Modern Contraceptive Use and Influencing Factors in Amhara RegionalState: FurtherAnalysisofEthiopianDemographicHealth Survey Data 2016

Background. Ethiopia is one of the Sub-Saharan African countries with a high unmet need for contraceptives. Contraception is a good indicator of the extent to which couples have access to reproductive health services. A study on contraceptives can provide overall direction by helping to identify the obstacles in society and weaknesses in services that need to be overcome. However, little is known in Amhara region context.)erefore, this analysis was aimed to assess modern contraceptive use and influencing factors in the Amhara regional state of Ethiopia. Methods. We used secondary data analysis of the regional representative sample of women aged 15–49 years from the 2016 Ethiopian Demography and Health Survey (EDHS). A total of 2207married reproductiveage women (15–49 years) selected using a two-stage stratified cluster sampling technique were included in this analysis. Both descriptive and logistic regression analyses were performed using STATA V.14. A 95% confidence interval was used to declare statistical significance. Results. Modern contraceptive use among married reproductive-age women was 51.3% (95% CI: 47.0–55.6). Being from households with rich wealth index (AOR� 1.6; 95% CI: 1.1–2.5), a secondary or higher level of education (AOR� 3.0; 95% CI: 1.4–6.2), and desire to space (AOR� 2.6; 95%CI: 1.9–3.7) or want nomore child (AOR� 2.4; 95%CI: 1.6–3.5) were found positively associated with modern contraceptive use. On the other hand, modern contraceptive use was negatively associated with women aged 35–49 years (AOR� 0.7; 95% CI: 0.5–0.9). Conclusion. Modern contraceptive use was relatively high in the Amhara region. )e odds of modern contraceptive use were higher among women with secondary or more educational levels. Women from households with rich wealth index and those who want to delay or avoid pregnancy had also more odds of using modern contraceptives.)erefore, strengthening women’s and community education could improve modern contraceptive use. Moreover, more emphasis should be given for income generation activities.


Background
Family planning (FP), defined as the ability of individuals and couples to have the number of children when they want, is a proven strategy to reduce maternal and child morbidity and mortality [1,2]. Recent studies identified that contraceptive use can reduce almost 230 million births every year [3,4]. Another study showed that contraceptive use alone can reduce maternal mortality by 44% [5]. Despite these benefits, modern contraceptive (MC) use among married or in-union reproductive-age women remains low. According to the 2017 Global Report, MC use among these women was 58% globally and 32% in Africa [6]. In developing countries, about 214 million married or in-union reproductive-age women had an unmet need for MC in 2018 [7]. If the world fails to supply this demand, women pay the price of unintended pregnancy and abortions, which can sometimes be unsafe. In 2015, almost half (44%) of global pregnancies were unintended and two-fifth of these pregnancies ended with abortion [8,9].
Modern FP service was introduced to Ethiopia by the Family Guidance Association of Ethiopia in 1966. e FP service at this time was mainly awareness creation due to social and political constraints. In 1993, the country adopted the population policy, and in 1996, the minister of health released FP guidelines to guide stakeholders on family planning service provision [10]. In 2003, Ethiopia launched the health extension program. FP service is one of the 16 packages in this program [11]. Using this and other programs, the health sector transformation plan planned to increase the contraceptive prevalence rate (CPR) to 55% and reduce the unmet need to 10% by the end of 2020 at national and regional levels [12]. Regardless of these efforts, MC use is low and unmet need is high in Ethiopia. According to the 2019 Ethiopia Mini Demographic and Health Survey (EDHS) report, only 41% of married reproductive-age women were using MC [13]. Surveys in Ethiopia showed MC use varied by regions [14,15].
Unintended pregnancy is a public health problem in Amhara regional state [16][17][18][19]. Almost one in four married women who want to delay or avoid pregnancy in the Amhara region was not using MC, and each woman experienced at least one unplanned birth [15]. Some studies in the Amhara region showed that contraceptive use is public health problem [20,21], but studies about factors affecting MC use among married or in-union women are limited. e objective of this study, therefore, was to assess modern contraceptive use and its associated factors among married nonpregnant reproductive-age women in the Amhara region.

