A decade of change in contraceptive use in Ethiopia 1

Transcription

1 A decade of change in contraceptive use in Ethiopia 1

2 Note: The views expressed and arguments made in this document are those of the author and do not necessarily reflect the views of the UNFPA. 2 A decade of change in contraceptive use in Ethiopia

3 Table of contents Foreword 2 Executive Summary 3 I. Introduction 5 II. Data and Method Data source and sample size Method of analysis Study Limitations 11 III. Analysis and Presentation of Results Characteristics of women Background characteristics Fertility Experience Reproductive goals Contraceptive use Trends in contraceptive use Determinants of current contraceptive use Decomposition of trend in contraceptive use Contraceptive method mix Unmet need for contraception Contraception and fertility 39 IV. Discussion 43 V. Summary and Programmatic Implications Summary Programmatic implications 53 References 57 Annex 1. Source of current method: 59 Annex 2. Information given to current contraceptive users: 59 Annex 3. Predicted relationship between CPR and TFR: 60

4 Foreword This report is commissioned by UNFPA, the United Nations Population Fund, and is based on the in-depth analysis of the three Ethiopia Demographic and Health Surveys (DHS 2000, 2005 & 2011). The wealth of data that the DHS provides is instrumental in monitoring and evaluating the performance of health and population programmes. The in-depth analysis primarily focuses on unraveling the evolution of family planning in Ethiopia in the last decade. It was guided by a conceptual framework in the family planning literature and employed rigorous statistical techniques. An independent research team led by Dr. Yared Mekonnen conducted the study. The in-depth analysis shows that Ethiopia has recorded an unprecedented increase in contraceptive use in the last decade largely due to the synergy of the creation of an environment conducive to family planning and favorable social changes. Improved access of the population to family planning information and services through the Government s Health Extension Programme for the rural, remote and underserved population, especially in the second half of the last decade, is among the main drivers of change in contraceptive use in the country. The social changes identified by the researchers were the increase in the participation of females in primary education and the expansion of urbanization in the last decade. The recent decline in child mortality has also been credited for the changes witnessed. Inequalities in contraceptive use across regions and socio-economic groups, the skewed method mix that is heavily tilted towards Injectables and the still high unmet need for family planning were highlighted by the study among the challenges of the country s family planning program. Several programmatic recommendations have also been discussed. I would like to put on record my sincere appreciation for the research team and for those who provided valuable comments on an earlier version of the report. We hope that this report will be of value and provide insights that will contribute to the understanding of the successes and challenges of the Ethiopia family planning programme. The programmatic areas highlighted in the report can also serve as useful input in any effort to address existing challenges. 2 A decade of change in contraceptive use in Ethiopia

5 Executive Summary Using data from the Ethiopia Demographic and Health Surveys, this study examines the trend and determinants of contraceptive use, the factors contributing to the recent change in contraceptive use, method mix and unmet need for family planning. The study also examines the effect of the recent increase in contraceptive use on the country s fertility. The analysis was based on 28,333 currently married women in the reproductive age of years that were interviewed in the 2000, 2005 and 2011 Ethiopia DHS. Data analyses encompassed trend, descriptive and multivariate methods. A Logit-based decomposition analysis was employed to tease out the factors contributing to the recent increase in contraceptive use in the country. From 2000 to 2011, contraceptive prevalence increased by more than threefold from 8.2% to 28.6%. Most regions, rural, urban areas as well as populations in different socio-demographics have seen significant increase in contraceptive use over the last decade. Yet, the increase vary greatly by region and there are also regions that exhibited contraceptive use stalling in recent years. Decomposition analysis suggests that the increase in contraceptive use in the country is largely a result of improvement in population access to family planning information and services through the Government s health extension program, increase in women s education and increase in urbanization over the last decade. Part of the increase is also associated with improvement in child survival in the last decade. It should be emphasized that contraceptive increase occurred in the country mainly through implementation of latent demand for fertility regulation without accompanying change in fertility desires. Inequalities in contraceptive uptake by urban-rural residence, region, education, women s employment and religion have persisted in the country. Moreover, the dominant role of men in shaping women s contraceptive behavior through influencing women s fertility preferences is also emphasized by this study. The skewed method mix that heavily relied on Injectables is not compatible with the high proportion of women who desire to limit birth. Analysis demonstrated that a good portion of current contraceptive users are in need of better i.e. long acting/permanent contraceptive method in order to decisively meet their desire for limiting. Notable improvement in the use of Implant has also been recorded in the last decade, accounting for 12% of the overall contraceptive use in The increase in contraceptive use during emerged as the single most important source for the recorded decline in TFR of one child per women; accounted for 23% of the decline in TFR. In conclusion, contraceptive use in Ethiopia has improved considerably in the last decade principally due to the synergy of a conducive family planning program landscape and favorable social changes. Nevertheless, Ethiopia still remains one of the countries with low contraceptive use rate. Unmet need is still high (25.3%) although it has declined in the last decade as contraceptive use has risen and about half of the women have unsatisfied demand for family planning. There is a great potential to further improve contraceptive usage in the country and this study discuses several programmatic implications of the findings and also suggests areas for improvement. A decade of change in contraceptive use in Ethiopia 3

6 4 A decade of change in contraceptive use in Ethiopia

7 I.Introduction Family planning is one of the most successful development interventions of the past 50 years. It is unique in its range of potential benefits, encompassing economic development, maternal and child health, educational advances, and women s empowerment [1]. Increasing access to and use of family planning is not one of the Millennium Development Goals (MDGs); but it can make valuable contributions to achieving many of the goals. Increased contraceptive use can significantly reduce the costs of achieving selected MDGs and directly contribute to reductions in maternal and child mortality [2]. Yet, today more than 200 million women and girls in developing countries who do not want to get pregnant lack access to contraceptives, information, and services which, for many, will cost them their lives [3]. With a population of nearly 83 million in 2010 [4], Ethiopia is the second most populous country in Africa next to Nigeria. The population grows at a rate of 2.6 percent per annum. The vast majority of the people (84 percent) reside in rural areas, agriculture being the major source of livelihood [5]. Women of reproductive age make up one-fifth of the total population of Ethiopia and about 45% of the female population. In Ethiopia, as in most African countries, women play the principal roles in the rearing of children and the management of family affairs. On the other hand, the health status of these women remains poor. Unwanted pregnancy and unmet need for family planning are still high in the country; as a result of which women in Ethiopia are characterized by high fertility children per woman. The maternal mortality ratio in Ethiopia is estimated at 676 per 100,000 live births, which is one of the highest in the world [5]. In 1966, the Family Guidance Association of Ethiopia (FGAE), which is an affiliate of the International Planned Parenthood Federation (IPPF), was formed. The program initiated the provision of family planning services with the aim of providing family planning information, counseling and services to families who voluntarily expressed their need to space or limit birth [6]. At the time the FGAE started its program it suffered from opposition from government officials, religious leaders, and the community due to the then strong attitude against birth control and pronatalist views of the government. FGAE was not given legal status until 1975 when it was officially registered with the then Ministry of Interior, Public Security Department, as a non-profit making voluntary origination. By 1975, the first family planning clinic was opened in Addis Ababa. The Ministry of Health (MOH) integrated family planning with a national maternal and child health (MCH) program in the early 1980s in public facilities [7]. Cognizant of the adverse consequences of rapid population growth such as a high unemployment rate, poor economic performance, a high demand for social services, and a decrease in resources, the government of Ethiopia adopted an explicit population policy in 1993 with an overall objective of harmonizing the country s population growth rate with that of the economy [8]. The policy in particular aims, among others, to achieve a Total Fertility Rate (TFR) of 4 children per women by One of the major strategies of the policy has been to expand family planning program so that contraceptive prevalence increases to 44% by 2015 [8] A decade of change in contraceptive use in Ethiopia 5

8 To this end the Policy aims to expand the diversity and coverage of family planning service delivery through clinical and community based outreach services; encouraging and supporting the participation of non governmental organizations in the delivery of population and family planning related services; creating conditions that will permit users the widest possible choice of contraceptives by diversifying the method mix available in the country. Apart from the National Population Policy, other policies such as the country s Health Policy and the National Policy on Ethiopian Women support the expansion of family planning programs in Ethiopia. For example, the Health Policy emphasizes the need to improve the coverage and quality of family planning services in the country [9]. The National Policy on Women also acknowledged the need to ensure women s access to family planning and other reproductive health services as one of the strategies to empower Ethiopian women [10]. The National Reproductive Health Strategy ( ) stipulates as one of its goals to reduce unwanted pregnancies and enable individuals to achieve their desired family size and to this end outlines several strategies [11]. Since 1975 family planning services have been provided through a variety of mechanisms in the country mainly from public hospitals to community-based distribution systems, to social marketing, and outreach services. At present almost all public hospitals, health centers, and health posts in the country provide family planning services. The advent of the health extension program (HEP) was a turning point in the country s effort to expand family planning services to the underserved rural population. The HEP, launched in 2003, aims to improve access to basic essential health services in severely under-served rural and remote communities. Since 2003 the HEP has been rolled out step by step and achieved full coverage of over 30,000 health extension workers (HEWs) in all rural Kebeles by the end of Family planning has been one of the prominent services of the 16 packages of the HEP. Started at slow pace though, Ethiopia has continuously experienced an increase in contraceptive prevalence in the last two decades. According to the first ever-national survey on fertility and family planning in 1990, only 4% of the women in their reproductive ages were using some family planning methods, of which only fewer than 3% were using modern contraceptives [12]. The contraceptive prevalence rate has doubled between the periods 1990 and 2000 and by the year 2000 it was estimated at 8.2% [13]. The increase has been rapid and unprecedented after 2000 and, subsequent DHS survey in 2005 recorded a twofold increase in CPR and put the rate at 14.7% [14]. With the trend continuing, contraceptive prevalence reached at 28.6% by the year 2011 [15]. Using the DHS trend data, this study provides a comprehensive analysis of a decade of change in contraceptive use in the country in order to provide an information base for the national family planning efforts towards achieving the overall goal of increasing contraceptive use and reducing unmet need for family planning. The analysis presented in this report examines the trends and determinants of contraceptive use, the factors contributing to the recent changes in contraceptive use, trends in method mix and unmet need for family planning. A subsidiary objective of the study was to estimate the effect of the recent increase in contraception on the total fertility rate. The subsequent sections of this report are organized as follows: section two presents the method and data analysis approaches. Section three presents the main results from the data analyses; that encompassed background and fertility characteristics of respondents, contraceptive use trends, determinants, composition of changes in contraceptive increase, trends in method mix, unmet need for family planning and the effect of contraceptive on fertility. Section four discuses the key findings emerging from the analyses. Finally, section five outlines the summary and policy implications of the findings. 6 A decade of change in contraceptive use in Ethiopia

9 II. Data and Method 2.1. Data source and sample size The 2011 DHS was the third DHS carried out in Ethiopia. The first was conducted in 2000 and the second in The surveys were based on nationally representative probability sample that covered the entire country. Women aged years and adult men years were interviewed using standard questionnaires. The three surveys collected several data from mothers or caretaker of live-born infants in the five-year preceding the date of interview. Socio-economic and demographic information was also collected from women and household. The data from the three surveys were pooled into one data file system for analysis. Details about the Ethiopia DHS procedure and methodology can be consulted from the national reports[13-15]. This analysis was based on 28,333 currently married women aged years i.e in 2000, 8644 in 2005 and 10,204 in We obtained the full datasets for the three surveys on a CD-ROM from the Central Statistical Agency of Ethiopia. The DHS data used for this study is openly available and can be downloaded [16] Method of analysis The data analysis encompassed descriptive and trend analysis of contraceptive prevalence rate (CPR), method mix and unmet need for family planning, as well as examination of the determinants of contraceptive use, decomposition of changes in contraceptive use and the fertility effect of contraception. Trend analysis: Trends in contraceptive prevalence rate, contraceptive method mix and unmet need for family planning were examined using descriptive analyses, stratified by region, urban-rural residence, and selected socio-demographics. The trend was examined separately for the and periods. Determinants of contraceptive use: Based on a conceptual framework of the determinants of contraceptive use [17], we examined several factors influencing contraceptive use. The framework outlines four broader sets of determinants of the use of contraception: (1) background characteristics (2) contraceptive goals, (3) fertility experiences and (4) contraceptive access. Contraceptive goals involve fertility preferences that couples may be able to achieve through the use of A decade of change in contraceptive use in Ethiopia 7

