Determinants of Modern Contraception use Among Reproductive Age Women in Cameroon.

Background: In Cameroon, 23% of married women, 34% of sexually active single women have unmet needs for family planning and 58% of reproductive age women are not interested in family planning. This contributes to the high mother mortality rate, which is at 600 per 100.000 live births. In this study, we tried to identify the factors contributing to the current use of modern contraception by Cameroonian women so that they can be act on to meet the unmet need for modern contraception. Methods: The study uses data from 12,411 women aged from 15 to 49 years old included in the demographic health survey of Cameroon 2018/19. Bivariate, then multivariate logistic regression analysis were conducted on the study outcome of Modern versus non-modern contraception. Statistical signicance was taken at p < 0.05. Results: We found out that 18% of the women in Cameroon use a modern contraception. The main determinants for this were; not working, increasing socioeconomic class, no more wanting children, wanting to delay the next childbirth by at least 2 years, and history of domestic violence. Conclusion: The above factors should be considered in the making of a national contraception improvement plan. Meanwhile, none working women being more likely to use a modern contraception should be considered with some reserve because this is a highly unexpected nding.


Plain English Summary
In Central and West Africa, 10% of women between 15 and 19 years old have a baby. Cameroon is a lower middle income country in Central Africa. Here, 600 women die for every hundred thousand life births. In high schools, young girls, when found pregnant are expelled from school if they are not married. In addition to this, 23 women out of one thousand risked their lives in 2010 through clandestine abortion.
Modern contraceptives can be use to prevent unwanted pregnancies. This is the reason why we seek to identify the raison why some women in Cameroon use or do not use modern contraception.
We got information on 12,411 Cameroonian women aged 15 to 49 years old from the demographic health survey 2018/19 of Cameroon. This is a nationally representative data collection on the population of Cameroon, except for the south west region. This dataset includes information on procreation, contraception, sociodemographic data and more. We analysed this data and found out that 18% of women use a modern contraception in Cameroon.
They do so because they are jobless, do not want more children, want to delay the next childbirth by at least 2 years, when they have been victim of domestic violence, or when they are from higher socio economic classes.
In other to address the unmet need for contraception in Cameroon, women corresponding to the above description can be targeted in priority because, they are most likely to accept to use a modern Page 3/19 contraception.

Background
Contraception is all the means used to prevent pregnancy [1]. In line with the sustainable development goal indicator number 3.7.1, 75.7% of the needs of women for contraception were supposed to be met by 2019 but less than half of these needs have been met in middle and west Africa [2]. Here we de ne a need for contraception as a fertile woman who is not pregnant and wants to delay her next child bird of at least two years; a women whose current pregnancy is unwanted or consecutive to the failure of a family planning or; a woman in the postpartum period whose last childbirth in the last 2 years was unwanted or consecutive to the failure of a family planning. Meeting these needs implies giving to every woman the modern contraception method that corresponds to her needs and her preferences [3].
In central and west Africa each woman has on average 5 to 6 children and 10% of girls aged between 15 and 19 years have a baby. Each year, 100,000 women are dying of preventable pregnancies; all this illustrating the 24% unmet women's needs for contraception in these regions [3].
Cameroon is a lower middle income country, located in central Africa, with a population of roughly 25 million people and a sex ratio of 1 in 2018 [4]. In Cameroon, 23% of married women and 34% of sexually active single women have unmet needs for family planning [5]. Around 48% of sexually active unmarried women use any type of contraception. Some of the barriers to accessing contraception in Cameroon include several misconceptions about contraception, the cost, the limited options, and so on [6][7][8]. This partly explains the high level of unplanned pregnancies and the mother mortality rate, which is at 600 per 100.000 live births [9]. Providing access to their favourite contraceptive method to these women can improve the health of all Cameroonians and the standard of life. A spacing of birth of 2 to 3 years reduces the infant mortality rate by 45% compared to when this is less [2]. This explains why it is important to identify these determinants of the use or non-use of modern contraception by women in Cameroon. This will allow us to act promptly on them to feel the gap of unmet need for family planning more e ciently and effectively; thereby contributing to the development of Cameroon by improving the literacy rate and the rights of women, reduction in maternal mortality rate and neonatal mortality among others [2]. Meeting these needs may also contribute to reduce the proportion of women who currently are not interested by any family planning which is at 58% [5]. These are the reasons why, we asked ourselves; what are the determinants for the use or non-use of modern contraceptive methods among women in Cameroon?

Study Design
The study was a retrospective cross-sectional study that extracted data from the 2018 demographic health survey (DHS) data set of Cameroon.

Study Population
The study population consisted of women of reproductive age: 15-49 years old who consented to participate in the DHS program. From this population were excluded pregnant women, and those with incomplete data on current family planning method.

Study variables
The study variables included socio-demographic and behavioural variables. These variables are as listed: age, marital status, number of co-wives, age at rst cohabitation, highest educational level, religion, work status, region, type of place of residence (urban/rural), number of children born, number of sons dead, daughters dead, number of children alive, sex of children, number of household members, number of children under 5 in households, sex of household head, age of household head, wealth index combined, wealth index for urban/rural, ever had a terminated pregnancy, time since last sex, desire for more children, husband's desire for children, exposure to need for contraception, decision maker for using contraception, person who usually decides on respondent's health care, ever been humiliated by husband/partner, ever been threatened with harm by husband/partner, ever been insulted or made to feel bad by husband/partner, ever experienced any form of violence, covered by health insurance, number of caesarean deliveries.