Data Source.
We used secondary community-based cross-sectional regional representative 2016 EDHS data collected through a two-stage stratified cluster sampling technique from January 18, 2016, to June 27, 2016. e survey was implemented by the Central Statistical Agency (CSA) at the request of the Federal Minister of Health (FMOH) [15].
Initially, each region in the EDHS was stratified into urban and rural areas yielding 21 sampling strata. After strata, there were 84,915 enumeration areas. From these, a total of 645 enumeration areas (202 in urban areas and 443 in rural areas) were independently selected proportionally based on the 2007 Ethiopia Population and Housing Census [15]. e survey covered 17,067 households, yielding response rate 98%, and 15,863 women, yielding response rate 95%. All women aged 15 to 49 years who were either permanent residents of the selected households or visitors who stayed in the selected household the night before the survey were eligible for the study. Of these 15,683 women, 3714 were from Amhara regional state, contributes 22% of national women. e analysis was restricted to married or inunion women (2414) [15]. Women who were pregnant or amenohearric at the time of the survey (207) also were excluded. Finally, 2207 nonpregnant married or in-union reproductive-age women were included in the final model ( Figure 1).

Study Variables
e outcome variable for this analysis was modern contraceptive use, which has two categories (yes or no). e 2016 EDHS questionnaire asked all reproductive-age women involved in the survey whether they were using contraceptives including the type of contraceptive. A woman was considered "using modern contraceptives" if she reported that she was using sterilization (tuba ligation or vasectomy), intrauterine device (IUD), injectable, oral contraceptive (pills), or condom at the time of the survey.

Independent Variables.
Demographic and socioeconomic variables are included in the analysis as predictor variables. Demographic variables included were as follows: age of women (15-34 or 35-49), family size (≤4, 5-8,or ≥9), age at first marriage (15-18, 19-24, or ≥25), number of living children (0. 1-2, 3-4, or ≥5), number of children ever birth (0, 1-2, 3-4, or ≥5), ideal number of children (≤3 or >3), future fertility preference (want more soon (within two years), want later (two years later), want time not decided, undecided, or want no more), knowledge on modern contraceptive (yes or no), and women's religion (orthodox, Muslim) are included. Socioeconomic variables included were as follows: residence (urban or rural), women's and partners' educational status (no, primary, secondary, or above), women's and partners' occupation (not working or working), wealth index (poor, middle, or rich), exposure to FP messages on mass media (yes or no), and visits by health workers and health facility visit (yes or no). e exposure to FP messages on mass media was constructed from other data (if women heard or saw family planning messages from radio, television, magazine, or phone message). e poor wealth index category was created by merging poorer and poorest, and the variable rich was constructed by merging richer and richest.

Statistical Analysis.
Weighted data were analyzed with a complex survey sampling analysis technique using STATA software version 14.1. Frequency distribution and descriptive statistics (mean ± standard deviation (SD)) were used to describe the characteristics of the study participants. Chisquare analysis was also used to describe the relationship of independent variables and dependent variables. Bivariable and multivariable logistic regression analyses were done to identify factors associated with modern contraceptive use. Variables are significant with 95%, and p value < � 0.05 in the multivariable analysis was used to declare association. Multicollinearity with variance inflation factor was less than ten was checked before multivariable logistic regression analysis was done. e goodness of fit of the final model was tested by Hosmer-Lemeshow (p value >0.05).

Sociodemographic and Other Characteristics of Women.
A total of 2207 reproductive-age married women were included in the analysis. e mean age of women was 32.0 years (SD ± 0.3 years). About three-fifth (61.0%) of women were aged 15-34 years. About 15.8% of women were Muslim, with the rest orthodox (84.2%). e majority of women (84.2%) were rural residents. e majority of women (81.6%) were married or in-union before their 19 th birthday. About two-thirds (69.1%) of women were not educated. Almost half (52.2%) of women reported that they visited a health facility, and only 31.6% of women were visited by health workers at home 12 months before the survey. Almost one-fourth (24.0%) of women reported that they heard or saw family planning messages through radio, television, magazine, or phone message.
About 89.4% of women were having at least one living child, of which about 28.6% had five or above living children. e mean number of living children was 3.3 children per woman (SD + 0.1children). irty-seven percent of women reported that they want no more children and 19.1% want within two years (Table 1).

Contraceptive
Use. Of all married reproductive-age women, half of them (51.3%) were using modern contraceptives and 0.5% were using traditional methods. Of modern contraceptive users, the majority of them (62.4%) were using injectable followed by implant/Norplant (25.8%). About two-thirds (67.5%) of women wanted to use contraceptives to limit or spacing their birth ( Table 2).