10 contraception. These include fertility preference (birth spacing or limiting needs), ideal family size, wife-husband concordance on family size and family planning attitude and reproductive issues. Fertility experiences considers broad life experiences that encompasses the number of living children, age, previous child death, marriage duration, age at first birth and abortion experiences. These factors are known to shape women s and couples decision to adopt contraceptive behavior. Contraceptive access is the availability and affordability of contraceptive methods. Due to paucity of data, only two variables were included to serve as proxy for access to contraceptive service - (1) home visit by HEWs or by community workers or any other health workers who discussed about family planning (last year)- a proxy for the health extension program effort and (2) women who received information and counseling on family planning from health workers in health facility during any visit to health facility (last year). Background characteristics influence each dimension of the determinants. These include residence (urban/rural), region, education, women s employment, and religion. The DHS raw data were provided along with wealth index. The wealth quintiles were trichotomized into low, medium and high wealth scores for the present analyses. Most of the variables are self-explanatory and well defined in the result section. The multivariate analysis of the determinants of contraceptive use was constructed using a Logistic Regression model via hierarchical modeling approach. In this modeling strategy potential independent variables were entered into the model progressively and step by step from distal factors to the proximate factors. We used backward elimination procedure, requiring a variable to reach p<0.05 to be retained in the model. The initial model included only the background variables (residence, region, women s education, husband s education, employment, and religion). This was followed by a backward elimination of variables to retain variables. Variables related to women s fertility experiences (i.e. age, number of children ever born, number of dead children, abortion, age at marriage, duration of marriage and age at first birth) were added on top the variables retained from the initial model. This was followed by a backward elimination procedure to retain variables. The final step added variables related to fertility goal (i.e. fertility preferences, ideal family size, and husband-wife concordance on family size) into the previous model. We present in this report adjusted odds ratio (AOR) and p-value for those variables retained in the final model in order to avoid possible confusion due to presenting several multivariate results. 8 A decade of change in contraceptive use in Ethiopia

11 Decomposition of contraceptive change: The purpose of the decomposition analysis was to identify the sources of changes in the use of contraception in the last decade. The decomposition analysis approach divides the trends in modern contraceptive prevalence into three components - compositional changes, processual changes and interaction. The analysis focuses on decomposing the trend in contraceptive use between the base year (2000) and the end year (2011). The logit or log-odds of contraceptive use where xi is a vector of determinants and βi is a vector of regression coefficients is presented in equation (A) below. Ln[p i /(1-p )] = β x equation (A) i i i The equation (B) below describes the decomposition components and the intercepts. Logit (DHS 2011 )-Logit (DHS 2000 ) = [β 0(2011) - β 0(2000) ]+ P ij(2000) * [β ij( β ij(2000) ]+ β ij(2000) *[P ij(2011) - P ij2=(2000) ] + [β ij(2011) - β ij(2000) ]* [P ij(2011) - P ij(2000) ]..equation (B) In the decomposition model, the various components are defined as follows, where; Pij(2000) is the proportion of the jth category of the ith determinant in the DHS 2000, Pij(2011) is the proportion of the jth category of the ith determinant in DHS 2011, βij(2000) is the coefficient of the jth category of the ith determinant in DHS 2000, βij(2011) is the coefficient of the jth category of the ith determinant in DHS 2011, β 0 (2000) is the intercept in the regression equation fitted to DHS 2000, and β 0 (2011) is the intercept in the regression equation fitted to DHS A decade of change in contraceptive use in Ethiopia 9

12 The compositional component i.e. β ij(2000) *[P ij(2011) - P ij2=(2000) ] is the difference in logits reflecting the changes in contraceptive use brought about by overall variations in proportions of determinants in the duration between the two surveys. The processual component i.e. [β 0(2011) - β 0(2000) ]+ P ij(2000) is the difference in logits which reflects the changes in contraceptive use brought about by overall variations in the impact of determinants in the duration between the two surveys. The interaction component i.e.; [β ij(2011) - β ij(2000) ]* [P ij(2011) - P ij(2000) ] is the difference in logits, which also reflects the changes in contraceptive use brought about by the interaction between changes in proportions of the categories as well as their effects on contraceptive use during 2000 and The difference in the intercepts was obtained by subtracting the 2011 intercept from the 2000 intercept, i.e. [β 0(2011) - β 0(2000) ]. Unmet need for family planning: Unmet need for family planning was divided into two parts as unmet need for spacing and unmet need for limiting. The total unmet need is the sum of unmet need for spacing and unmet need for limiting. The Ethiopia DHS (2011) final report defines unmet need as follows [15] and this present study adopted the same definitions. Unmet need for spacing: Includes women who are fecund and not using family planning and who say they want to wait two or more years for their next birth, or who say they are unsure whether they want another child, or who want another child but are unsure when to have the child. In addition, unmet need for spacing includes pregnant women whose current pregnancy was mistimed, or whose last pregnancy was unwanted but who now say they want more children. Unmet need for spacing also includes amenorrheic women whose last birth was mistimed, or whose last birth was unwanted but who now say they want more children. Unmet need for limiting: Includes women who are fecund and not using family planning and who say they do not want another child. In addition, unmet need for limiting includes pregnant women whose current pregnancy was unwanted but who now say they do not want more children or who are undecided whether they want another child. Unmet need for limiting also includes amenorrheic women whose last birth was unwanted but who now say they do not want more children or who are undecided whether they want another child. Each of the unmet need related variables (unmet need for spacing, limiting and total unmet need) was dichotomized as 1, if a woman has unmet need, 0 otherwise. 10 A decade of change in contraceptive use in Ethiopia

13 Fertility effect of contraception: Bongaarts proposed a multiplicative model where the total fertility rate of a population can be calculated primarily from five proximate determinants and the total fecundity (TF) [18]. These are the index of marriage (Cm), the index of contraception (Cc), the index of induced abortion (Ca), the index of postpartum infecundability (Ci) and the index of primary sterility (Cs). This framework allows the estimation of the relative contribution of contraception for the total fertility. The Model summarizes the effect of each of the proximate determinants of fertility using individual indices that range from 0 to 1, with 0 indicating the greatest possible inhibiting effect on fertility and 1 indicating no inhibiting effect. The index of contraception equals 1 if no contraception is used in the population and 0 if all fecund women use modern methods that are 100 percent effective. The index measuring the effect of marriage patterns on fertility takes the value of 1 when all women of reproductive age are in a union and 0 when no women are in unions. To measure the effect of postpartum infecundability, a value of 1 indicates no women are experiencing postpartum infecundability and 0 means all women are experiencing postpartum infecundability. The index of abortion equals 1 in the absence of induced abortion and 0 if all pregnancies are aborted. A fifth proximate determinant, sterility, is frequently used in analyses of fertility in populations where sterility is common. The index of primary sterility equals 1 when primary sterility is absent among all women, and 0 if all women of reproductive age are sterile. An estimate of the observed total fertility rate (TFR) is produced by multiplying the indices together with the total fertility rate (TF) that one would expect in the absence of the inhibiting effects of the proximate determinants. (i.e. TFR=TF x Cm x Cc x Ci x Ca x Cs). Based on studies of historical populations with the highest recorded fertility, Bongaarts recommends using 15.3 as an estimate of TF, or the maximum number of births. Data analysis software STATA 10 (Stata Corporation, College Station, TX, USA) was employed for data management and analyses. The survey command in STATA was used to declare the strata and primary sampling unit. Proportions, rates and odds ratios presented in this paper were all weighted for the sampling probabilities Study Limitations We did not examine the full array of determinants of contraceptive use; especially those related to service access and quality since they were not collected in the DHS. Yet, we held a strong view that the inclusion of these measurements wouldn t change our main findings and subsequent conclusion, as our analysis captured the most important service access measurements for the rural population. The fact that multivariate analysis was adjusted for region ruled-out some potential disparities in access across regions. Moreover, with the advent of the HEP rural population access to family planning information and services have been greatly improved, diminishing previously-existed inequalities across rural communities. A decade of change in contraceptive use in Ethiopia 11

14 12 A decade of change in contraceptive use in Ethiopia

15 III. Analysis and Presentation of Results 3.1. Characteristics of women Background characteristics Table 1 presents background characteristics of respondents. The DHS surveys interviewed 9485, 8644 and 10,204 currently married women, respectively, in the 2000, 2005 and The vast majority of the women were sampled from the rural area in the three surveys (87.8%- 82.1%), which reflects the demographic reality of the country. There is however a slight change. The proportion residing in the urban areas has shown an increasing trend, from 12.3% in 2000 to 17.9% in 2011, signaling the expansion of urban areas in the country provided that there was no bias in the DHS sampling across the three surveys. Substantial improvement in women s education has been documented over the years. This was in particular the case for primary education that increased significantly from 11.8% in 2000 to 27.8% in But there has not been a similar trend in the proportion of women with secondary or higher education. This finding corroborates the country s recorded success in improving education of girls and women in the last two decades. Similarly, education attainment has been on the rise for the men (partners of respondents) but the improvement is mainly clustered around primary education from 23.2% in 2000 to nearly 40% in Women were asked whether they worked for pay outside their homes. Women s working pattern over the three surveys did not show a clear pattern. In 2000, 63.1% of the women reported that they were involved in some type of work for pay; this was declined significantly to 31.4% in By 2011, there was a reversal trend in that 56.5% were reported working for pay. Across the three surveys, most respondents were Orthodox (43.7% in 2011), followed by Moslem (31% in 2011) and Protestant (22.5% in 2011). Of note, the proportion of Protestants increased substantially from 16% in 2000 to 22.5% in While the proportion Orthodox declined slightly from 49.6% to 43.5% during the period. The vast majority of the respondents (over 85%) were sampled form the three big regions of Oromia, Amhara and SNNP. On the whole there has not been significant change in the proportion of women sampled by region in the three surveys. A decade of change in contraceptive use in Ethiopia 13

16 Table 1: Background characteristics of currently married women, Ethiopia Demographic and Health Surveys, 2000, 2005 & 2011 Year Background Characteristics Residence N=9485 N=8644 N=10204 Urban Rural Women s education Not educated Primary Secondary and higher Husband education Not educated Primary Secondary Higher Working No Yes Religion Orthodox Moslem Protestant Others Region Tigray Affar Amhara Oromiya Somali Benishangul Gumz SNNP Gambela Harari Addis Dire Dawa Percentages weighted 14 A decade of change in contraceptive use in Ethiopia

