1. A Decade of Change in Contraceptive Use in Ethiopia
___________________
Yared Mekonnen (Ph. D)
Mela Research PLC
Addis Ababa
13 February 2013

2. Family planning in Ethiopia Important Landmarks
1966
The government of Ethiopia approved the formation of the FGAE, which is an affiliate of the International Planned Parenthood Federation (IPPF)
1975
The FGAE given legal status and officially registered with the then Ministry of Interior
The first family planning clinic was opened in Addis Ababa 2

3. Family planning in Ethiopia Important Landmarks
1980:
Family planning was integrated with a national maternal and child health (MCH) program at public facilities
1992:
The first community-based distribution (CBD) program initiated
1993:
National Population Policy, Health policy & Policy on Women
2003:
Health Extension Program launched 3

4. Focus of this study Trends in contraceptive use
Drivers of change in contraceptive use
Family planning Method mix
Unmet need and the demand for family planning
Contraceptive increase and fertility decline

5. Data and Method Ethiopia DHS (2000, 2005 & 2011)
The analysis was based on 28,333 married women (age of 15-49)
Descriptive and Trend analysis
Logistic Regression model using hierarchical approach
Logit-based decomposition analysis

6. Trends in Contraceptive use

7. Unprecedented increase in contraceptive use in the last decade…

8. Most regions recorded increasing trend in contraceptive use BUT trend varies….

9. Slow trend or stalling in some regions…..

10. Inequalities in contraceptive use by region….
National average=28.6% (2011)
National average=28.6% (2011)

11. Drivers of contraceptive increase in the last decade

12. Steps followed to examine the drivers of contraceptive increase
First:
Determinants of contraceptive use examined (via Multivariate Logit model with hierarchical approach)
Separate multivariate analysis for the 2000 and 2011
Second:
The compositional, processual and interaction components of the change in contraceptive use were identified (via Logit-based decomposition method) 12

13. Conceptual framework for the determinants of contraceptive use
Background:
Residence (urban/rural), Region,
Women's education,
Husband's education,
Wealth, Employment, etc
Access to information
and service:
Told about FP (home visit)
by HEWs/vCHW
(proxy to HEP),
Heard/saw family planning
message
Fertility Experience:
Age, Parity, Child death,
Marriage duration,
Age at marriage,
Age at first birth,
Abortion
Reproductive Goals:
Wife-husband concordance on family size,
Approval of family planning use,
Fertility preference (spacing/limiting)
Contraceptive
use/non-use
Logistic regression:
Ln[pi/(1-p i)] = ∑β i xi 13

14. The Decomposition Approach
Change in contraceptive use is a function of complex relationships between the determinants of contraceptive use and time
Change in the proportion of the determinants through time (compositional changes)
Change in the influence of the determinants through time OR change in behaviors leading to adoption of contraception in a certain population group (processual change)
Interaction of the two

15. The Logit-based Decomposition Method
The method divides the trends in contraceptive use between the first (2000) and the last DHS (2011) into Composition, Processual and Interaction components:
Logit (DHS2011)-Logit (DHS2000) =
∑Pij(2000) * [βij(2011)- βij(2000)] +
∑βij(2000) *[Pij(2011)- Pij(2000)] +
[β0(2011)- β0(2000)]
∑[βij(2011)- βij(2000)]* [Pij(2011)- Pij(2000)] +
Processual
component
Compositional
component
Interaction
component
Difference in
intercept

16. Increased proportion of women with primary education
Compositional changes accounted for over 40% of the increase in contraceptive use in the last decade
Increased population access to FP information and services (Visit by HEW/vCHW at home – proxy to the HEP)
Increased proportion of women with primary education
Increased proportion living in urban area

17. Drivers of contraceptive increase ....
The Health Extension program
Proportion of women visited at home & received FP information and counseling by HEWs/community workers (last year) increased from 2% in 2000 to 20% in 2011.
Proportion of women who received their current FP method from Health Post increased from 0.7% in 2000 to 28% in 2011
Contraceptive use increased by 30% among women visited by HEWs in the homes compared to those without home visits

18. Drivers of contraceptive increase.....
Women’s education
(primary education)
Proportion of women age years who had primary education increased from 12% in 2000 to 28% in 2011
Proportion of women age years who had primary education increased from 15% in 2000 to 42% in 2011
Contraceptive use is higher by nearly two-third among women with primary education compared to those with no education