Modern Contraceptive Use by Women's Characteristics.
Modern contraceptive use varied by women's age. e level of modern contraceptive use among women aged 15-34 years was 57.4% higher compared to women aged 35-49 years (p < 0.001). Modern contraceptive use also varied by women's educational status. About 76.1% of women with secondary or above educational level were using modern contraceptives higher compared to women with no education (45.9%) (p < 0.001). About two-thirds (65.7%) of women whose husband with secondary or above educational level used modern contraceptives higher compared to women whose husband with no education (46.6%) (p � 0.003). Modern contraceptive use decreased as the number of living children increases. About 60.8% of women who had no living children used modern contraceptives compared to 36.6% of women who had five or more living children (p < 0.001). About 57.4% of women who received family planning messages used modern contraceptives compared to women not received messages (49.4%) (p � 0.040). About 56.0% of women who visited by health workers used modern contraceptives compared to 46.0% among women not visited by health workers (p � 0.040).
ere was no statistically significant difference in contraceptive use among married reproductive-age women by religion, occupation, residence, age at first marriage, visit a health facility, and partner occupation (Table 3).

Reason for Not Using Contraceptives.
e most common reasons for nonuse of contraceptives among married reproductive-age women were thinking that contraceptives are fatalistic (17.6%), menses not returned (15.2%), on breastfeeding (9.1%), infrequent sex or have no sex (5.9%), and fear of side effect (3.0%).

Factors Associated with Modern Contraceptive Use.
On the bivariable analysis, age, age at first marriage, family size, exposure to FP message, educational status, wealth index, the ideal number of children, future fertility preference, visited by health workers, and residence were significantly associated with modern contraceptive use among married or in-union reproductive-age women. On multivariable analysis, age, future fertility preference, educational status, and wealth index were significantly associated. e odds of modern contraceptive use among women aged 35-49 years were 30% less compared to women aged 15-34 years (AOR � 0.7; 95% CI: 0.5-0.9). Women with a secondary or higher level of education had 3 times (AOR � 3.0; 95% CI: 1.4-6.2) higher odds of modern contraceptive use compared to women with no education. e odds of modern contraceptive use among women who belonged to the rich wealth index were 3 times higher compared to women who were in the poor wealth index category (AOR � 3.0; 95% CI: 1.4-6.2) ( Table 4).
Total reproductive-age women in Amhara regional state = 3714 Married or in-union women = 2414 Currently not pregnant = 2207 Pregnant or amenohearric = 207 Unmarried women = 1300 Excluded in the analysis of contraceptive use

Discussion
4According to this analysis, 51.3% (95% CI: 47.0-55.6) of married or in-union reproductive-age women in Amhara regional were used modern contraceptives. Of which, 63.3% were for spacing and 36.7% for limiting. e majority of them (62.4%) were used injectable followed by implant/ Norplant (25.8%).   Advances in Public Health e overall level of modern contraceptive use was consistent with studies done in Northwest Ethiopia (51.3%) [22] and Sudan (51.5%) [23]. However, it was lower compared to the study done in the Oromia region, Ethiopia, 55.7% [24], and western Ethiopia (71.9%) [25]. e reason for this variation might be the educational status and cultural difference of study participants. About 89% of women in the study of western Ethiopia were educated. Conversely, the prevalence of modern contraceptive use was higher compared to the previous EDHS report [26], and other studies done in Ethiopia were as follows: North Shewa Zone (46.9%), Dabate (32.5%), Butajira (25.4%), Dembia District (31.7%), and southern Central Ethiopia 31.8%) [20,21,27,28]. And it also higher compared to studies done in Ghana (21.5%) [29], Tanzania (34%) [30], Afghanistan (29%) [31], and FP2020 focus countries (45.7%) [32]. is variation might be attributed to the accessibility and availability of the family planning service provision, traditional beliefs, religious, and cultural differences of study participants [33,34]. e most frequently mentioned reasons for not using modern contraceptives were fear of side effects, fatalistic, on breastfeeding, menses not returned, and infrequent sex or have no sex. e findings were consistent with other studies done in Ethiopia, Nigeria, and Saudi Arabia [35][36][37][38].
e proportion of women's modern contraceptive use increased with their husbands' educational level (0.003). is finding was consistent with other studies [22,27,28]. Increasing husband's education might be helpful in a discussion on family planning and family size would increase knowledge and utilization of modern contraceptive. Modern contraceptive uptake was higher among women who reported that they were exposed to FP messages (through radio, television, magazine, or phone message) and visited by health workers at home 12 months prior to the survey (p � 0.040). is finding was consistent with other studies [14,[39][40][41][42]. e reason for this variation might be women received more information about family planning through mass media and during the discussion with the health workers, improving modern contraceptive methods and knowledge level along with increasing self-efficacy or empowerment in making better decisions regarding FP and contraceptive use [43]. e proportion of modern contraceptive use was higher among women who had four or less family sizes compared to women who had nine or above Table 4: Factors associated with modern contraceptive use among married or in-union reproductive-age women in the Amhara region, Ethiopia 2016 EDHS.