17 Fertility Experience Table 2 presents the fertility experiences of women including their age, number of living children, dead children, age at first birth, age at marriage and duration of marriage and abortion experiences. The mean age of respondents is close to 31 years and this has remained nearly unchanged over the past decade. Adolescents age years comprises of 7.4% in 2011 while three-quarter were in the age group years. Clearly, marital fertility is notably high in this population with a stable trend over the last decade. On average, women gave birth to a little bit over 4 children. The mean number of living children was 3.3, 3.6 and 3.4, respectively, in 2000, 2005 and Over 30% of the women in 2011 reported five or more children and this has remained nearly unchanged since Notably, there has been a significant decline in the proportion dead children over the last decade. The mean number of dead children declined from 0.91 in 2000 to 0.72 in 2005 and 0.63 in This suggests an average of 31% decline in the proportion dead children over the last decade. The proportion of women who reported three or more dead children declined significantly from 10.9% in 2000 to 7.2% in On the whole, this finding is in agreement with the recently recorded decline in under-five mortality in the country [15]. Women s experience of abortion (induced) has shown significant decline from 17.3% in 2000 to 12.1% in This data is however difficult to interpret as it is often subjected to underreporting besides the possibility of mix-up of induced abortion and miscarriage by the women respondents. For the married women, the mean age at first marriage was reported at round 16 years with no sign of a decline. Because this analysis is restricted to married women it doesn t reflect the true mean of the age at first marriage in the general women population. Only life table analysis that includes both married and unmarried provide the true picture of age at first marriage. The data on duration of marriage revealed that nearly two-third of the women in the three surveys were married for 10 or more years while about 19% for 5-9 years. In 2011, only about 17% were married for 5 or less number of years with no sign of a decline over the last decade. A good indicator of women s fertility initiation is the age at first birth. In the whole, married women across the three surveys began childbearing, on average, at the age of 18 years. On average, these married women had their first birth about two years after marriage. Notably, 42% of the respondents in the 2011 survey reported that they had their first birth before the age of 18 years; another 52% between ages years. These data taken together suggest that early childbearing has been an apparent phenomenon among married women in the country. A decade of change in contraceptive use in Ethiopia 15

18 Table 2: Fertility experiences of currently married women, Ethiopia Demographic and Health Surveys, 2000, 2005 & Year N=9485 n=8644 n=10204 Age Mean age Number of living children Mean Number of dead children Mean Abortion No Yes Age at first marriage <16 years years years Mean Duration of marriage Age at first birth < Mean Percentage weighted 16 A decade of change in contraceptive use in Ethiopia

19 Reproductive goals Data on fertility preferences are useful indicator of general fertility attitudes and the possible future course of fertility. Fertility preferences data also facilitate the assessment of the need for family planning and the extent of unwanted fertility. In the DHS, women were asked whether they wanted to have another child, and if so, how soon. Those who want no more children are considered as having a limiting need; those who want to postpone the next birth for two or more years are considered as having a spacing need. As shown in Table 3, women s fertility preference has changed slightly over the last decade. In particular, there appears a modest change in the proportion of women with birth limiting need from 31.5% in 2000 to 36.5% in While trend was almost stable for birth spacing; at 36.5% in 2000 and 38.2% in Another measure of fertility preferences is a woman s ideal family size. In determining ideal number of children, a respondent was asked to perform a very difficult abstract task of stating the number of children she would like to have if she could start childbearing all over again. In the survey, women with no children were asked, If you could choose exactly the number of children to have in your whole life, how many that would be? Women who already had children were asked, If you could go back to the time you did not have any children and could choose exactly the number of children to have, how many would that be? Non-numeric responses for the ideal family were given by 23.1%, 17.2% and 19.7% of the women, respectively, in 2000, 2005 and 2011 surveys. Of note the majority of the non-numeric responses fall under the category of up to God. Of all women who stated either numeric or non-numeric responses, 37.4% reported five or more children in This represents a significant decline from 48.2% in By contrast, the proportion that reported two or less children increased from 6.7% in 2000 to 14% in In the whole, the noted slight decline in ideal family size over the last decade hints a positive attitudinal change towards smaller family. Understanding the fertility and contraceptive behaviors of couples as a unit is critical because programs focused exclusively on either women or men may fail in their purpose as most sexual, family planning, and childbearing decisions are made or may potentially (and perhaps ideally) be A decade of change in contraceptive use in Ethiopia 17

20 made by both partners together [19]. Available studies show that in many developing countries males often dominate when important decisions are taken in the family, such as on reproduction, family size, and contraceptive use [20]. In the DHS the wife s response is taken as proxy for the couple s response, which may not necessarily reflect the actual fertility behavior of the husband/partner. With this caveat, we present in Table 3 couples concordance on family size (number of children) in the three surveys, taking the wives responses as proxy to the couples. The reporting of concordance in the number of children the couple wanted to have increased significantly from 34% in 2000 to 41.4% in Yet, a third of the women in 2011 reported the lack of concordance with 25% reporting husbands wanted more children. Only 8.7% in 2011 said their husbands wanted fewer children than they did, which is significantly higher than the 5.2% in The reporting of do not know for the question on family size concordance has declined significantly from 33.4% in 2000 to 25.4% in 2011, signaling improved husband-wife communication on family size and, perhaps about family planning over the last decade. Table 3: Characteristics of currently married women by fertility goals, Ethiopia Demographic and Health Surveys, 2000, 2005 & 2011 Year n=9485 n=8644 N=10204 Fertility preference Spacing Limiting Neither Ideal family size (IFS) <= Non numeric Family size concordance Both want same Husband wants more Husband wants fewer Do not know Percentage weighted 18 A decade of change in contraceptive use in Ethiopia

21 3.2. Contraceptive use Trends in contraceptive use This section presents trends in contraceptive use during the period by urban-rural residence, region, and selected socio-demographics, as shown in Table 4. The analysis is restricted to currently married women. On the whole, the country has seen a dramatic increase in contraceptive prevalence rate (CPR) over the last decade - from a low of 8.2% in 2000 to 14.7% in 2005 and 28.6% in This can be translated to an average of 2% increase per annum. Dividing the study period into two i.e and , we examined the trend separately before and after Clearly, the data revealed that the larger share of the increase in CPR occurred during the second half of the last decade. Between 2005 and 2011 the CPR in the country increased by an absolute rate of 13.9% while the corresponding absolute increase during the period was only 6.5%. Though the increase was not equally shared, most regions, rural, urban areas of the country as well as populations in different socio-demographics have seen increase in contraceptive use over the last decade. In 2000 the rural prevalence was staggeringly low at 4.3% where over 85% of the women comprise. In 2005, this has increased significantly to 10.9% and by 2011 the rate reached at 23.4%. The pattern of increase in contraceptive use in the rural area influenced the national pattern in which a faster increase was recorded during the period with an absolute increase of 12.5% in contrast to an absolute change of 6.6% during the period The urban prevalence of 35.8% in 2000 has also shown a significant increasing trend and by 2011 estimated at 52.5%. But most of the increase in the urban areas has occurred during the first half of the last decade - absolute change 10.9% during and 5.8% Regional variation in the rate of change of contraceptive use over the last decade has been apparent. The most dramatic increase (in absolute percentage) was recorded in Amhara region from a low of 7.4% in 2000 to 33.9% in 2011 (absolute change, 26.5%). The recorded change in the Amhara region should be emphasized because the region now ranks third out of the 11 regions in terms of its CPR compared to a rank of 8th in the 2000 survey. Now that Amhara s CPR compares well with the city state of Dire Dawa. Next to Amhara, a substantial absolute increase in CPR (in the range of 17.3% %) was recorded in Gambela, SNNP, Oromia, Benishanfgul Gumuz and Addis Ababa. Regions with markedly slow increase in CPR include Somali, Afara and Dire Dawa with an absolute change in the range of 1.8% to 4.9% between 2000 and Based on the 2011 survey, Somali has the lowest CPR at 4.3% and Addis Ababa the highest at 62.5%. There appears a slow or stabilization of recent trend in CPR in four of the 11 regions, namely Dire Dawa, Harari, Afar and Somali with an absolute increase of less than 3% during the period Addis Ababa has also seen a much slower trend in the second half of the last decade (absolute change 5%) compared to a much faster increase of 12.3% (absolute change) during the period By contrast, the rest of the regions, except Tigray, have been exhibiting a much faster increase in the second half of the decade without a sign of stabilization. Tigray s CPR has increased steadily with comparable rate of growth in the first and second half of the last decade. Increase in CPR over the last decade almost equally shared across the different education groups although in relative terms the uneducated women have exhibited the faster increase than any other education group; nearly 5 times higher than the 2000 rate. Yet, significant variation in CPR by education is quite apparent % for no education, 35.7% for primary and 62.2% for secondary or higher - as per the most recent DHS. A decade of change in contraceptive use in Ethiopia 19

22 The relationship between age and CPR follows an inverted U-shape pattern with relatively lower prevalence among adolescents age and older women age years while higher among women age years (Table 4). Trend in CPR also varies by women s age. The fastest trend was noted among women age years (absolute change at 27.2%), followed by those age years (absolute change, 22%) and age years (absolute change 19.9%). Relatively the lowest increase in CPR was noted among older women age years (absolute change 15.2%). High parity women (5 or more children) have the lowest CPR as well as the slowest trend compared to the women in the lower parity categories. As per the 2011 survey, the highest CPR (32.4%) was associated with women in low parity of 0-2 children while the lowest CPR (22.8%) with women in high parity (5 or more children). CPR among high parity women has shown an absolute increase of 13.3% during the period This was high at 25.8% and 20.6%, respectively, for women with parity of 0-2 and 3-4 children. Not only the levels but also the trends in contraceptive use vary by religion. As per the most recent survey, CPR reported the highest among the Orthodox Christians at 35.1%, followed by Protestants (29.9%), Moslem (19.7%) and other religion groups (16.9%). Trend also follows similar pattern in that the fast increase in CPR was recorded among the Orthodox (absolute change 25.1%) and Protestants (absolute change 23.6%). Among the Moslems the trend was slower at an absolute change of 13.2% during the last decade. 20 A decade of change in contraceptive use in Ethiopia

23 Table 4. Trend in contraceptive use among currently married women, Ethiopia Demographic and Health Surveys, 2000, 2005 & 2011 DHS 2000 DHS 2005 DHS 2011 Absolute change in CPR N=9485 N=8644 N= CPR% CPR% CPR% % % % Residence Urban Rural Region Amhara Gambela SNNP Oromiya Benishangul gumz Addis Ababa Harari Tigray Dire dawa Afar Somali Women s education No education Primary Secondary or higher Age Number of living children Religion Orthodox Moslem Protestant Others Total Percentages weighted A decade of change in contraceptive use in Ethiopia 21

24 Determinants of current contraceptive use Determinants of contraceptive use were examined using multivariate Logistic Regression analysis. The inclusion of variables in the model was based on the conceptual framework discussed elsewhere in this report. Table 5 presents those variables that were retained in the final model. Few variables were erased because their effect waned in the backward elimination process. DHS survey year was included in the model to control for the effect of temporal trend in CPR. The model was also adjusted for region to control for potential disparities in access to services and other unmeasured socio-cultural factors that could vary by region. Several factors emerged as significant predictors of contraceptive use. Women in Addis Ababa were 4.6 times more likely than their rural counterparts to use contraception and this was nearly 3.1 times higher among women in other urban areas. The lower contraceptive use in the rural areas compared to the urban may operate through unmeasured mediating factors. Although the multivariate analysis adjusted for several factors, there are several other factors such as access to services, psychosocial, cultural factors, community/contextual factors that were not included in our analysis due to paucity of such information in the data. The role of education in shaping women s health behaviors has long been established. As expected, we found higher odds of contraceptive use among women with primary (AOR=1.46) and secondary or higher (AOR=1.89) education compared to women with no education. Husband s education also emerged among the predictors of contraceptive use. Compared to women with uneducated husbands, those whose husbands have a minimum of primary education were more likely to use contraception. There was also a dose effect response relationship between husbands education and women s contraceptive behavior, as the likelihood of using contraception in women increased positively with increase in husbands education. Working for pay in women is significantly associated with contraceptive use. A 30% excess odds of using contraceptive was found among women working for pay compared to women who were not working for pay. Possible mediating factors between women s work status and their contraceptive behavior, irrespective of their likely higher education, may include exposure to a network of peers with positive attitude towards small family and family planning, and competing time demand for child care may work against large family thereby increasing their receptiveness to family planning. The major religions in Ethiopia, Orthodox and Muslims, do not openly approve the use of family planning. Nevertheless, we found a significantly higher contraceptive use among the Orthodox than any other religious group. Compared to the Muslims, Orthodox women were found 57% more likely to use contraception. But we didn t find significant difference in the likelihood of using contraception between Protestants and Muslims. Followers of other religion (other than the three predominant religions) were 22% less likely to use contraception than their Muslim counterparts. Women age years were 14% more likely than the adolescents age years to use contraception. On the other hand older women (35-49 years) were not different than the adolescents in their odds of using contraception. Women who experienced child death were less likely to adopt contraception compared to women who have not experienced child death. The odds of using contraceptive increased by 36% among women who did not experience child death at all as compared to women who experienced the deaths of two or more children. 22 A decade of change in contraceptive use in Ethiopia

