Kennedy Machira1,2, beston b. Maonga2
1North West University-Mafikeng, Population and Research Unit, Mmabatho, Republic of South Africa;
2Lilongwe University of Agriculture and Natural Resources. Faculty of Development Studies, Department of Agricultural and Applied Economics, Lilongwe.
AbSTRACT
Contraceptives uptake among rural adolescent girls remains a major challenge despite efforts aimed at promoting adolescent health in Malawi. The study, therefore, examined factors influencing non-use of family planning methods among rural adolescent girls. A sample of 4358 rural adolescent girls from 2010 Malawi Demographic and Health Survey and using logistic regression was used to estimate determinants.
About 90.1% of the rural girls had never used family planning methods. Community factors such as distance to access health care and insufficient knowledge about contraceptives explained non-use status. The need to implement community based family planning interventions, targeting rural adolescent girls is paramount not only improve family planning uptake practices, but also their health well-being for country’s socio-economic development benefits.
Keywords: Family planning, contraceptives, teen mothers, sexual intercourse, Malawi
INTROduCTION
In 21st Century, family planning (FP) is one of the top 10 public health achievements around the world1. Despite the achievement, little gains have been reaped in an effort to have low total fertility level per woman, more especially in developing countries.2 Young mothers below the ages of 19 are the major victims3, and this is attributed to differentials in socioeconomic status in developing countries, Malawi included 4, 5 This is attributed to high occurrence of teenage marriage, a factor increasing proportion of teen motherhood in rural communities.6, 7 Yet, the 1989 United Nations Convention on the Right of the Child stipulated the dangers of child marriage on young women health, their babies and increased risk of mortality or morbidity compared to their counterparts aged over 20. Nevertheless, in low income societies, young women continue falling pregnant despite contraceptives availability. This consequently translates into policy and public health relevance as younger women susceptibility to reproductive health risks increases.8 9 This consequently affect younger women participation towards socio-economic development.10
In Malawi, the 2010 Demographic and Health Report indicate that the proportion of teen mothers is gradually increased to 71.6%.11 This is partly explained
by younger women exposes to risk sexual risk practices which disadvantages them greatly, a factors would have been avoided if family planning was adequately used.10 This social imbalances exacerbate rural community poverty, more especially among young couples. It is worth noting that despite registered remarkable increase in contraceptive prevalence in Malawi from 13% in 1992 to 46.1% in 2010, 10, 11 teen-motherhood proportion is on the increase,11, 12 implying that unmet need for family planning methods exist. Despite numerous studies done on contraceptives in Malawi, little is known on adolescent girls’ non-use of contraceptive products.7, 13, 14 Therefore, an examination on determinants influencing non-use of family planning on rural adolescent girls at individual, household and community level is imperative.
MATeRIAlS ANd MeThOd
The study used 2010 Malawi Demographic and Health Survey (MDHS) in which a total of 23020 women participated of which 5040 (21%) were adolescent girls.
Among them, 86.5% (4358) were from rural, of which, 90.1% reported to have never used contraceptives.
In the study, “non-use of Family Planning (FP) was defined as 1 if not using and 0 for otherwise. In terms DOI Number: 10.5958/0976-5506.2018.00251.6
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 31 of analytical approach, descriptive statistics, Pearson
chi-square and a nested multivariate logistic regression analysis was employed to explain and estimate non-use of family planning methods status. Furthermore, a decomposition technique was used to find relative contribution that each determinant had on rural adolescent girls’ non-use of FP at individual, household and community levels.
Individual level factors included sexual intercourse practices, literacy, marital status and adolescent motherhood; Household factors include autonomy, health seeking practice, health care support and household head sex and community factors were distance to health facility and exposure to FP information. Exposure to FP was derived using Principal Component Analysis of health information access indicators on radios, televisions, drama, newspapers, posters, and clothing’s.
The Concentration index was used to measure socioeconomic inequality on non-use of FP on respondents in Malawi15and was calculated as twice the covariance of the health variable and person’s rank relative to their economic status divided by the mean as illustrated in equation (i).
C = 2
m cov (yi, Ri) …(i)
where yi and Rj are, the contraceptive usage status of individual rural adolescent girl i and a fractional rank of ith individual in terms of the economic status index, respectively; m is the mean scalar of individual woman non-use of FP and represents a covariance. The concentration index span between -1 and +1 for women disadvantaged and advantaged status respectively. A zero concentration index value denotes equality.
As a preamble, parameter coefficients estimate non-use of FP using the binomial regression model in equation (ii) below;
log P P
j
j j jx j
1
b …(ii)
Where Pj denoted the probability of not- using modern FP methods among rural adolescent girls and 1 − Pj its compliment. xj denotes the vector of jth independent variables, bj parameter coefficients vectors corresponding the independent variable vectors and ∈j is an error term.