Variables
COR (95% CI) AOR (95% CI) Age  Advances in Public Health 5 family sizes. Similarly, contraceptive use decreased with the number of living children increase. is finding was consistent with other studies. e reason might be those women who had a large number of families and children were not educated, poor, and rural residents. Not educated women and women from rural residents and poor households are having a large ideal number of children [15]. e other reason might be that women who had a large family size and living children may be aged 40 years and declared infecund.
On multivariable analysis, the age of women, future fertility preference, educational status, and household wealth index were significantly associated with modern contraceptive use. Women with secondary or higher levels of education had more odds of using modern contraceptives compared to women with not educated. is finding was in line with other studies done in Ethiopia [20,25,28,[44][45][46], Sudan [23], Ghana [29,47,48], and Afghanistan [31]. e reason for this might be that women's education helps them to understand their rights and responsibilities on the reproductive and sexual issues. And also it enables them to discuss with their partners and make joint decisions on FP and family size. Women empowerment is essential to improve maternal health service uptake. Also, educated women are more likely to receive family planning-related messages from different sources. Furthermore, the positive effect of education on modern contraceptive use may be associated with the delay in marriage and first pregnancy [25,34,[48][49][50].
is study revealed that women's future fertility preference was significantly associated with modern contraceptive use. e odds of modern contraceptive use among women who want no more children and want to space were higher compared to women want soon. is finding was in line with previous studies [22,45]. e reason might be that women who decide to delay or avoid pregnancy are internally motivated to use modern contraceptives. Aged women (women aged 35 years or more) had lower odds of using modern contraceptives. is finding was in line with studies done in Ethiopia [14], Nigeria [51], and Mali [52]. e reason might be that older women preferred traditional methods to delay or limit the number of birth [34]. is may be one of the reasons why the prevalence of unplanned pregnancy is generally higher among older women compared to younger women [50].
Women from households with the wealth index rich had higher odds of using modern contraceptives compared to those with the poor wealth index. is finding was in line with studies conducted in Ethiopia [14], Nigeria [51,53], Angola [54], Bangladesh [39], Ghana [55], and Mali [56]. e reason for this might be direct or indirect that the costs women may incur to access contraceptives. e other reason might be the biases and misconceptions related to contraceptive use. Women may believe that contraceptives are not favorable for women involved in laborious activities, in which poor women usually engage in. Exposure to family planning messages through mass media may be the other reason, which showed a significant association with contraceptive use in other studies [39][40][41][42], in which rich women are accessible for it.

Conclusions
Modern contraceptive use among married or in-union reproductive-age women was relatively high compared to other studies done in the region. Age of women, educational status, future fertility preference, and wealth index were statistically significant factors associated with modern contraceptive use. Strengthening women's and community education may improve modern contraceptive use. Health care providers should be given special attention for women aged 30 and 40 years when they provide family planning counseling. Also, more emphasis should be given to income generation activities.
Data Availability e data used for this analysis are available in the repository (https://dhsprogram.com/data), upon permission from the DHS program.
Ethical Approval e 2016 EDHS protocol was reviewed and approved by the Federal Democratic Republic of Ethiopia Ministry of Science and Technology and the Institutional Review Board of ICF International.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
MBA conceived, designed, and performed the analysis. GWD, GAF, and YMG were equally involved in the analysis, interpretation, and writing of the results. All authors read and approved the final manuscript.