25 Experience of abortion is negatively associated with contraceptive use. There was a 14% decreased odds of using contraception among women who had experienced abortion compared to those without such experience. This could be bi-direction because unwanted pregnancy is naturally higher among non-contracepting women and abortion is often practiced to terminate unwanted pregnancy. Women s fertility goal as measured by their stated need for birth limiting or spacing as well as their ideal family size were found to significantly shape their contraceptive behaviors. Higher odds of contraceptives use was associated with women having birth limiting (AOR=2.96) and birth spacing (AOR=2.12) needs compared to women without birth spacing or limiting needs. Women with an ideal family size of four or less were significantly more likely than those who did not state their ideal family size i.e. with non-numeric response to use contraception (AOR= ). On the other hand, a 15% lower odds of contraceptive uptake was associated with an ideal family size of five or higher compared to those who did not state their ideal family size. In order to measure husband-wife concordance on the number of children, wife s response was taken as proxy for the couple s response. The multivariate analysis shows that after adjusting for several factors, spousal disagreement on the number of children they would like to have significantly influences women s contraceptive behavior. In particular, in couples where the husbands preferred to A decade of change in contraceptive use in Ethiopia 23

26 have more children than the wives, the likelihood of using contraception decreased by 28% as compared to couples who concord on the number of children. By contrast, higher family size preference by women as opposed to their husbands did not influence their contraceptive behavior negatively. This finding is indicative of the prevailing power relationship between couples and the dominant role of men in making fertility decision on behalf of the couples. The likelihood of contraceptive use was lowered by 48% among women who did not know the family size preferences of their husbands. Such couples may represent those who lack communication or discussion about family size and family planning. Two indicators were examined as proxy for access to family planning information and services - (1) home visit by community worker, health extension workers, or any other health workers who discussed about family planning (last year) - a proxy to the HEP effort; and (2) women who received information and counseling on family planning from health workers in health facility during any visit to health facility (last year). Other access indicators such as distance to the nearest facility, availability of services in the cluster, availability and accessibility of family planning commodities, among others, were not included in this analysis because information on these variables were not available in the DHS. With stipulation of these data gap, our analysis shows that women who reported being visited by community workers/hews/health workers in their homes to discuss family planning were 27% more likely to adopt contraception compared to those women without access to family planning information via home visits. Similarly, when women received information and counseling about family planning in health facilities they were 91% more likely to use family planning. This finding should be interpreted with caution since it doesn t suggest causality and could be bi-directional. It may well be that women who are using family planning were told about the method they were adopting during regular visit for the family planning service. 24 A decade of change in contraceptive use in Ethiopia

27 Table 5. Multivariate adjusted odds ratio (AOR) and p-values in the estimation of the current contraceptive use (Final model), Ethiopia Demographic and Health Surveys, 2000, 2005 & 2011 AOR (p-value) Residence (ref: Rural) Addis Ababa 4.6*** Other urban 3.1*** Women s education (ref: no education) Primary education 1.46*** Secondary education 1.89*** Husband s education (ref: no education) Primary education 1.46*** Secondary education 1.62*** Higher education 1.87*** Women s work (ref: not working) Women working 1.30*** Religion (Ref: Moslem) Orthodox 1.57*** Protestant 1.05 Others 0.78* Age (ref: age year) * Experiencing child s death (ref: 2 or more dead children) No dead child 1.36*** One dead child 1.11 Abortion experience (ref: never had abortion) Had abortion 0.86* Fertility preference (ref: neither spacing nor limiting) Wanted to space 2.12*** Wanted to limit 2.96*** Ideal family size (ref: Non-numeric) *** *** * Husband-wife on family size (ref: Husband-wife concords on the number of children) Husband wants more children 0.72*** Husband wants fewer children 0.97 Do not know husband s preference 0.52*** Visited by HEW/community worker (last year) who told about FP (ref: No) Yes 1.27*** Told about FP in health facility (last year) (ref: No) Yes 1.91*** Final model adjusted for year of DHS and Region, AOR (Adjusted odds ratio) for the reference category=1; ****p<0.000, **p<0.001, *p<0.05 A decade of change in contraceptive use in Ethiopia 25

28 Decomposition of trend in contraceptive use Ethiopia has seen an unprecedented increase in contraceptive use over the last two decades. In 1990, only 4% of the women were using family planning and this has doubled to 8.2% in 2000 and trend was faster afterwards and by 2011 the country achieved a prevalence of 28.6%. Identifying the source of changes in contraceptive use (changes in structure or changes in population behavior) over the last decade has programmatic importance. The decomposition approach divides the trends in contraceptive prevalence into temporal change in population composition (compositional changes) and change in behaviors leading to adoption of contraception (processual change) from the first (2000) and the last DHS (2011). The Logit-based Decomposition was described in the method section of this report. This section presents findings from the decomposition analysis. The findings suggest that both compositional and processual changes were responsible for the increase in contraceptive use over the last decade but compositional changes appeared to have the greater role (Table 6). Sixty-nine percent of the change in contraceptive use during the period was attributable to compositional changes. Nearly 40% of the overall increase in contraceptive use was accounted for by the compositional changes related improved population access to family planning information and services and social changes (as measured by increase in women s education and urbanization). As shown in Table 6, 14.5% of the change in contraceptive use during the period was attributable to improved population access to family planning information and services through home visit by HEW/community workers (a proxy to the HEP). Increase in the proportion of women who achieved primary education contributed to 14.1% of the change in contraceptive use in the last decade. About 11% of the increase in contraceptive use was the result of increased urbanization, as measured by the proportion of women who resides in the urban area. Compositional changes related to women s and couples reproductive goals appeared to have modest contribution to the decline in contraceptive use. Of all the changes in contraceptive use, about 9% was attributable to the increase in the proportion of women who wanted to limit birth; another nearly 9% due to increased couple s concordance on family size. Compositional changes that have small contribution towards contraceptive include increase in the educational attainment of husbands, increase in the proportion of women who want to space birth, increase in husbands positive attitude towards fewer children among few others. Of note, the negative signs on the percentages indicate those compositional changes having reversal effect on contraceptive use. Figure 1 presents the major compositional changes that occurred in the population over the last decade to bring about significant increase in contraceptive use. Unprecedented increase in the proportion of women visited by HEWs/community workers for family planning information and services from 2% in 2000 to 19.3% in 2011 was the major driver for the recent increase in contraceptive use in the country. During the last decade, the proportion of women with primary education increased from 11.8% in 2000 to 27.8% in At slow pace though urbanization has been on the raise in Ethiopia in the last decade. The data show the proportion of women residing in the urban area rose from 12.3% to 18%. Positive changes towards birth limiting from 31.5% in 2000 to 36.5% in 2011 has been reported in the last decade. Couples concordance on family size has also increased slightly in the last decade from 34% to 41.4%, which contributed to change in contraceptive use. Changes in propensity towards family planning 26 A decade of change in contraceptive use in Ethiopia

29 adoption by some group of women have also contributed to the increase in contraceptive use. Indeed, about 23% of the changes in the overall contraceptive increase were attributable to processual changes. The processual changes are predominantly related to increased adaptation of family planning over time by the Orthodox and Protestant women and those women who have not at all experienced child death or with one dead child as opposed to those women who experienced the death of two or more off springs. Small part of the processual change was also related to an ideal family size of 3-4 children and by women working for pay. In these groups of women receptivity towards family planning has increased over the last decade. Whereas no similar trend towards receptiveness to family planning was seen in the other population groups studied. We compared Multivariate regression Adjusted odds ratio (AOR) that were obtained by fitting the data on the 2000 and 2011 survey data. Higher AOR suggests stronger association between the factor and contraceptive use. As shown in Figure 2, the AOR for an ideal family size of 3-4 children increased from 1.08 (in 2000) to 1.51 (in 2011). For instance, in 2000, the likelihood of using contraception was only 16% higher among the Orthodox compared to their Muslim counterparts. By 2011, this likelihood has increased to 1.88; this means the odds of using contraceptive by Orthodox women was 88% higher than that of Muslims. Similarly, the adjusted odds ratio for Protestants (vs. Muslim) increased from 0.7 in 2000 to 1.35 in In concrete terms, these findings indicate that Orthodox and Protestant women (unlike in the Muslims) have recently become more receptive to family planning and began implementing their desires for fertility regulation. Women with an ideal family size of 3-4 were only 8% more likely to use contraception compared to those with non-numeric responses in By contrast, the odds ratio for the same was increased to 1.54 in 2011, indicative of the increased behavioral change towards contraception adoption by women with an ideal family size of 3-4 over the last decade. Similarly, increased adoption of family planning by women who experienced no or one child s death has also contributed to the overall change in contraceptive use in the country. The increased adjusted odds ratio of 1.45 in 2011 compared to 1.14 in 2000 was statistically significant. Another processual change that occurred over the years was the increase in the propensity to use contraception by women working for pay that contributed to the overall change in contraceptive. Change in AOR for working women (vs. non-working) from 1.19 in 2000 to 1.35 during was seen. Though accounted for a small percentage of the change in contraceptive use, some interaction effects were also apparent. The synergetic effect of the increase in the proportion of women without dead off springs (from 53% to 61%) and the increased adoption of contraceptive by these women contributed to 6.1% of the increase in contraceptive use. Similarly, the interaction effect of increase in the proportion of protestants (16.5% to 11.5%) and the increased adoption of contraception by protestants accounted for 5.5% of the increase in contraceptive use. A decade of change in contraceptive use in Ethiopia 27

30 Table 6. Decomposition of changes in contraceptive use related to processual (%), compositional changes (%) and interaction effects (%) during the period , Ethiopia Demographic and Health Survey Processual (%) P 2000 * (β β 2000 ) Logit (DHS 2011 )-Logit (DHS 2000 ) Compositional (%) β 2000 *(P P 2000 ) Logit (DHS 2011 )-Logit (DHS 2000 ) Interaction (%) (β β 2000 )* (P P 2000 ) Logit (DHS 2011 )-Logit (DHS 2000 ) Urban (-) (-)3.5 Primary education (-) (-)9.7 Secondary education (-) (-)1.1 Primary education (husband) Secondary education (husband) (-)6.2 (-) Higher education (husband) (-) (-)2.3 Women working 10.0 (-)1.5 (-)1.0 Orthodox 31.1 (-)1.1 (-)3.8 Protestant 13.6 (-) Others (-) Age: (-) (-)0.8 Age: (-)12.7 (-) No dead child One dead child 16.8 (-) Had abortion (-) (-)0.7 Wanted to space Wanted to limit Ideal family size: Ideal family size: Ideal family size: (-)0.3 Husband-wife concords on the number of children (-) (-)2.4 Husband wants more children (-)8.6 (-) Husband wants fewer children (-) (-)0.4 Visited by HEW/community worker (last year) who talked about FP (-) (-)8.0 Told about FP in health facility (last year) (-)10.5 (-) % contribution to CPR change % of the change in CPR is attributable to change in the intercept 28 A decade of change in contraceptive use in Ethiopia

31 Figure 1. Selected major compositional changes (%) that occurred during the period , Ethiopia Demographic and Health Survey % women visited by community workers/hew at home (who talked about FP) % women with primary education % women who live in urban area % women who wanted to limit birth % women who reported couples' concordance on famil size Figure 2. Selected major processual changes (expressed by change in AOR) that occurred during the period , Ethiopia Demographic and Health Survey 1.88 Adjusted Odds Ratio (AOR) AOR= AOR for Orthodox christians (Ref. Muslim) AOR for Protestants (Ref: Muslim) AOR for women with no or 1 dead child (Ref: 2+ dead children) AOR for women with ideal family size 3-4 (Ref: Non-numeric) AOR for women working for pay (Ref: Non working) A decade of change in contraceptive use in Ethiopia 29

