We analyze variations in contraceptive use and age cohort effects of women born from 1957 to 1991 based on the hypothesis that individuals born at different time periods experience different socio-economic circumstances. Differential exposure to socioeconomic circumstances may influence women's attitudes and behavior towards critical life issues such as contraceptive use. We use data from the 2006 Uganda Demographic and Health Survey by limiting the analysis to 5,362 women who were currently married (or cohabiting) at the time of the survey. Logistic regression analyses show a higher likelihood of contraceptive use among older cohorts than younger cohorts. These results call for interventions that target young women to reduce fertility and reproductive health challenges associated with too many or too closely spaced births. Although variations in age cohorts are critical in influencing current contraceptive use, other factors such as wealth status, education level, and place of residence are equally important. Thus, interventions that focused on selected regions (e.g., the North and the West Nile), rural communities, and efforts to increase literacy levels will accelerate uptake of contraception and improve maternal and child health.
Age, period, and cohort effects on sociodemographic outcomes are typically interlinked and generally, researchers cannot study them in isolation. Age is a summary measure of exposure to social influences or norms. Therefore, to understand variations in health and demographic rates, it is important to measure the underlying variables for which age is a proxy [
Contraception, defined as methods or devices used to prevent pregnancy, is categorized into two types: modern and traditional methods. Modern methods include clinic and supply methods such as the pill, intrauterine device (IUD), condom, and sterilization whereas traditional methods include periodic abstinence (rhythm), withdrawal, and folk methods [
Contraceptive use in Uganda still remains low despite the increase from 15.4% in 1995 to 18.6% in 2000/01 and 24.4% in 2006. The increase in contraceptive use accelerated in the five years prior to the 2006 DHS than in the 1990s due to improvements in economic growth, literacy, and education [
According to the cohort historical model, social changes are mainly influenced by the interaction between individuals’ life experiences and changes in the socioeconomic environment [
The aftermath of independence (gained in 1962) and early 1970s until 1986 was characterized by upheavals and inconsistencies in the economic, political, and social life of Ugandans. Uganda’s economic potential was one of the most vibrant and promising at the time of her independence but was curtailed by 15 years of civil strife between 1966 and 1986. During this period, Uganda’s poverty was rampant, the population grew at an alarming rate and characterized by high dependency rates, and levels of schooling were very low. As a result, social and health systems were dysfunctional and contraceptive use was negligible. These dynamics were followed by an era of HIV/AIDS from 1982 (when the first case was diagnosed) to its peak in the early 1990s. This period was also characterized by an increased proportion of orphans. Despite these challenges, the Ugandan Government implemented a universal primary education policy in 1997 that provided an opportunity for orphans and other Ugandan children to be educated [
The aforementioned dynamics, and the civil strife in particular, affected Uganda’s health system and compromised its ability to provide adequate services to people. For instance, although contraceptive prevalence rate increased between 1995 and 2006, it is still very low compared to other sub-Saharan African countries such as Kenya (45.5% in 2008/09), Tanzania (34.4% in 2010), and Zambia (40.8% in 2007) [
Cohort studies account for differences in the attitudes and practices that people exhibit in relation to utilization of services. Hence, cohort studies can be used to demonstrate and document the factors that influence many demographic processes. Majority of age cohort studies have not focused on the effect on contraceptive use in Uganda. Therefore, our aim is to establish the effect of age cohorts on contraceptive use in Uganda and to find out the extent to which contraceptive uptake is affected by other micro- and macrolevel factors.
Data come from the 2006 Uganda DHS, which was the first survey to cover the entire country compared with previous surveys that were obstructed by insecurity. The 2006 survey was also the fourth in a series of DHS in Uganda. In the survey, a nationally representative sample of 8,531 women aged 15–49 years was selected for interviews. For this study, women living in marital unions and born within the periods 1957–1971, 1972–1981, and 1982–1991 were selected. These periods were translated into age cohorts of 15–24 years, 25–34 years, and 35–49 years, respectively. This cohort allocation was translated into an analytical sample of 5,362 women.
