Modern Contraceptive Use in Ethiopia: Trend, Determinants, and Spatial Distribution in Women of Reproductive Age

Abstract

Background: The use of modern contraceptives is a cost-effective strategy to reduce high-risk and unplanned pregnancies, abortions, and their associated consequences. However, many developing countries in sub-Saharan Africa, including Ethiopia, are facing low utilization rates and significant unmet needs. In Ethiopia, previous evidence does not provide strong, comprehensive evidence among all women to explain the persistently low modern contraceptive prevalence and high unmet needs. Hence, it is essential to identify trends in modern contraceptive use over time, factors that influence use and unmet needs, and its spatial distributions. Objective: The PhD project aimed to assess the modern contraceptive use in Ethiopia, including trends, determinants of use, and unmet needs, and spatial distribution in reproductive-age women. Methods: A community-based cross-sectional survey using data from the 2014 to 2019 Performance Monitoring for Action Survey datasets was employed for the analysis. Ethiopia is divided into eleven geopolitical provinces, each comprising enumeration areas (EAs) that serve as the sampling frame. Respondents for the PMAET were chosen using a two-stage cluster sampling approach. The first stage involved selecting clusters (EAs) as the primary sampling units, with sampling conducted based on probability proportional to size. The second stage involved systematically sampling households from the selected clusters. The sample for the PMA study consisted of women aged 15-49 from households randomly selected to be nationally representative. For this study, we extracted 30,631 for the trends analysis, 6,117 for the determinants of modern contraceptive use, and 6,636 for the unmet need for modern contraceptives. Data analysis was conducted using Stata version 16.0, R version 4.1.3, ArcGIS version 10.8, and SaTScan version 10.1. The logit-based decomposition analysis, a two-level mixed-effects logistic regression, multinomial logistic regression, and spatial analysis statistical modeling were employed during the analysis. Results: Based on the trend analysis, modern contraceptive utilization increased from 32.5% in 2014 to 37% in 2019, with 94% of the change attributed to changes in behavior. The most significant increase in the mix of modern contraceptive methods from 2014 to 2019 was in the utilization of implants. The proportion of women who utilized modern contraceptives in 2019 was 37% (34.3 to 39.8). The method information index, which assesses the quality of family planning counseling, indicated that only 9.5% of modern contraceptive users reported being informed about all four method information indices. Women who attained primary, secondary, and above secondary XIII levels of education were more likely to report modern contraceptive utilization with AORs of 1.47, 1.73, and 1.58, respectively. Community-level factors have a significant influence on modern contraceptive utilization, which is attributed to 21.9% of the total variance in the odds of using modern contraceptives (ICC = 0.219). Clusters with a higher proportion of agrarian (AOR: 2.27, 95% CI 1.5, 3.44), higher literacy (AOR: 1.46, 95% CI 1.09, 1.94), empowered women and girls about FP (AOR: 1.47, 95% CI 1.11, 1.93) and high supportive attitudes and norms toward FP (AOR: 1.37, 95% CI 1.04, 1.81) had better modern contraceptive utilization. The proportion of unmet need for modern contraceptives in 2019 was also 19.7% (95% CI: 18 21.5). Of these, 13.67% (95% CI: 12.2-15.25) of the women have unmet needs for birth spacing, while 6.03% (95% CI: 5.28-6.87) have an unmet need for birth limiting. Women with supportive norms towards family planning had a lower risk of unmet need for spacing (RRR = 0.92, 95% CI: 0.86, 0.99). Older age lowered the risk of unmet need for spacing in the age groups 40-44 (RRR=0.28, 95%CI; 0.13, 0.59) and 45-49 (RRR=0.11, 95%CI; 0.04, 0.31). Being married increased the unmet need for spacing (RRR = 1.9, 95% CI: 1.36, 2.7) and limiting (RRR = 3.7, 95% CI: 1.86, 7.4). Increasing the number of live children increases the risk of unmet need for spacing (RRR=1.27, 95% CI: 1.16, 1.38) and limiting (RRR=1.26, 95% CI: 1.15, 1.4). Older age increased the risk of unmet need for limiting 40-44 (RRR = 10.2, 95% CI: 1.29, 79.5) and 45-49 (RRR = 8.4, 95% CI: 1.03, 67.4). A significant hotspot cluster of unmet need for modern contraceptives was observed. The significant hotspot clusters of unmet need are located in Harari (RR=2.82) and SNNP, Oromia, Gambella, and Addis Ababa (RR=1.33). Conclusions: Over the past six years, from 2014 to 2019, behavioral factors have driven a noticeable change in modern contraceptive utilization in Ethiopia. Individual and community characteristics that influenced modern contraceptive utilization. In addition, high levels of unmet need for modern contraceptives, particularly for spacing, were observed in Ethiopia, which was influenced by different factors and showed geographical variations. Recommendations To improve modern contraceptive use in Ethiopia, it is recommended to focus on behavioral interventions and education for women in pastoralist communities. Further, it is essential to focus on women's and girls’ empowerment, foster supportive attitudes towards family planning, and enhance overall community literacy to strengthen family planning intervention programs. Finally, it is essential to address the key factors affecting women and work towards reducing disparities in modern contraceptive unmet needs among different Ethiopian regions.