32 Contraceptive method mix An understanding of the distribution and trends of contraceptive method mix in the population is of paramount importance for programmers who are involved in the provision of contraceptive commodities and forecasting future needs. It also provides information on whether women are using contraceptive methods that are suitable for their fertility preferences. A skewed method mix: Figure 3 presents estimates of the method mix for the three surveys. A skewed method mix has been apparent in the country with only three methods, namely Injectables, Norplant and Pill accounted for 92% of all contraceptive use in Indeed, Injectables is by far the most predominant method in use. The share of Injectables has been on the rise over the last decade from 37.5% in 2000 to 67.2% in 2005 and by 2011 about 72.6% of all contraceptive use accounted for Injectables. The data also captures the recent effort by the Government of Ethiopia that promoted the use of Implanon in the country. In 2000 and 2005 the share of Implanon to the total contraceptive use was very low at 0.5% and 1.2%, respectively. There has been a remarkable shift in the share of Implanon to 12% in A reversal trend in the proportion of all contraceptive use that was accounted by the Pill has been recorded over the last decade. The recent DHS found that only 7.4% of the total contraceptive use was accounted by the Pill; this was by far lower than the 31.2% and 21.1%, respectively, of the share of the Pill in 2000 and Other methods taken together contributed to less than 8% of the overall contraceptive use in Figure 3. Distribution of current contraceptive users by type of method, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey 30 A decade of change in contraceptive use in Ethiopia

33 Trend in method mix: Table 7 presents trend in method-specific prevalence. We estimated the annual percentage-point change, which is a linear interpolation of prevalence between two-points. It is simply the difference in prevalence between the two time-points, divided by the number of years elapsed between surveys. The most substantial growth in method-specific prevalence occurred for Injectables - from 3.1% in 2000 to 20.8% in The annual percentage point change for Injectables was 1.61% during the period 2000 to Increase in the use of Injectables has been much faster in the second half of the decade - from 9.9% in 2005 to 20.8% in This represents an annual percentage change of 1.81%. Implanon has been increasing at annual rate of 0.54% in the second half of the last decade; prevalence increased from 0.2% to 3.4% between 2005 and Pill prevalence has shown a reversal trend from 2.6% in 2000 to 2.1% in 2011; an annual rate of decline of -0.04%. Of note, other family methods not only are rarely in use but also have not improved over the last decade. Table 7. Trend in current contraceptive prevalence by method, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey % using method Annual percentage-point change (%) Injectables Implanon Pill Rhythm method Female sterilization IUD Withdrawal Condom Lactation Amenorrhea A decade of change in contraceptive use in Ethiopia 31

34 Figure 4 depicts trend in the three predominant contraceptive methods by place of residence. Irrespective of the place of residence, the prevalence of Injectables increased significantly since The annual percentage point of change of Injectables was 2%, 1.9% and 1.5, respectively, in Addis Ababa, other urban area and the rural. The relative rate of increase has been dramatic in the rural area from 1.5% in 2000 to 17.6% in 2011, which can be translated to an increase of 97.6% per annum. In Addis Ababa and other urban areas, the relative increase in Injectables was 13% per annum. The increase in Implanon has been more vivid in the rural and urban areas other than Addis Ababa. In the rural and other urban areas it increased from almost nil to 3.3% and 4.1%, respectively. Of note, the 2011 prevalence of Implanon in Addis Ababa (2.8%) was lower than the rate in the rural as well as in the other urban areas. Figure 4. Trend in the use of Injectables, Implanon and Pills by residence, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey 32 A decade of change in contraceptive use in Ethiopia

35 Need for better contraceptive methods: A closer look at the data on method mix reveals that a good portion of current contraceptive users were not using appropriate method and thus are in need of better methods. Current contraceptive users can be categorized in accordance with their fertility preferences - birth limiters or spacers. A woman is considered using inappropriate contraceptive method (thus in need of better method) if she wants to limit birth but uses a short-term (or spacing) method. In 2011, 19.3% of the contraceptive prevalence was associated with appropriate methods while the remaining 9.3% with inappropriate methods (Figure 5). This means of all current contraceptive users in 2011, about a third was using inappropriate method and were in need of a better method i.e. long term/permanent method. The trend data depicts that the proportion using inappropriate contraceptive method rose in parallel with the overall prevalence of contraceptive use - 3.2%, 7.1% and 9.3%, respectively, in 2000, 2005 and Figure 5. Among all currently married women in the reproductive age, the percentages that were using appropriate and inappropriate contraceptive methods, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey Inappropriate method, 9.3 % Inappropriate method, 3.2 % Appropriate method, 5.0 % Inappropriate method, 7.1 % Appropriate method, 7.6 % Appropriate method, 19.3 % A decade of change in contraceptive use in Ethiopia 33

36 Unmet need for contraception The indicator unmet need for contraception is defined in greater detail in the method section of this report. When unmet need is measured in a comparable way at different dates, the trend indicates whether there has been progress towards meeting women s needs in this regard. It should be noted that, even when contraceptive prevalence is rising, unmet need for family planning may sometimes fail to decline, or may even increase. This can happen because the demand for family planning increases due to declines in the desired number of children. Changes in the desired spacing or limiting of births or changes in the percentage of women who are at risk of pregnancy can also influence the trend in demand for family planning, independently of trends in contraceptive prevalence [21]. Figure 6 presents the distribution of unmet need and demand for family planning overtime. Unmet need for family planning declined significantly over the last decade from 35% in 2000 to 25.3% in The decline was almost equally shared by the unmet need for spacing (from 21.3% to 16.3%) and limiting (from 13.7% to 9%). Across the three surveys unmet need for limiting was lower than that for spacing. The sum of the percentage of currently married women using contraception (met need) and the percentage with an unmet need gives the total potential demand for family planning [22]. The demand for family planning also increased significantly from 43.2% in 2000 to 53.9% in By 2011, 53.1% of the demand for contraception was satisfied; this was remarkably higher than the 19% documented for Figure 6. Trend in unmet need, demand for family planning and the proportion of total demand satisfied, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey Unmet need for spacing Unmet need for Limiting Total Unmet need Contraceptive Prevalence Rate Demand for family planning (CPR+Total unmet need) % Demand satisfied A decade of change in contraceptive use in Ethiopia

37 Trend in unmet need for family planning: Trend in the total unmet need for family planning is shown in Table 8. At the national level, the faster decline in unmet need occurred in the second half of the last decade than in the first half. During the period unmet need declined by 8.5% (absolute percentage points); the corresponding decline during the period was only 1.2%. This pattern holds for the rural population with the faster decline occurring in the second half (absolute change, 8.3%) versus a change of 0.6% during the period By contrast, in the urban area unmet need declined quickly in the first half of the last decade (absolute decline, 8%) while stabilizing in the second half (absolute decline, 1.8 %). This pattern also holds in Addis Ababa. After declining by an absolute rate of 8.6% during , trend has stabilized in the second half of the last decade in Addis Ababa (absolute change +0.4%). The 2011 data revealed variation in unmet need by region, ranging from a low of 10.6% in Addis Ababa to 29.9% in Oromia. This variation across region in unmet need should be interpreted with caution because low or high unmet need rates do not necessarily reflect family program success or failure. Afar s situation is a good example for this. Afar has both low unmet need and low contraceptive use predominantly due to the low desire for fertility regulation in the region. In contrast, the observed low unmet need in Addis Ababa is the synergy between high contraceptive use and low demand for birth limiting or spacing, as most of the demand for family planning was satisfied in the region. Trend in unmet need also varies substantially by region. Nine out of the 11 regions saw decline in unmet need over the last decade; exceptions to this were Afar and Somali where reversal trends were recorded. The fastest decline in unmet need was observed in Amhara from 39.6% in 2000 to 22.1% in 2011 (absolute change 17.5%). Next to Amhara, trend was fast in Gambela (absolute change, 13.8%), SNNP (absolute change, 9.9%), Addis Ababa (absolute change, 8.2%), Benishangul Gumuz (absolute change, 7.4%), Oromia (absolute change, 6%) and Harari (absolute change 5.3%). An absolute decline of less than 5% was noted in Dire Dawa and Tigray. Unmet need has been on the raise in Somali in the last decade from 12.9% in 2000 to 24% and in Afara from 11.5% to 16%. Levels and trends of unmet need also vary by education, age and number of living children. An inverse relationship between women s education and unmet need can be noted from the data. As per the 2011 data, unmet need was lower at 10.1% among women with secondary or higher education while higher at over 26.3% for those without secondary education. Trend was also faster for women with secondary or higher education during the last decade (an absolute change of 18.6%) vis-à-vis absolute changes of 8.2% and 14.4%, respectively, for women with no education and primary education. Trend in unmet need also varies by religion. The fastest decline in unmet need was recorded among the Orthodox from 37.6% in 2000 to 21.9 % in 2011 (an absolute decline of 15.7%). But trend was nearly stable for the Muslims at 31% in 2000 and 29.8% in 2011 (an absolute decline of 1.2%). Protestants also exhibited considerable decline in unmet need (about 10 % decline), next to the Orthodox. Adolescents age in particular exhibited the highest unmet need for family planning in 2011 (32.7%). Moreover, trend was relatively sluggish for this group with an absolute change over the last decade of 4.3%. By contrast, trend was much faster for women age years (absolute change 15.4%). On the other hand, women with smaller family size (0-2 living children) had the lowest unmet need than high parity women. But trend was faster and compares well between women with 0-2 and 3-4 living children (absolute change 11%). Whilst the change was relatively slow, with an absolute change 7.6%, for women with parity 5 or more children. A decade of change in contraceptive use in Ethiopia 35

38 Table 8... Total unmet need for family planning according to selected characteristics, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey Residence DHS 2000 DHS 2005 DHS 2011 Absolute change in unmet need N=9485 N=8644 N= Total unmet need (%) Total unmet need (%) Total unmet need (%) % change % change % change Urban Rural Region Addis Ababa Afar Gambela Dire Dawa Tigray Amhara Somali Harari Benishangul Gumz SNNP Oromia Women s education No education Primary Secondary or higher Religion Orthodox Moslem Protestant Others Age Number of living children Total Percentage weighted 36 A decade of change in contraceptive use in Ethiopia

39 Demand for family planning: satisfied vs. not-satisfied: The proportionof women whose demand for family planning was satisfied is obtained by dividing the proportion of current contraceptive users by the total demand for family planning. Total demand is the sum of total unmet need and current contraceptive prevalence. Based on the 2011 DHS, we compute the proportion whose demand for family planning was satisfied by region (Figure 7). About 85% of the women in Addis Ababa had their demand for family planning satisfied. In contrast, the proportion whose demand satisfied was the lowest in Somali (15.2%), Afar (37.3%) and Oromia (46.7%). Over half of the demand for family planning was satisfied for women in eight of the 11 regions. Figure 7. The proportion of women with demand for family planning satisfies, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey Addis Ababa Gambela Dire dawa Amhara Harari Benishangul gumz SNNP Tigray Oromiya Affar Somali % 100% Demand satisfied Demand Not satisfied A decade of change in contraceptive use in Ethiopia 37