The dependent variable is current contraceptive use with the birth or age cohort as the key independent variable. The dependent variable was coded as “1” when a woman was using contraception at the time of the survey and “0” if otherwise. The age cohorts were grouped into three categories namely, 15–24, 25–34, and 35–49 years. Other independent variables included in the analysis are residence of the woman (urban or rural); parity (because the number of children ever born will determine the need for family planning); education level; region of residence; and wealth index (computed from information on household durable assets such as radio, bicycle, and car ownership).
We use logistic regression analysis because the dependent variable (current contraceptive use) is binary. Analysis was done at three levels and conclusions were drawn at the multivariate level. In the first level of analysis, we include age cohort as a baseline model, whereas the second model adds education level, urban/rural residence, and wealth index. In the final model, we include parity and region of residence to assess the effect of age cohort on current contraceptive use before and after controlling for other factors.
We use the birth cohort since people who were born and grew up during different periods experience different circumstances that may shape their attitudes and practices related to reproductive health. For instance, one would expect that women born between 1982 and 1991 (aged 15–24 years) are more likely to use contraceptives than their counterparts because they were born when Uganda experienced a number of political and socioeconomic changes. As a result, these women were more likely to have benefited from family planning services during that period. Women born during the 1972–1981 period may not report more contraceptive use at the time of the survey than those born much earlier. This may be related to the fact that these women were born during a period of political and socioeconomic turmoil, associated with low levels of schooling.
Table
Percentage distribution of women in marital unions who were born between 1957 and 1991 by selected background characteristics, Uganda 2006 DHS.
Characteristics | 1982–1991 | 1972–1981 | 1957–1971 | Total |
---|---|---|---|---|
Ages (15–24) | Age (25–34) | Age (35–49) | ||
Mean age | 21.0 | 29.2 | 40.8 | 30.7 |
Mean parity | 1.7 | 4.5 | 7.2 | 4.6 |
Current contraceptive use | ||||
No | 81.6 | 76.2 | 75.7 | 77.6 |
Yes | 18.4 | 23.8 | 24.3 | 22.6 |
Residence | ||||
Urban | 14.7 | 13.8 | 9.2 | 12.6 |
Rural | 85.3 | 86.2 | 91.0 | 87.4 |
Education level | ||||
None | 14.0 | 23.7 | 40.3 | 26.4 |
Primary | 67.4 | 58.9 | 50.2 | 58.5 |
Secondary+ | 18.6 | 17.3 | 9.5 | 15.2 |
Wealth | ||||
Poor | 48.8 | 42.2 | 44.8 | 44.8 |
Middle | 16.3 | 17.8 | 19.8 | 18.0 |
Rich | 34.9 | 39.9 | 35.4 | 37.1 |
Region | ||||
Central 1 | 9.9 | 8.9 | 6.9 | 8.6 |
Central 2 | 7.0 | 9.3 | 9.1 | 8.5 |
Kampala | 8.0 | 7.5 | 3.9 | 6.5 |
East central | 11.0 | 11.7 | 11.3 | 11.4 |
Eastern | 13.2 | 11.9 | 12.4 | 12.4 |
North | 21.9 | 20.4 | 24.4 | 22.1 |
West nile | 7.4 | 9.2 | 9.5 | 8.8 |
Western | 11.7 | 9.8 | 11.1 | 10.8 |
South west | 9.1 | 11.5 | 11.4 | 10.8 |
| ||||
Number of women | 1,481 | 2,158 | 1,723 | 5,362 |
Note: Some percentages may not add up to 100 due to rounding of figures.
Women from poor households (based on the wealth status index) were a majority (44.8%) and those from middle status households accounted for 18.0%. That more women from poor households were in the young age cohort (1982–1991) may be related to early marriages that are usually associated with low rates of schooling completion and economic challenges. Close to nine out of 10 women (87.4%) were rural residents, and most of them were from the Northern (22.1%) and Eastern (12.4%) regions.