Data Management
Data was cleaned and analyzed using R version 4 for windows. The recoding of variables and the study outcomes was done as per previous literatures. The study objective was to assess factors in uencing the use of modern contraceptive. A binary outcome variable was generated by coding 1 for the use of modern contraceptive and 0 for the non-use of modern contraceptive or not using at all any contraceptive. The outcomes were classi ed as shown in Table 1  Data was analyzed using R version 4.0 for Windows. The participant characteristics were presented by use of frequencies and percentages for categorical variables and were strati ed by type of family planning method. Difference between these groups were assessed by use of chi-square statistics and sher's exact count for variables that had cell counts less than 5. The prevalence of family planning use was presented by use of frequencies and percentages. Bivariate logistic regression analysis was conducted for the study outcome of Modern versus non-modern contraceptives. Variables that had a p < 0.1 in the bivariate logistic regression analysis were t in the multivariate logistic regression analysis. All the study data was weighted. Associations were reported by use of unadjusted and adjusted odds ratios with their respective 95% con dence intervals (CIs). Statistical signi cance is taken at p < 0.05.

Participants' characteristics
The study analyzed data from 12,411 women aged 15 to 49 years old. All the participants had had sex at least once in their lives. We found out that, the biggest age category in this group is 20 to 29 years old, representing 34% (4,185 women) of the studied population. Of all the women included in the study, 56% (6,965 women) were living in an urban area and 44% (5,446 women) in the rural area; 55% (6,773) were married or cohabiting, and 45% (5,638) were single, separated or widowed.

Modern contraception use
Of the included 12,411 women, 18% (2,231 women) were using a modern contraception split into 9.8% using a short acting contraception, 8.2% a long acting contraception, 8% a long acting reversible, and 0.2% a long acting non reversible.
a. Factors associated with the use or non-use of modern contraceptives On the univariate regression model, the main factors associated with an increased likelihood of using a modern contraception were: age below 40, increasing level of education, not working, increasing wealth, history of terminated pregnancy, desire to delay or stop childbirth, ever been victim of domestic violence, being cover by a health insurance, the household head being a female. People from the East region and Catholics were the most likely to use a modern contraception (p < 0.05).
The factors found to be associated with a lesser likelihood of use of modern contraception were: increasing number of co-wives in a polygamous marriage, having more than two children alive, having had a death child, decision about the respondent's healthcare made only by the partner, postpartum period, husband wanting more children, and living in a rural area. Women from the Adamawa region were the less likely to use a modern contraception (p < 0.05).
There was no association between the use of modern contraception and marital status, sex of children, number of household members, and decision maker for using contraception. (Table 2)

Discussion
The study provides a global picture on the use of modern contraception in Cameroon, in the years 2018 and 2019. It was based on nationally representative data, except for the South-west region, and included 12,411 women aged 15 to 49 years old. The study revealed that the national prevalence of modern contraception is 18% (2,231 women), 9.8% for short acting contraception, 8.2% for long acting contraception, 8% for long acting reversible, and 0.2% for long acting non-reversible contraception. The prevalence of 18% for modern contraception among women in Cameroon is less than the 58.9% found in the Biyem-Assi Health District in Yaounde, inferior to the 34.8% use of male condom in the health district of Mbouda [8,10]. This is because these areas are relatively urbanized and living in an urban area has been shown to be associated with an increase in the use of modern contraception (Table 2). This prevalence of modern contraception is higher than the 14% observe in the neighbouring country Nigeria [11]. This might suggest a better enforcement of modern contraception in Cameroon compare to Nigeria.
Not working, increasing wealth, no more wanting children, wanting to delay the next childbirth by at least 2 years and ever being victim of domestic violence were found on multivariate analysis to increase the likelihood to use a modern contraceptive. Not working as a determinant of modern contraception use was unexpected because, inconsistent with the ndings in Malawi, Ghana, and other parts of the world where working or working out of the house, for women were associated with an increase in the use of modern contraception [12,13]. This might suggest that Cameroonian women understand the nancial burden related to childcare, therefore prefer to delay childbirth until they have an income. Nevertheless, the real raison for this is unclear and further exploration is needed to understand this relationship. Increasing wealth as a determinant for the use of modern contraception is consistent with ndings in other middle income countries [14]. About domestic violence a similar effects was observed in Kenya in 2014 and in Honduras in 2011-12 [15].
The postpartum period and having 2 children under 5 years old in the household, on multivariate analysis were associated with a reduction in modern contraception use. This is in line with the ndings of WHO which shows that postpartum women are those with the highest unmet needs for contraception whereby 95% of women in their rst year postpartum would like to avoid pregnancy in the following 2 years but 70% are not using a modern contraception. Meanwhile, if the postpartum period, appear to be a determinant for the non-use of contraception, this suggest that during this period, women might be going more for lactation amenorrhea as the contraception of choice which is not a reliable method [16]. Further explorations need to be made to clearly understand the raisons for this. The results also suggest that having 2 children under 5 years old in the household might make women wanting to take a break thereby, using a modern contraception.

Conclusion
This study helped us to draw a big picture of modern contraception among women of reproductive age in Cameroon in the years 2018 and 2019 with a low usage at 18%. We also identify some of the factors playing a key role into the current picture. We hope that the government and other key people will make use of these information and address factors such as poverty, postpartum period and so on in order to improve the modern contraception use among women of reproductive age in Cameroon.

Availability of data and materials
The datasets generated and/or analyzed during the current study are available in the Cameroon demographic and health repository, http://dhsprogram.com/data/available-datasets.cfm