40 Reasons for not using family planning among women with unmet need: The study also examined the reasons for not using family planning among women with an unmet need for family planning (Figure 8). As revealed by the most recent survey, the main reason that women failed to act on their desire to limit or space birth was the fear of side effects or health concerns (20.7%). Notably, the proportion who blamed fear of side effects/health concerns for not using family planning increased over the last decade - from 15% in 2000 to 20.7% in Other method related reasons such as lack of knowledge of family planning method and source were diminished in the recent year. Of note, the proportion that cited lack of knowledge of source of family planning declined sharply from 15% to 3.7%. Likewise, in 2011 only 3% said lack of knowledge of method was the reason for not using family planning; this was much lower than the nearly 8% reported in Fertility-related reason such as breastfeeding and postpartum amenorrhea were also implicated among the reasons for not using family planning. In particular, the proportion that cited postpartum amenorrhea as a reason for not using family planning rose from 9.1% in 2000 to 12.4% in On the other hand, a reversal in trend was seen for the reporting of breastfeeding as a reason for not using family planning. Opposition to family planning, as expressed by husband s opposition, religions prohibition and fatalistic view against family planning were reported among the reasons for not using family planning. Fatalistic view against family planning was cited by 7.9% in 2011 and trend was nearly stable. Religious prohibition was implicated by 5.3% in 2011, which has shown an increasing trend from the 3.5% reported in The citing of husband s opposition among the reasons slightly declined from 6.3% to 5.2% during the period. Figure 8. Trend in the reasons for not using contraception among women with unmet need, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey Knows no method Knows no source Husband opposed family planning Religious prohibition Fatalistic Breast feeding Postpartum amenorrhea Fear of side effect/ health concern A decade of change in contraceptive use in Ethiopia

41 3.3. Contraception and fertility One of the subsidiary objectives of this study is to examine the impact of the recent increase in contraception on fertility. The model is described elsewhere in this report. Using the 2000, 2005 and 2011 Ethiopia DHS we estimated the effect of contraception on fertility separately for the three survey periods. Trends in proximate determinants of fertility: Before presenting the indices, we present in Figure 9 the levels and temporal trends of the key proximate determinants fertility. Of all the proximate determinants, contraceptive use has shown dramatic changes (increase from 8.2% to 28.6%) over the last decade while the others exhibited nearly stable or slight reversal trends. The proportion of women in union has not changed significantly over the years at 63.7% and 62.3%, respectively, in 2000 and The mean duration postpartum insusceptibility (PPI) declined from 19.6 months in 2000 to 16.7 months in 2005 and afterwards it stagnated at 16.6 months in The total abortion rate declined significantly from 12.8% to 8.6% during the last decade. Similarly, the proportion of women with primary sterility 1 declined from 2.5% to 1.9%. The fact that contraceptive use has shown the greatest change of all the proximate determinants in the last decade necessitates an examination of its impact on fertility. Figure 9. Trends in the proximate determinants of fertility, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey Contraceptive Prevalence Rate (CPR) Postpartum insusceptability (in months) Total abortion rate Sterility (% women age years who are childless) Percent women in Union 1 Sterility is defined as the proportion of women age who are childless [18] A decade of change in contraceptive use in Ethiopia 39

42 Effects of contraception and other proximate determinants on fertility: Table 9 presents the trends of the five indices. As discussed above, an index with a smaller value has a larger effect on fertility. Across the three surveys, postpartum insusceptibility has been playing the greatest role of the other principal proximate determinants in reducing fertility from its biological maximum (natural fertility) of 15.3 children per woman. Next to postpartum insusceptibility and marriage, contraceptive use emerged to have important inhibiting effect on fertility, especially in recent year. The index of contraceptiion has shown a dramatic decline (relative decline of 25%) from 0.93 in 2000 to 0.7 in 2011; this means the role of contraception in lowering TFR has increased over the last decade. The index values of postpartum insusceptibility (Ci) have shown a slight increase (relative increase 9.6%) during the last decade from 0.52 in 2000 to 0.57 in In concrete terms this means, although postpartum insusceptibility still remains to have the greatest effect on fertility, its fertility inhibiting effect has declined slightly over the last decade. The index of marriage (Cm) has shown a slight decline (relative decline, 3%) during the last decade - from 0.64 to 0.62, suggesting that the fertility impact of marriage has remained stable over the last decade. The other proximate determinants, abortion and sterility, have the lowest effect on fertility over the years, as their index values are closer to 1. The lack of good data on abortion makes the measurement of abortion less reliable. Survey respondents often underreport their abortion experiences. The predicted TFR based on the Bongaarts model was 4.90, 4.94 and 3.94, respectively, for the years 2000, 2005 and This suggests a decline in TFR by an average of one child in the last decade. The difference between the predicted and observed TFR is consistent over the years and within the expected range (a difference of one child). Since the model does not fully explain the variation in fertility, observed TFR are always higher than predicted TFR. In fact, it should be underlined that the purpose of the model is not to estimate TFR rather to decompose the effect of the different proximate determinants of fertility. Surveys provide TFR estimates that are more reliable than model predictions. Table 9. Trend in the indices of proximate determinants of fertility (among all women in the reproductive age), 2000, 2005 & 2011, Ethiopia Demographic and Health Survey Index measure 2000 N=15, N=14, N=16,515 Cc (Index of contraception) Cm (Index of marriage) Ci (Index of postpartum insusceptibility) Ca (Index of abortion) Cs (Index of sterility) TF Predicted TFR (Bongaarts Model) TFR (reported-dhs) Sterility is defined as the proportion of women age who are childless [18] 40 A decade of change in contraceptive use in Ethiopia

43 Contribution of contraception to fertility decline: Figure 10 portrays the effect of contraception on fertility decline over time. To estimate the marginal effect of contraception, first we predicted TFR (based on Bongaarts model) excluding contraception from the model, i.e. the index values of contraception for the three time periods were set at 1. The predicted TFRs without contraception were 5.29, 5.81 and 5.62, respectively, for the year 2000, 2005 and Then TFR was predicted using the model by including the index values of contraception for the three time periods. The resulting TFR with contraception were 4.90, 4.94 and 3.94, respectively. The difference between the predicted TFR with and without contraception yielded the marginal effect of contraception on fertility. Accordingly, an average of 0.39, 0.87, 1.68 births were averted by contraception in 2000, 2005 and 2011, respectively. This implies the contribution of contraception for the overall decline of TFR has been on the raise over the last decade; and by 2011 it was estimated that 30% of the decline in TFR was attributable to contraception. Only 7.4% of the decline in TFR was attributable to contraception in 2000 and by 2005 this was estimated at 15%. Another way of looking at the impact of contraception on fertility is to examine the effect of the change in CPR on TFR through time. Indeed, the increase in contraceptive use appeared the single most important factor, among all other proximate determinants, for the recorded decline in TFR by one child per woman over the last decade. The increase in CPR from the 2000 (baseline) of 8.2% to 28.6% in 2011 resulted in a 22.6% reduction in TFR. Likewise, the TFR reduced by 8.2% in 2005 as a result of the increase in CPR from 8.2% in 2000 to 14.6 % in 2005 (Figure 11). Since the other determinants did not change on the positive direction in the last decade their contribution to the decline in TFR was either insignificant or unfavorable. For instance, the decline in the mean duration of PPI offset further decline in TFR that could have resulted from the increase in CPR. Figure 10. Predicted total fertility rate (TFR) with and without contraception and number of births estimated to be averted by contraception, 2000, 2005 and 2011 Ethiopia Demographic and Health Survey contribution to fertility decline 7.4 % contribution to fertility decline 15 % contribution to fertility decline 30 % Average number of Births averted by contraception, 0.39 Average number of Births averted by contraception, 0.87 Average number of Births averted by contraception, 1.68 TFR without contraception=5.29 Predicted TFR (with contraception), 4.90 TFR without contraception=5.81 Predicted TFR (with contraception), 4.94 TFR without contraception=5.62 Predicted TFR (with contraception), A decade of change in contraceptive use in Ethiopia 41

44 Figure 11. Trend in the effect of contraception on TFR, 2000, 2005 & 2011, Ethiopia Demographic and Health Survey % Reduction in TFR due to increase in CPR from the 2000 (baseline) 22.6 % CPR increased from 8.2% in 2000 to 28.6% in % CPR increased from 8.2% in 2000 to 14.7% in A decade of change in contraceptive use in Ethiopia

45 IV. Discussion This study was embarked to examine the trends and determinants of contraceptive use, the factors contributing to the recent changes in contraceptive use, trends in method mix and unmet need for family planning using data from the three Ethiopia Demographic and Health Surveys. A subsidiary objective of the study was to estimate the impact of the recent increase in contraception on fertility. This section discusses the salient findings of the study. Trend in contraceptive use: Contraceptive prevalence has shown a dramatic increase in the last decade from 8.2% in 2000 to 14.7% in 2005 and 28.6% in The increase was relatively faster in the second half of the last decade ( ) with an absolute annual increase of 2.3%. Increase in contraceptive use has been shared almost uniformly between urban and rural areas. Although most of the regions in the country have seen increase in contraceptive use over the last decade, the increase was not equally shared across the regions. Only Amhara recorded a rate of increase that was much higher than the national average (absolute change of 26.5 percentage points). Absolute changes that were within less than 3 percentage points of the national average increase were documented in five of the 11 regions. Two regions (Harari and Tigray) have shown an increasing trend which is relatively slower; absolute increase in the range of percentage points. On the other hand, average increase was lower than 5 percentage points in three of the 11 regions. Of note, trend was almost stagnated in Afar and Somali regions over the last decade (absolute change- 1.8%). A closer look at the most recent trends ( ) suggest that Dire Dawa (absolute change of 0.1%), and Harari (absolute change of 1.2%) appeared to have exhibited contraceptive use stalling. It is however unclear why contraceptive prevalence stalls in these regions with a prevalence rates around 34%. Some part of the variations in the trends across regions may be explained by the differences in baseline (year 2000) contraceptive prevalence rate but this doesn t explain most of the variations. This argument can be supported by the remarkable trend recorded in the Amhara region. In 2000, Amhara ranked 8 th out of the 11 regions in terms of its contraceptive prevalence rate; by 2011 it has ranked third for the same. We believe that these notable variations in the trend of contraceptive use by region can be used to gauge regional performances in regards to the implementation of family planning programs. Both supply- and demand-related factors may play their part for these variations in performance and further investigation is warranted to elucidate this finding. Whatever the reasons may be, such regional inequalities deserve due consideration in any effort aimed to expand family planning in the country and also in framing regional plans and programs on family planning. Factors influencing contraceptive use: The factors associated with use of modern contraceptive methods were analyzed based on a conceptual framework that encompasses four sets of determinants namely, background, contraceptive goals, fertility experiences and contraceptive access. Several factors emerged as shapers of women s contraceptive behavior in our analysis. Most of the factors have been reported elsewhere and are in agreement with the family planning literature. Background factors associated with contraception include urban-rural residence, women s education, husbands education, women s work and religion. Age and women s previous experience of child death were also found to have significant association with contraceptive use. Women s fertility preferences and goals as measured by the desire A decade of change in contraceptive use in Ethiopia 43

46 for birth spacing or limiting, ideal family size and couples concordance on family size also appeared to have greater influence on contraceptive use. Perhaps a finding that is more pertinent to the Ethiopian situation is the increased in contraceptive use associated with home visit by health extension workers (HEW)/community workers who provided family planning information and services, mostly to rural communities (a proxy to the health extension program effort). In terms of the effect of urbanization on contraceptive use, it has long been established that urban contraceptive rates are pervasively higher than rural rates, especially in developing countries. After adjusting for several factors, we found urban women were four times more likely to use contraception that the rural counterparts. There are large inequalities in population health in general and women s health in particular by residence and contraceptive use is one among the many health indicators that suffered from such inequalities. There are unmeasured channels that could influence contraceptive use in urban areas such as better access to services, psychosocial factors that may be related to the urban way of life, higher exposure to mass and print media that promote small family size and contraceptive use, among others. In this study we have assessed the independent effects of each partner s education on contraceptive behavior. Both wife s and husband s education emerged to have independent and positive influence on contraceptive use. In concrete terms this means that a woman s education affects her contraceptive behavior irrespective of her husband s educational status and vise versa. In most developing countries including Ethiopia women have a lower social status and autonomy than men, and this has been shown to be associated with lower fertility control[23, 24],. Improving women s education has been seen as one way to increase their status and autonomy [25, 26]. The impact of women s education levels on fertility, contraceptive behavior, and contraceptive method choice has been extensively studied and shown to have a significant negative effect on fertility levels and a positive effect on the use of contraception [27]. Similar effect of education on contraceptive use has been documented previously in Ethiopia [28] and elsewhere in developing countries [29-31]. As one of the indicators of women s autonomy we examined the role of women s labor-force participation (work for pay) on their contraceptive behavior in a multivariate set up and found increased likelihood of contraceptive use associated with women s participation in labor force. Previous empirical studies on the association of women s labor-force participation with fertility and contraceptive use show mixed results especially in developing countries. Some posit that employment opportunities create certain viewpoints and values among women that may be favorable to having smaller families and thereby to adopt contraception as a way of life [32, 33]. Others argue that in developing countries, where kinship networks provide unpaid child care for working women, or where child care and working for pay are not incompatible, working for pay and fertility levels and contraceptive use may not be associated [34]. Despite the varying view points we found compelling results that may bolster the indirect role of women s labor-force participation on their contraceptive behavior. Limited works are available concerning the role of religion on contraceptive use in Africa. Our study is one among the few that sheds light on the relationship between women s religion and their contraceptive behavior. Orthodox and Protestant followers in contrast to the Muslim were found to have higher likelihood of contraceptive use. Moreover, trend in contraceptive use was in general 44 A decade of change in contraceptive use in Ethiopia