19. Drivers of contraceptive increase…...
Increase in urbanization
Proportion living in the urban area increased from 12.4% in 2000 to 18.7% in 2011
Contraceptive use is over 2 times higher in the urban area than in the rural

20. Decline in child Mortality…...
Under 5 mortality declined by 47% in the last decade
The persistent high child mortality is a cause of high demand for children, low demand for contraceptives, and thus high fertility.
“Replacement effect” - 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.
Improvements in children’s survival chances increases couples’ motivation to practice contraception
Contraceptive use is higher by three-quarter among women without dead child compared to those who experienced child death

21. Interaction components: % women with surviving children increased AND adoption of contraceptive by women with surviving children increased 21

22. Processual components:
About a fifth of the change in contraceptive use accounted for processual changes
Processual components:
Increased adoption of contraception by
Orthodox Christians
Working women
Women with ideal family size of 3-4 children

23. Processual changes….increased contraceptive adoption by the Orthodox, women with IFS (3-4) and working women over time

24. Contraceptive Method Mix

25. Skewed method Mix – Injectables accounts for over 70% of the current method

26. Increasing trend in Injectables and Implant use; the use of pills and natural methods has been diminishing….

27. About a third of current contraceptive users are in need of better method (long acting/permanent)

28. Reasons for poor method mix (Previous studies)
Lack of women’s knowledge of the different methods
Resistance to adopting some of the long term and permanent methods by women due to misconceptions and fear of side effects,
Health workers biases to certain methods
Absence of a range of methods in health facilities

29. Unmet need and the demand for family planning

30. Unmet need for family planning declined but still high … a quarter of the women have unmet need for family planning
2005
2005
2011
2011
2005
2011

31. Reasons for unmet need Fear of side effect /health concern
Religious prohibition
Fatalistic view
Lack of access to family planning services (in some of the emerging regions)

32. 54% of the women have demand for family planning

33. Contraceptive increase and fertility decline

34. Bongaarts Model Proximate determinants of fertility
TFR=TF x Cm x Cc x Ci x Ca x Cs
Where
TFR=total fertility rate
TF= total fecundity (15.3)
Cm= index of marriage
Cc= index of contraception
Ca= index of induced abortion
Ci= index of postpartum infecundability
Cs= index of primary sterility

35. Trends in proximate determinants

36. TFR declined by 1 child per woman in the last decade due to contraceptive increase
Births averted by other determinants
TF=15.3
Births averted by contraception
TFR
Births averted by contraception

37. Summary
Contraceptive use in Ethiopia has improved considerably in the last decade primarily due the synergy of a conducive family planning program landscape and favorable social changes.
Unmet need is still high (25.3%) although it has declined in the last decade as contraceptive use has risen and about 47% of the women have unsatisfied demand for family planning.
There is a great potential to further improve contraceptive usage in the country  HEP, expansion of female education, urbanization, decline in child mortality….

38. Programmatic Implications
Strengthen home visits to rural households through the HEP
Information and counseling on family planning
Involve Health Development Armies/Volunteers
Create new demand for family planning by dispelling the prevailing high value for large family
Integrate family planning with maternal and child health programs at the community level

39. Programmatic Implications
Regions need to adapt tailor-made strategies, prioritize interventions based on evidence and set their own targets in relation to family planning
Some regions have Low CPR, Low Unmeet need, and High value for children
Some regions have recorded significant increase in CPR and a modest decline in unmet need (e.g. Amhara!)
CPR stalling in some regions (Dire Dawa, Harari)
High CPR, Stalling of unmeet need, BUT low use of long-term methods in Addis Ababa 39

40. Programmatic Implications
Integration of family planning with child survival program at all levels
At program/policy level
At facility level: entry points - maternity care, Child immunization, treatment for seek child, postnatal care
Home visits by HEWs/HDAs: FP information and counseling services can be provided during child health/nutrition counseling, postpartum period 40

41. Programmatic Implications
Understanding the link between social changes and the demand for family planning
The country’s population and family planning programs need to be cognizant of the increasing demand for family planning arising from the expansion of female education and urbanization 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. 41

42. Programmatic Implications
Address the high unmet need for family planning
Overcome fear of side-effects/health concerns
Address Religious (cultural) opposition
Improve access (especially in some regions)

43. Programmatic Implications
Address the skewed contraceptive method mix
Women should be given correct information about the different methods including their likely side effects…. Informed choice
Health workers should be trained on how to counsel women about the different family planning methods based on their fertility preferences
Ensuring availability of a range of methods 43