Table
Associated
Characteristics | Not using | Percent | Using | Percent |
---|---|---|---|---|
|
| |||
Age cohort |
|
|||
1982–1991 | 1,209 | 81.6 | 272 | 18.4 |
1972–1981 | 1,644 | 76.2 | 514 | 23.8 |
1957–1971 | 1,305 | 75.7 | 418 | 24.3 |
Residence |
|
|||
Urban | 375 | 55.6 | 299 | 44.3 |
Rural | 3,783 | 80.7 | 905 | 19.3 |
Education level |
|
|||
None | 1,258 | 88.9 | 156 | 11.0 |
Primary | 2,451 | 78.2 | 684 | 21.8 |
Secondary+ | 449 | 55.2 | 364 | 44.8 |
Wealth index |
|
|||
Poor | 2,136 | 88.8 | 269 | 11.2 |
Middle | 779 | 80.6 | 188 | 19.4 |
Rich | 1,243 | 62.5 | 747 | 37.5 |
Parity |
|
|||
0 |
1,237 | 80.7 | 295 | 19.3 |
3 |
1,413 | 76.1 | 443 | 23.9 |
6+ | 1,508 | 76.4 | 466 | 23.6 |
Region |
|
|||
Central 1 | 303 | 66.3 | 154 | 33.7 |
Central 2 | 294 | 63.8 | 167 | 36.2 |
Kampala | 183 | 51.5 | 172 | 48.5 |
East Central | 474 | 77.7 | 136 | 22.3 |
Eastern | 534 | 80.2 | 132 | 19.8 |
North | 1,081 | 91.1 | 106 | 8.9 |
West Nile | 407 | 86.4 | 64 | 13.6 |
Western | 459 | 79.5 | 118 | 20.5 |
South West | 423 | 73.2 | 155 | 26.8 |
About nine out of 10 women (88.9%) with no schooling did not use contraceptives whereas, 44.8% of those with secondary and higher schooling used contraceptives. Consistent with the literature [
Table
Odds ratios (95% CI) for contraceptive use among women in marital unions, Uganda 2006 DHS.
Variable | Model 1 | Model 2 | Model 3 |
---|---|---|---|
Age cohort | |||
1982–1991 (r) | 1.00 | 1.00 | 1.00 |
1972–1981 |
|
|
1.01 (0.80, 1.25) |
1957–1971 |
|
|
1.18 (0.92, 1.53) |
Education level | |||
None (r) | 1.00 | 1.00 | |
Primary |
|
| |
Secondary+ |
|
| |
Residence | |||
Urban (r) | 1.00 | 1.00 | |
Rural |
|
| |
Wealth Index | |||
Poor (r) | 1.00 | 1.00 | |
Middle |
|
1.25 (1.00, 2.57)) | |
Rich |
|
| |
Parity | |||
0–2 (r) | 1.00 | ||
3–5 |
| ||
6+ |
| ||
Region of residence | |||
Central 1 (r) | 1.00 | ||
Central 2 | 1.08 (0.81, 1.40) | ||
Kampala | 0.81 (0.56, 1.80) | ||
East Central |
| ||
Eastern |
| ||
North |
| ||
West Nile |
| ||
Western |
| ||
South West | 0.96 (0.72, 1.28) | ||
Log likelihood | −2845.6208 | −2557.4157 | −2508.1772 |
Prob > |
0.000 | 0.000 | 0.000 |
| |||
Number of observations | 5,362 | 5,362 | 5,362 |
“r”: reference category. Bolded odds ratios are statistically significant (
In Model 2, the odds of current contraceptive use for women with primary education almost doubled (OR = 1.96) compared with women with no schooling. Women with secondary and higher schooling were 3.52 times more likely to use contraceptives than those without schooling. When residence was included in Model 2, rural residents were 35% less likely to use contraceptives than urban residents. Belonging to households categorized as middle income was associated with 64% likelihood of using contraceptives, whereas those belonging to rich households had odds that almost tripled (OR = 2.94) in using contraceptives.