47 slower in Muslims compared to the two other religion groups. Of note, birth control is not generally encouraged by the Orthodox and Islam, the two prominent religions in Ethiopia, with over 75% of followers across the country. Further research may clarify the cause for the prevailing disparity in contraceptive adoption between the religion groups. Srikanthan et al extensively reviewed the role of different religions on contraceptive acceptance and concluded that religious and cultural factors have the potential to influence the acceptance and use of contraception by couples from different religious backgrounds in very distinct ways [35]. Within religions, different sects may interpret religious teachings on this subject in varying ways, and individual women and their partners may choose to ignore religious teachings. Our finding of higher contraceptive use among women who experienced one or no child death vis-à-vis those with two or more dead children corroborates the theory of replacement effect, which refers to couples deliberate attempts to replace any child who dies at an early age in order to attain a desired number of surviving off-springs at the end of their reproductive life. Similar findings were reported from elsewhere [36]. For instance, a study suggested that substantial improvements in children s survival chances can increase couples motivation to practice contraception, even if the desired number of living children remains stable [37]. Family planning programs can help to reduce fertility and maternal and child health risks substantially by supplying appropriate methods to those couples who have experienced a young child s death; to be most effective, methods should be supplied immediately after the child s death [38]. Needless to say, a strong individual-level relationship between fertility preferences and contraceptive behavior has been found by this study in the multivariate analysis. Higher likelihood of contraceptive uptake was associated with women s desire for birth limiting and spacing. Similarly, a relatively smaller ideal family size (0-4 children) was also associated with higher contraceptive usage. Such associations have been well documented in previous studies elsewhere [39]. Indeed, women s fertility preferences are the most proximate determinants of contraceptive and it is natural to find association between fertility preference and contraceptive use although the degree of association can be influenced by women s place of residence, socio-demographics and access to family planning services. Whether or not a couple agrees on the number of children they would like to have appeared to have significant influence on a woman s contraceptive behavior. In couples where the husbands preferred to have more children than the wives, the likelihood of using contraception decreased significantly as compared to couples who reported to have concordance in the number of children. By contrast, higher family size preference by women compared to their husbands did not appear to influence contraceptive behavior. According to the 2011 DHS data presented and discussed elsewhere above in this report, only 41.4% of the couples reported to have the same preference for the number of children and about a quarter of the women reported that their husbands wanted more children. Notably, only 8% of the women reported preferring higher number of children than their husbands. Clearly, this finding is indicative of the prevailing unbalanced power relationship between couples and the dominant role of men in making fertility decision on behalf of the couples. It is well known that Ethiopian society, as elsewhere in most sub-saharan African countries, is principally male-dominated with regards to power relationship including economic control, reproductive health, among others. Similar findings were reported in Pakistan [40] and Ghana [30]. Finally, we examined two variables that served as proxy for access to family planning information and services since other access indicators such as distance to the nearest facility, availability of services in the cluster, availability and accessibility of family planning commodities were not available in the DHS. The two access indicators examined were - (1) home visit by HEWs or by community workers or any other health workers who discussed about family planning (last year) and (2) women who received information and counseling on family from health workers in health facility during any visit to health facility (last year). A decade of change in contraceptive use in Ethiopia 45

48 The home visit indicator is principally used as a proxy to the health extension program (HEP) because one of the key strategies of the HEP is to provide family planning and other primary health care information and services to the community through home visits by the HEWs and volunteer community workers/health development armies who are working under the direct supervision of the HEWs. It is worth mentioning that previous family planning programs that were supported by NGOs in some parts of the country were also promoting family planning using community-based reproductive health agents and others through home visits but these efforts have stopped functioning in the last four years. Therefore, any reporting of home visits by the women in the 2011 DHS was by and large related to the HEP. Moreover, as part of the HEP, the Government of Ethiopia constructed about 15,000 health posts in the rural Kebeles throughout the country, as a result of which family planning and other primary health care services have become more closer to the community than ever. After adjustment for several factors, we found that woman who reported being visited by community workers/hews in their homes that discussed family planning were 27% more likely to use contraception compared to those women without a similar access, indicating of the net effect of home visit on contraceptive use. Although limited family planning methods are provided in the health posts (mostly limited to Injectables, Pills and condoms) the DHS data clearly portrays that more and more women have begun accessing family planning in the health posts in recent years; without these health posts these women wouldn t have easy access to family planning. The proportion of current contraceptive users who obtained their current methods from the health posts increased from nearly nil in 2000 to 18.4% in 2005 and 27.6% in 2011 (Annex 1). Another access indicator examined by this present study is the receipt of family planning information and counseling in health facilities. We found a higher likelihood of using contraception among women who received information in health facilities (last year) compared to those who didn t. This finding should be interpreted with caution since it doesn t necessarily imply causality and could be bi-directional. Part of the association could be related to the information given to contracepting women during regular visit for family planning service. Regardless of this, most women were not given information on family planning in health facilities. For instance, only 11% of the women responded to the 2011 DHS were told about family planning from health providers during any visit last year, which may well represent a real missed opportunity and signals the lack of integration of family planning information and services with other services in health facilities. Decomposition of changes in contraceptive use: The recent unparalleled increase in contraceptive use in the country necessitates an understanding of the causes of the change since this can provide relevant information for framing family planning program and policy. A Logit-based decomposition analysis was employed to unravel the different factors contributing to the change in contraceptive use. The analyses revealed that the majority of the increase (69%) in contraceptive use over the last decade was attributable to compositional changes. The compositional changes having the greatest contribution (contributing to 40% to the total change) were the increase in population access to family planning information and services (especially through the health extension program), increase in women s attainment of primary education and increase in urbanization. The role played by the Health Extension Program (HEP) for the recent upsurge in contraceptive use in the country, especially in the rural area where over 85% of the population resides, has already been discussed in the preceding section. In the last decade the proportion visited in the homes by the HEWs/volunteers increased dramatically from 2% in 2000 to 19.3% in 2011, an improvement in service access that contributed significantly to the recent increase in contraceptive use primarily by allowing women to implement their latent desire for fertility regulation rather than changes in fertility desires. 46 A decade of change in contraceptive use in Ethiopia

49 Compositional change related to women s education emerged amongst the drivers of the recent increase in contraceptive use in the country. The increase in the share of educated women (primary education) in the population certainly results in increased contraceptive use because of the apparent role of women s education in shaping the contraceptive and fertility behaviors of the population. Indeed, our analysis also found significantly higher contraceptive uptake associated with primary and higher education. There has also been a steady improvement in the participation of girls/women at primary level over the years in Ethiopia. Among married respondents of the DHS, the proportion with primary education increase significantly from 11.8% in 2000 to 27.8% in In 2004 the enrollment rate for females was 63.6% at the national level and this has increased to 86.5% by 2010 [41]. Ethiopia is also considered to be well on track to achieve universal primary education target of the MDG, which is expressed through increase in gross enrollment and the total number of primary and secondary schools in the country. The Government of Ethiopia has made achieving universal primary education a central aspect of public policy and public spending on education has increased over the decades [41]. Therefore, the increase in contraceptive use that was attributable to increase in women s participation in primary education over the last decade can be viewed as the result of the country s successful education policy. Our results also shed light on the role of urbanization for the recent increase in contraceptive use in the country. A previous study concluded that the main driving forces behind city growth and urbanization in Ethiopia are greater mobility of labor, capital and production and improvements in road infrastructure between large cities, as well as increases in population density along transportation corridors [42]. It was also reported by the same study that urbanization rate increased from 3.7% to 14% over the last two decades, almost quadrupling the national urban share. Although this represents quite a dramatic transformation in the economic landscape, Ethiopia remains one of the least urbanized countries in Sub Saharan Africa; the average rate of urbanization in sub-saharan Africa is about 30% [43]. The behavioral and lifestyle changes that accompany or result from urbanization are believed to be responsible for increased desire for small family and adoption of contraception [44]. Urban women are also exposed to better access to family planning information and services that reinforces their receptiveness to birth control. Rural-urban migration also plays an important part in increasing urban contraceptive use and leading to lower fertility because it selects younger and relatively more educated persons who are more predisposed to lower fertility than their rural counterparts [45]. These and other factors thus create conducive environment for urban women to adopt contraception. Other compositional changes having relatively modest contribution was related to the increase in the proportion of women who wanted to limit birth and the increase couples concordance on the number of children they would like to have. The modest change in contraceptive use attributable to these fertility goals have paramount programmatic importance in relation to promoting smaller family size, couple s discussion on family planning and A decade of change in contraceptive use in Ethiopia 47

50 men s involvement as primary partners in family planning and fertility matters. About 23% of the overall changes in contraception were attributable to processual change related to some socio-demographic groups. The processual change operates either due to adoption of new reproductive behavior that was receptive to contraceptive use or due to increased implementation of the unsatisfied desire for fertility regulation. Major processual change was related to increased adoption of contraception by Orthodox and Protestant women (in contrast to the Muslims) and those women who have not experienced the death a child or only one dead child (in contrast to those with two or more dead children). What exactly cause positive changes towards contraception adoption by these religion groups unlike the Muslims remain to be explored. Whereas the finding of improved contraceptive uptake associated with child survival supports the hypothesis that there is a replacement effect in the relationship between child survival and fertility, in other words, the death of a child shortens the next birth interval [46]. A skewed method mix and need for better methods: A skewed method mix characterizes the country s contraceptive use. Ninety-two percent of the contraceptive use is accounted for three methods Injectables, Implanon and pills. In particular, Injectables contributed the lions-share, accounting for 73% of all contraceptive use in Furthermore, its share has grown remarkably in the last decade. Injectables use has also been on the rise in most African countries in the last decade [47, 48]. The rapid increase in Injectables use is largely attributable to its widespread accessibility [49]. Furthermore, women can use this method without others knowing about it; injections are administered periodically (once a month or every three months) and there are no supplies to keep on hand [50]. In addition to these, Injectables have become even more convenient for women in Ethiopia as availability increases since the HEWs are providing Injectables in the health posts. A recent boost in the use of Implanon should be emphasized. In 2000 and 2005 the share of Implanon to the total contraceptive use was very low at 0.5% and 1.2%, respectively. This has increased to 12% in 2011, indicative of the country s recent effort to promote Implanon use in the population. Contrary to the expectation, Implanon use was the lowest in Addis Ababa compared to the other urban and rural areas. Given the high desire for birth limiting (40% in 2011) and a much better access for family planning services in Addis Ababa than any other region in the country, the use of Implanon and other long acting and permanent methods should have been widespread in Addis Ababa. It may well be that the on going effort to promote Implanon has given marginal attention to Addis Ababa or program may suffer from a lack of women s receptiveness to Implanon use. We examined the type of method used by the women in relation to their fertility preferences. A woman is considered using inappropriate contraceptive method (thus in need of better method) if she wants to limit birth but uses a short-term (or spacing) method. A third of the contraceptive users in the country were using inappropriate methods that were not compatible with their fertility preferences, thus are considered in need of a better family planning method (long term or permanent). The trend data also depicted that the proportion using inappropriate contraceptive method has risen in parallel with the overall prevalence of contraceptive use. This finding implies that the prevailing contraceptive method mix has not been compatible with the growing demand for birth limiting in the country. It may well be that family planning program face higher contraceptive costs and women also experience more unintended pregnancies if limiters use Injectables for long periods, rather than changing to longer acting and permanent methods, which provide greater contraceptive efficacy at lower cost, when they are sure they want no more children [48]. Lack of women s knowledge of the different methods, resistance to adopting some of the long acting and permanent methods by women due to misconceptions and fear of side effects, health workers biases to certain methods and absence of 48 A decade of change in contraceptive use in Ethiopia