The decomposition technique used was adopted from different scholars that used the method to find relative contributions of different factors on outcome variables.15,16
FINdINgS
Table 1 presents background characteristics of the respondents based on the usage status of FP methods in Malawi. The study found that 61.6% of the rural adolescent girls had sexual intercourse did not use FP methods. Additionally, 21.8% of them were married.
At household level, 82.2% of the girls were dependent.
In terms of health seeking practices, 18.3% of the girls were able to seek own maternal health, of which, 67.4%
were from male-headed households. At community level, distance to health care facilities affected 60.8% of adolescent girls’ use of modern FP methods, negatively.
Furthermore, a test on the association between non-use of FP methods among adolescent girls and the factors revealed that sexual intercourse practices, marital status and adolescent motherhood relate significantly at individual level. Furthermore, girls’ autonomy, health seeking behaviour and household head sex related significantly at household level.
Table 1: Characteristics of rural adolescent girls based on their FP usage status
Variables FP usage status
Chi-square
N = 4358 3928 430
No yes
Individual factors
Sexual intercourse practices
No 38.4 0.7 581.9***
Yes 61.6 99.3
Literacy
Yes 70.7 64.4
7.2**
No 29.3 35.6
Marital Status
Never Married 78.2 19.8 663.9***
Ever Married 21.8 80.2 Adolescent Motherhood status
No 85.1 16.3
22.1***
Yes 14.9 83.7
32 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 Contd…
household Factors
Adolescent household autonomy
No 82.2 27.9
641.2***
Yes 17.8 72.1
Health seeking behaviour
No 81.7 28.1 616.6***
Yes 18.3 71.9
Health care support within family
Yes 36.6 33.5
No 63.4 66.5 1.61
Contd…
Sex of household head
Female headed 32.6 18.8
34.2***
Male headed 67.4 81.2
Community factors Distance to health facility
No problem 39.2 40.7 0.35
Problem 60.8 59.3
Exposure to FP Information
Adequate 37.2 44.0 7.5**
Inadequate 62.8 56.0
*** p < 0. 001; ** p < 0. 05; * p < 0.1
In Table 2, three models estimate of non-use of FP methods among rural adolescent girls are presented. In mode 1, sexually active adolescent girls were more likely not to use FP methods compared to those not sexually active significantly at 1% level (p < 0.001). Furthermore, illiterate adolescent girls were associated with on-use of FP methods compared to their literate counterparts. In Models 2 and 3, ever married adolescents were consistently and significantly (p<0.001) increased non-use of modern contraceptives.
Table 2: Logistic regression outcome estimating factors influencing rural adolescent girls non-use of FP in Malawi
Individual factors Model 1 Model 2 Model 3
Sexual intercourse practice OR 95% CI OR 95% CI OR 95% CI
No 1.00 3.2 - 5.87 1.00 1.06-2.03 1.00 0.56-1.11
Yes 4.33*** 1.47** 0.79
literacy
YesNo 10.14***1.00 8.8 -11.7 4.51***1.00 3.81-5.33 3.02***1.00 2.48-3.67 Marital Status
Never MarriedEver Married 1.001.20 0.85-1.68 3.31***1.00 1.93 5.67 2.33**1.00 1.37-3.98 Adolescent Motherhood status
No 1.00 0.06-0.13 1.00 0.05-0.11 1.00 0.06-0.12
Yes 0.09*** 0.08*** 0.09***
household factors
Adolescent household autonomy
No 1.00 0.13-0.82 1.00 0.18-1.04
Yes 0.33** 0.44*
health seeking behaviour
No 1.00 0.23-1.45 1.00 0.37-2.12
Yes 0.58 0.89
health care support within household
YesNo 3.65***1.00 3.04-4.39 3.69***1.00 3.00-4.54
Sex of household head
Female headed 1.00 3.75-5.55 1.00 1.65-2.88
Male headed 4.56*** 2.18
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 33 Contd…
Community factors distance to health facility
No problem 1.00
2.85-4.31
Problem 3.51***
exposure to FP Information
Adequate 1.00
2.92-4.41
Inadequate 3.59***
Notes: ***p < 0. 001; ** p < 0.05; *p < 0.1; OR =Odds Ratios and CI = Confidence Interval At household factors, sexual intercourse practices,
literacy levels and marital status (p<0.001) increased the likelihoods of non-use of FP methods among girls whereas adolescent motherhood status had had a decreased likelihood. Furthermore, adolescence household autonomy relates significantly yet less likely on non-use of FP methods 5% in model 2 and 10%
in model 3. Inadequate, health care support among adolescent had had a significant (p<0.05) effect in increasing non-use of contraceptives, noted in both models 2 and 3. In Model 3, distance to health care facilities and inadequate exposure to family planning information increased non-use status of modern FP on rural adolescent girls significantly (p<0.05).