In Model 3, the effect of age cohort on current contraceptive use was no longer significant after including parity and region of residence. Nevertheless, education, residence, and wealth status were still robust though their effects were attenuated (except for secondary schooling). When compared to women with 0–2 children, the odds for current contraceptive use were higher for women with six or more children (OR = 2.03) than for women with 3–5 children (OR = 1.71). This finding could be explained by the desire to limit births among older women with six or more children while for the young cohorts, they still desire to have children hence were less likely to use contraception. Living in Central 2, Kampala, and South West regions was not associated with contraceptive use. However, women in East Central, Eastern, North, West Nile, and Western regions were 36%, 33%, 59%, 52%, and 30%, respectively, less likely to use contraceptives than women living in Central 1 region.
The importance of age cohort differences in health and demographic outcomes has been highlighted elsewhere [
Contraceptive use increases with increased schooling and is highly significant with secondary and higher education than with primary education. This is partly explained by the fact that secondary schooling allows a woman to stay in school longer thereby reducing the risk of exposure to marriage. Educated women are also more likely to earn an income, understand their physiology and social needs, and adopt appropriate reproductive health behavior [
The results also showed that contraceptive use increased with increased parity. This finding may partly be related to the fact that older women desire to limit their births because they have reached their desired family size. Results from the 2006 Uganda DHS also confirm that current contraceptive use is higher for limiting (12.7%) than for spacing (11.0%) [
Compared with women in Central 1, living in the North and the West Nile regions reduced the likelihood of using contraceptives by more than half. The Northern region was hit hard by the 18-year-old war led by Joseph Kony, which forced people to live in camps with limited family planning services. Schooling opportunities during the civil strife were virtually nonexistent and this negatively impacted the socio-economic life of the people in the region [
Compared with the poor, the rich were associated with odds that more than doubled in using contraception. In addition, most of the contraceptive nonusers were young. Coming from a middle status household was not associated with contraceptive use partly because wealth status is also associated with education. If a woman is from a middle status household but not educated, there may not be significant differences between her and the noneducated women because they are not informed about the benefits of family planning. Rural residence was also associated with lower odds of contraceptive use among women than urban residence, consistent with earlier studies in Uganda [
Generally, the effect of age cohort on current contraceptive use was higher among older women than younger women. This finding is of great concern since young women who are more likely to be exposed to pregnancy and childbirth for longer periods need contraception for spacing their births. It is not surprising that under such circumstances, Uganda’s total fertility rate (TFR) was high at 6.7 in 2006 (7.1 in rural areas, 4.4 in urban areas). The high TFR may be associated with women who are exposed to sexual intercourse frequently (either in marital unions or otherwise) without family planning. These results call for an urgent need to target family planning campaigns to young women because they are more at risk of getting pregnant.
That age cohort was less significant after controlling for other socioeconomic factors such as education calls for efforts that aimed at increasing secondary and tertiary school enrollment and completion rates for women in Uganda in order to increase family planning uptake. According to the United Nations in 2011 [
Urban residence was also associated with increased contraceptive use since health facilities are generally well stocked and within reasonable distance from women’s residencies. Further, urban women are also more likely to be exposed to social and media messages on family planning than their rural counterparts. Efforts to expose women to family planning programs in rural and remote areas are inevitable. Specifically, sensitization campaigns will be relevant because they expose women to family planning messages a great deal [
Efforts to improve wealth status of women will have a long lasting impact on contraceptive use in Uganda. Policies should be aimed at increasing women’s productivity at home and at improving their earnings. This will directly empower them, especially within the family, and boost their ability to make decisions [
The authors would like to thank the United States Agency for International Development, ICF Macro, the Uganda Bureau of Statistics, and other partners for supporting the collection and processing of the Uganda 2006 DHS data as well as making the data available for public use.