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

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

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

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

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

Trends in Contraceptive use

Unprecedented increase in contraceptive use in the last decade…

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

Slow trend or stalling in some regions…..

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

Drivers of contraceptive increase in the last decade

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

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

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

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

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

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

Drivers of contraceptive increase..... Women’s education (primary education) Proportion of women age 15-49 years who had primary education increased from 12% in 2000 to 28% in 2011 Proportion of women age 15-24 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

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

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

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

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

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

Contraceptive Method Mix

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

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

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

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

Unmet need and the demand for family planning

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

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)

54% of the women have demand for family planning

Contraceptive increase and fertility decline

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

Trends in proximate determinants

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

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….

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

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

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

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

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)

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