Decomposition analysis results in Figure 1 found that an overall absolute contribution of 0.19 explained the non-use of modern FP methods, in general. By levels, community factors such as distance to health care facilities and exposure to FP information had positive and higher contribution of 28% and 28.9%, respectively.
Aggregately, Figure 2 illustrates community factors contribution dominates with a contribution of 56.2%.
Figure 1: Percentage ccontributions of determinants influencing non-use of FP methods among rural
adolescent in Malawi
Table 3: Concentration index and relative contribution of factors on non-use of FP among
rural adolescent girls in Malawi Factors Concentration
index Relative contribution Individual
Sexual Intercourse
during adolescent 0.00 0.39
Literacy 0.13 2.35
Marital Status 0.04 0.71
Adolescent
Motherhood status 0.03 0.02
household
Adolescent household
autonomy 0.08 0.11
Seeking own health 0.08 0.23
Health support within
household 0.44 1.49
Sex of household head 0.04 3.18 Community
Distance to health
facility 0.17 5.43
Exposure to FP
information 0.19 5.49
Overall contribution 19.39
Figure 2: Aggregate percentage contributions of individual, household and community determinants
associated with non-use of FP among rural adolescent girls in Malawi
34 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2
dISCuSSION
The study decomposes individual, household and community inequalities in order to understand factors highly contributes more on non-use of modern contraceptives among rural adolescent girls in Malawi.
The study found that community barriers such as distance to health care facilities and inadequate exposure to FP information are the major predictors associated with non-use of modern FP methods. Also to note, percentage contribution from decomposition methods found these factors ranked highly in influencing non-use of contraceptives among girls in Malawi. At household level, sex of household head contributed 16.4% towards inequalities to non-use of FP yet other factors had marginally low contribution. This implies better support initiatives among girls at household level their utilization pattern of modern contraceptives would increase.14, 18 The study also found that low income status contribute greatly on non-use of contraceptives among girls in Malawi.
This result concurs with the findings of a similar study in Mexico, despite low income status among married women, proper financial supported from their spouses increases contraceptives uptake significantly.19 This implies that if rural women are oriented and supported, their uptake of contraceptives increase.
These results provide a justification for policy approaches to tackle problems associated with low uptake and non-use of contraceptives among rural adolescent girls. Such approaches may include interventions using informal media to ensure information regarding opportunities and benefits of contraceptives are advocated in the country. This is attainable through enacting innovative best-practices aimed at improving use of contraceptives.20, 21 Similarly, improved literacy position targeting adolescents provides a competitive advantage that reduces teenage pregnancy, sexual risk behaviour,7, 13,
21 and their improved health dividends.22, 23, 24
At community level, due to distance in Malawi, the odds of non-use of modern family planning methods increases. It is echoed that proper and adequate Family planning information access from structured institutions has had a subsequent positive impact in promoting women’s use of modern contraceptives and thereby improved health outcome. 7, 19, 21 On the contrary, in the current study, inefficient access to family planning information at community level, increased non-use of
FP among rural adolescent girls. This finding relates to a study that reiterates that inadequate exposure to FP information through relevant media among women predicts low contraceptives utilizations.23, 24
CONCluSIONS
The study findings indicate that community level factors such as distance to the health facility and insufficient FP information disseminated through different media are major significant factors that contribute towards non-use of modern methods in the country.
Other factors include sexual intercourse practices, illiteracy, marital status, adolescent motherhood status, and sex of household head are also predictors of non-use of modern FP methods among rural adolescent girls in Malawi but to a lesser extent.
The study therefore, recommends promotion of community based family planning interventions, targeting rural and underserved adolescent girls. This would improve uptake of FP methods among girls in this reproductive age group. Such efforts should aim at reducing barriers to health care facilities and ensure improved access of FP among adolescent girls in the country. This development would motivate the rural and underserved adolescent girls’ access to knowledge about the significance of FP and consequently improve update of different methods mix. Such promotion, would result in rural adolescent girls minimise increased risk of maternal morbidity and mortality aggravated by early motherhood assumed statuses. As such the country’s quest to attain maternal health statuses adopted through Sustainable Development Goals, a reality.10
This study recognizes the need to have a longitudinal record of community level data, therefore, a recommendation for a more robust and comprehensive approach to conduct an assessment on the impact on non-use of modern FP in Malawi, despite gain in contraceptive prevalence, is imperative. The results have however, provided an important and significant step to formulate community based reproductive health strategies and policy to achieve improved use of modern family planning methods among adolescent girls.
The study asserts that addressing community based challenges and promoting use of modern contraceptives requires introduction of family planning from early ages of the adolescent reproductive health.
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 35 Conflict of Interest: None
ethical Clearance: Secondary data was provided by Measuredhs and upon given authenticity to use it.
Issues of ethics were handled by them as they are data custodian.
Source of Funding: Self
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