51 a range of methods in health facilities were implicated among the obstacles to achieving a balanced method mix in the family planning literature [49]. The prevailing poor family planning counseling and information provision to contraceptive users by health providers in the country may have contributed to the skewed method mix. For instance, only 38.3% of the contraceptive users in 2011 were told about other methods than they were practicing (Annex 2). Trend in unmet need and the demand for family planning: Unmet need for family planning has decreased over time as contraceptive use has risen. The decline was almost equally shared between the unmet need for spacing and limiting. Despite the decline, unmet need is still high in Ethiopia with about a quarter of the women in the reproductive age having unmet need for family planning, and 54% of the women estimated to have demand for family planning. Thus, of all women with demand for family planning, 47% had their demand unsatisfied. Unmet need stalling can be more apparent in Addis Ababa in the second half of the last decade. Since unmet need is a relatively complex indicator to measure as it involves several variables related to sexuality, pregnancy, amenorrhea status, and contraceptive use, one cannot provide a full explanation to the trend in unmet need in the country. Perhaps the slower trend in urban contraceptive use during the period may partly explain the lack of decline in unmet need. For the purpose of informing the design of programmatic interventions to reduce unmet need, it is crucial to understand the causes for the unmet need. Whether or not unmet need can be successfully addressed through programming depends, first, on the nature and strength of the obstacles to the implementation of fertility preferences and, second, on the degree to which the obstacles can be weakened or even eliminated through programmatic interventions [51]. As discussed elsewhere in this report, the leading reasons that women failed to act on their desire to limit or space birth was the fear of side effects/health concerns; followed by opposition to family planning and fertility related reasons. These findings can serve as important inputs in the design of interventions to address the high unmet need for family planning in the country. The effect of recent increase in contraceptive use on fertility decline: In the last decade the TFR declined slightly, only by one child per woman, from 5.9 in 2000 to 4.8 in The basic question is thus to what extent this small decline in TFR was affected by the increase in contraceptive use vis-à-vis the other proximate determinants. Using Bongaarts model, we estimated the effect contraception on the total fertility rate. Of all the proximate determinants of fertility, only contraceptive use has increased significantly in the last decade (from 8.2% to 28.6%). By contrast, the other proximate determinants did not show any trend to affect fertility negatively. The mean duration of postpartum insusceptibility (PPI) declined from 19.8 to 16.6 months; this trend was not favorable for fertility reduction. The percentage of women in union remained nearly stable at 63.7% and 62.3%, respectively, in 2000 and Total abortion rate declined from 12.8% to 8.8%, another proximate factor that could have a reversal effect on the TFR. The proportion of childless women age years were 2.5% in 2000 and 1.9% in Therefore, it is apparent that any decline in TFR over the last decade was entirely linked to the increase in contraceptive use. The model estimate showed that the increase in contraceptive use in the last decade accounted for a 22.6% reduction in TFR. In concrete terms this can be translated to a reduction of the TFR by an average of 1.29 births per women. On the other hand, the decline in the duration of PPI offset some of the additional gains in fertility decline over the last decade. A decade of change in contraceptive use in Ethiopia 49

52 50 A decade of change in contraceptive use in Ethiopia

53 V. Summary and Programmatic Implications 5.1. Summary The salient findings of this study can be recapitulated as follows: First, the country has seen an unprecedented increase in contraceptive use in the last decade with the larger share of the increase occurring in the second half of the last decade. Yet, the trend was not equally shared across the regions and there are also regions that exhibited contraceptive use stalling in recent years. Regional gains in contraceptive prevalence in the last decade vary greatly from less than 2 percentage points in Afar to 26.5 percentage points (absolute increase) in Amhara. Second, the compositional changes related to improved use in the family planning environment and social changes during the period contributed more toward an increase in contraceptive use than any other factors. Improved population access to family planning information and services through the Government s health extension program for the rural, remote and underserved population, especially in the second half of the last decade, emerged among the main drivers of change in contraceptive use in the country. It is logical to deduce from this finding that improved access to contraception can in itself lead to increased contraceptive use because it can help women to implement their latent demand for fertility regulation without accompanying change in fertility desires. The social changes were mainly related to the increase in the participation of females in primary education and the expansion of urban areas in the last decade. They influence contraceptive use either through implementation of unsatisfied demand for fertility regulation or through changes in fertility desire. A decade of change in contraceptive use in Ethiopia 51

54 Third, the contraceptive increase associated with child survival in the last decade cannot be overemphasized. The child survival influence on contraceptive use in our study predominantly operates through the increased adoption of contraception by women who haven t experienced the death of their off springs or only one child death (vis-à-vis those with two or more dead children) and, to some extent, through the recent improvement in the survival chances of children in the country. This finding emphasizes that an increase in the survival chances of children appeared to motivate couples to practice contraception irrespective of whether or not the desire number of children remains stable. Fourth, a skewed method mix that heavily relied on Injectables and incompatible with the high proportion of women who desire to limit birth is a real challenge for the country s family planning program. We have demonstrated that a good portion of current contraceptive users are in need of better i.e. long term/permanent contraceptive method in order to decisively attain their desire for limiting. As a result of the poor method mix, the country s family planning program may not be as cost effective as birth limiters use Injectables for long periods, rather than switching to longer acting and permanent methods. This may well strengthened the real merits of the recent expansion of Implant in the country, which is well documented by this study. Fifth, although the current increase in contraceptive use represents quite a dramatic transformation in the family planning landscape, Ethiopia still remains one of the countries with low contraceptive use rate. Unmet need is still high although it has declined in the last decade as contraceptive use has risen. About half of the women had unsatisfied demand for family planning with substantial variation across regions from 14.5% to 84.8%. This signifies the presence of a great potential to further improve contraceptive coverage in the country if program can overcome the barriers to contraceptive use. The reasons for not using family planning among women with unmet need, as documented by this study, revolve around few issues fear of side effects/health concerns and socio-cultural oppositions. For family planning programmers, the barriers related to health concerns/fear of side effect are relatively easier to tackle through information and counseling interventions than those related to opposition to family planning, which may require dealing with deep-rooted cultural and religious values. Sixth, the dominant role of men in shaping women s contraceptive behavior through influencing women s fertility preferences is emphasized by this study. This finding underpins the importance of involving men as key partners in reproductive health matters is a crucial factors for program success. Finally, the increase in contraceptive use during emerged as the single most important source for the recorded decline in TFR of one child per women; accounted for 23% of the decline in TFR. Despite the recent dramatic increase in contraceptive prevalence in the country, fertility decline has been slow in Ethiopia. This is because the current contraceptive prevalence rate is not large enough to bring about a much faster decline in TFR. Indeed, a much stronger effect of contraceptive use on fertility can be achieved with increased contraceptive prevalence. For instance, given the effects of the other proximate determinants constant, a contraceptive prevalence rate of 60% is predicted 1 to bring down the TFR to 3 children per women. 1 The authors of this report did the prediction using the Bongaarts model 52 A decade of change in contraceptive use in Ethiopia

55 5.2. Programmatic implications Findings of this study can have a number of important implications for policy, programming and research: The HEP should continue to reinforce family planning information and counseling efforts through home visits to rural households by the HEWs and volunteer community health workers/health development armies to maintain the current impetus in contraceptive use and record further gains. The current home visit coverage of 19% needs to be increased for better effect on contraceptive uptake since there is a high level of unsatisfied demand for fertility regulation in the population. In conjunction with this, the HEP should also work towards creating new demands for family planning by dispelling the prevailing high attitude towards and value for large family and obstacles to contraceptive use. Contraceptive use and thereby fertility levels in the country are certainly influenced by a host of social and structural factors. Apart from family planning program related factors, there is a huge potential for contraceptive use to grow further in response to the expansion of females education and urbanization in the country. It is therefore imperative that the country s population and family planning programs are cognizant of the increasing demand for family planning arising from these social changes and prepare to respond to these demands. Incorporating these social changes in the planning of future demand for contraception, forecasting and costing exercises is of paramount importance. Program needs to be responsive to the emerging demand for contraception arising from the recent decline in child mortality. With further decline in child mortality, there is a potential for the demand for family planning to continue growing in the country. While the role of family planning in improving child survival has long been established, the reciprocal effect should also be acknowledged. Hence, integrating family planning and child survival programs should be given high priority as this has an added effect on child survival, contraceptive use and thereby fertility reduction. In broader sense, integration of family planning with maternal and child health services can be more beneficial. A decade of change in contraceptive use in Ethiopia 53

56 Program should acknowledge the huge disparities in the actual levels and trends of contraceptive use, unmet need and the demand for family planning across regions and prioritize region specific strategies based on evidence. Some regions are suffering from extremely low contraceptive prevalence (less than 10%) as well as low unmet need for family planning. In such regions efforts to curtail the prevailing high value for large family and to lessen obstacles to family planning use are among the priority interventions. In some of the more urbanized regions and city state a contraceptive prevalence stalling has become an emerging challenge. By and large most of the regions unequivocally benefit from a strong supply-side factor, especially expansion of home visits and clinic services and a range of family planning methods. Enlisting men as primary partners in family planning and reproductive health of women should be considered as part of the broader effort of improving gender relations and promote gender equity. Given the prominent role of men in influencing women s contraceptive behavior, program should involve men as primary audiences of family planning. Couple counseling on fertility and family planning matters, encourage communication between spouses on family planning and other reproductive issues should constitute among the priority interventions. The poor contraceptive method mix in the country is an area of concern, as this affects contraceptive effectiveness as well as commodity cost; and requires proper programmatic considerations. The main reasons for the poor method mix in the country are not well understood but several factors can play their parts. Lack of women s knowledge of the different methods, resistance to adopting some of the long acting and permanent methods by women due to misconceptions and fear of side effects, health workers biases to certain methods and absence of a range of methods in health facilities were implicated among the obstacles to achieving a balanced method mix in the family planning literature. Program should continue to devise ways to encourage women to adopt the most effective method that meets their personal requirements based on their fertility desires, health situation and other circumstances while pending for operational studies to clarify the major barriers of method mix in the country. The recent improvement in Implant should be viewed as a strategy towards balancing method mix and need to be expanded further based on women s fertility desires both in the rural and urban areas. 54 A decade of change in contraceptive use in Ethiopia

57 The high unmet need for family planning can be addressed by lifting the barriers to up taking contraception among women with unmet need. Strategies to overcome fear of side effect/health concern should encompass information and counseling interventions by health workers, HEWs and community health workers to provide correct information about the different methods including their likely side effects. Periodic follow-up of contraceptive users with special attention to assessing side effects is of paramount importance and could encourage continuous use. Addressing socio-cultural barriers such as religious opposition and fatalistic views require active involvement of religious organizations and community leaders in program intervention. Any strategy to improve family planning coverage in the country needs to address inequalities in contraceptive uptake by urban-rural residence, region, women s education, employment and religion. An in-depth understanding of the role of religion on contraceptive use deserves further investigation. A decade of change in contraceptive use in Ethiopia 55

58 56 A decade of change in contraceptive use in Ethiopia