision making in about family planning is may be addition possible reason for traveling far distance to access family planning.
This study also revealed geographical region where a woman lived was found to be an important predictor of modern contraceptive utilization. This supported by study done in Malawi(36), Bangladesh(37) and Uganda (7). This might be due to the fact that attributable to the tendency of some region to have higher fertility compared to others .Additional reason may be family planning services ,cultural and religious reason (55).
Community access to health services found to have a positive signi cant association with modern contraceptive utilization. Those young married women who have no big problem to access health services in community were more likely to use modern contraceptive. It is in line with study done in Sub Saharan country, Zimbabwe and Boston (17,56,57). Evidence show that family planning among young women in static health facility is not enough but geographical access has attracted huge attention as a possible major constraint on uptake of services (21). It might be due to provision of community-based programmers have had high success in raising contraceptive use in many settings including social marketing and conventional health facilities ,and have been central to achievements in some countries (23).
Community educational level found to have a positive signi cant association with modern contraceptive utilization. Young married women who lived in high educated community were more likely to use modern contraceptive. Likewise, this is support by study done in low and middle-income countries and Zimbabwe (17,18). The possible explanation might be increasing education might help the discussion on contraceptive and would increase knowledge and utilization of FP methods. Education improves cognitive skills, awareness about health, nancial resources and decision-making power. It provides improved access to the mass media, knowledge and attitude about family planning, access to contraception, correct use of contraception, and nally promotes contraceptive use(58).

LIMITATION OF STUDY
Including GPS can contribute to show more information about modern contraceptive utilization but all cluster has no GPS which few cluster is excluded from this study. This would limit to show modern contraceptive utilization in some area of country. This study not include modern contraceptive utilization among unmarried woman those who are sexually active which need further research to encompass all issue of modern contraceptive utilization. Moreover, this research has limitation to dig out why women not use family planning that needs qualitative study in cold spot area of modern contraceptive utilization.

Conclusion
A total of modern contraceptive utilization in Ethiopia was 36.7% .This study showed that there was a low prevalence of modern contraceptive utilization in the Ethiopia. Religion wealth index, religious, family size, health facility visits within 12 months, husband desire more children, perception of distance from health facility, region, Community access to health services and community educational level were statically signi cant variables for modern contraceptive utilization.
Modern contraceptive utilization is a valuable indicator for national family planning programs because it shows how well achieving a key mission therefore observing statistics of modern contraceptive utilization may understate the true demand for family planning. Intervention to increase modern contraceptive utilization should be by considering spatial distribution and factor associated with it. Factor associated with modern contraceptive utilization is not only individual characteristics of the young married women but also community-level factors that determine it. Thus efforts to increase modern contraceptive utilization in Ethiopia should focus both on individuals and on communities. Ethical clearance was obtained from the ethical review board of Ethiopia public health association (EPHI). Written consent was obtained from Measure DHS International Program which authorized the data-sets and GPS coordinate les. All the data which used in this study are publicly available. The data treated as con dential, and no effort should be made to identify any household or individual respondent interviewed in the survey that was maintained through identi cation number rather than names.

Consent to Publication
Not applicable

Availability of data and materials
The data is available from DHS program. All relevant data are included in the manuscript. However, the minimal data underlying all the ndings in the manuscript will be available upon request.
58. Ahmed A, Zahangir MS. The Impact of Education and Residence on Current Use of Contraception in Ethiopian Women. Global Journal of Health Science. 2019;11(9). Figure 1 Regional of prevalence of modern contraceptive utilization among young married women SatScan analysis of modern contraceptive among young married women