RISK OF FIRST CONTRACEPTION AMONG ETHIOPIAN WOMEN DAWIT ADANE Master’s Thesis in Demography Multidisciplinary Master’s Program in Demography, spring term 2013 Demography Unit, Department of Sociology, Stockholm University Supervisor: Professor Elizabeth Thomson Abstract: In this study, I examine the risk of first contraception among Ethiopian women. I use the 2005 Ethiopian Demographic and Health Survey and apply Continuous-Time Event-History Analysis to follow women from age ten to the time of first use or at the interview, whichever comes first. The multivariate analyses by controlling all variables show that risks for first contraception are higher at higher parities, at younger and older ages, for Orthodox religion followers, the Tigrie ethnic group, women who completed primary education, in the Benishangul-Gumuz and Gambela regions and in urban areas and for younger cohorts. Keywords: Contraception, Relative Risk, Ethiopia, Parity, Event-History Analysis 1 Table of Co ntents Introduction 3 Literature Review 4 Background of the Stu dy Area 12 Data and Methods 18 Results 24 Discussion and Concl usions 36 Acknowledgements 43 References 44 Appendix 51 2 Introduction Most developing countries have been experiencing a rapid population growth due to high fertility rates. High birth rates, a decline in death rates, and low prevalence and use of contraception are some of the responsible factors for the rapid population growth in these countries (Oyedokum: 2007). This high population growth has been exerting pressure on the existing infrastructures if it is not accompanied by economic growth. Contraception is a way to limit and space births in order to achieve a desirable family size. Contraception also helps to improve the reproductive health of women thereby reducing maternal and child morbidity. Distal demographic and socio-economic factors influence current use of contraceptive through proximal factors such as spousal communication, women’s sexual empowerment, access to the service and attitudes and knowledge about family planning. The previous studies on contraception use in Sub-Saharan Africa in general and in Ethiopia in particular mainly focused on the determinants and factors affecting current contraceptive use. Studies on contraception use over the life course transition are scarce. Ethiopia is the second largest populous country in Africa with a population of 77.3 million people. Currently, the country is experiencing high (but declining) fertility rate and low (but increasing) contraceptive use. In this study, I will use the 2005 Ethiopian Demographic and Health Survey (EDHS) data in order to analyze women’s risk of first contraception related to demographic and socio- economic variables. As stated in APHRC and Macro International (2001) “Understanding the factors associated with the transition from non-use to use may provide useful information to program managers in the design of appropriate programs to encourage greater adoption of contraception use among sexually active women, especially adolescents.” Therefore, this study will be used as an input for future studies on fertility and contraception use. 3 Literature Review Contraceptive use is one of the four proximate determinants of fertility; the other three are proportions married, induced abortion and period of lactation infecudability (Bongaarts, 1978). Bongaarts developed a simple but comprehensive model for analyzing the relationship between intermediate fertility variables and the levels of fertility. In his model, indirect determinants of fertility like socio-economic, cultural and environmental variables affect contraception directly (Bongaarts, 1978). Some of the factors include women’s education, income level, age, desired number of children, marital duration, religion, and female mobility. However, these factors are necessary but not sufficient condition to adopt contraception. Other factors like knowledge about contraception, access to family planning service, communication with husband and women's empowerment are some of the necessary conditions for adopting contraception. Easterlin and Crimmins (1985) developed a model of demand and supply which assumes that in order to limit family size three factors should be taken into account: potential family size, desired family size and fertility regulation costs (Easterlin and Crimmins, 1985). Based on this theory, couples would use fertility control methods when the number of living children exceeds the desired number of children. In this case the couples would not use family planning until their desired number of children is satisfied. There are two types of costs: psychic costs (attitudes and feelings about fertility control) and market costs (time and money in learning about and using fertility control). If the costs are high, this might result in refusal to adopt the method (Easterlin and Crimmins, 1985). Another theory on family planning is presented by Muhwava (2003) using the Bulatao and Lee (1983) fertility decision-making model. This model is based on the notion that as society modernizes, changes occur including rational 4 decision-making and changes in the structure of the family. Decision-making consists of three elements: knowledge, motivation and assessment of fertility regulation. The first step involves being aware of the alternatives of influencing one’s reproductive behavior. Knowledge is not sufficient to influence fertility regulation although it is a necessary condition. Knowledge about contraception would be accompanied by perceptions about access and availability of methods in order for proper consideration to be given whether to use or not. In other words, for women to adopt contraception, they should have perception on the availability and accessibility of means of fertility regulation so that they can translate these perceptions in to action (Muhwava, 2003). The second stage of the decision-making process involves motivation. Motivation is influenced by socioeconomic, cultural and family life cycle patterns. This stage more or less is related to the demand-supply theory of Easterlin as motivation is the balance between supply and demand of family size; motivation is closely related to reproductive ideals and preferences which are influenced by the advantages and disadvantages of a large family. The last stage called assessment is weighing of positives and negatives of adopting contraception. Other factors included in the assessment are fear of detrimental side effects, availability of services and social norms (Muhwava, 2003). This is also related to the costs of fertility regulation of Easterlin’s model. Islam et al have proposed a theoretical framework to analyze the determinants of contraceptive use among married teenage women and newlywed couples in Bangladesh. Their framework distinguished distal and proximal influences on contraceptive use like demographic, socioeconomic, cultural and programmatic factors. These factors affect contraception through their influence on an individual's knowledge about family planning, motivation to use contraception and access to family planning (Islam et al, 1998). Figure 1 shows how the distal factors influence contraceptive use through knowledge, motivation and assessment. The research described below focuses 5 on distal influences, but to understand them, it is first useful to discuss how proximal factors influence contraception. Figure 1: Theoretical Framework Distal Determinants Intermediate Determinants Outcome Source: Bulatao and Lee (1983) and Islam et al (1998) Determinants of Current Contraceptive Use Intermediate/ Direct Determinants Desired number of children is the one of the intermediate factors that affects the use of contraception. The main motivation for contraceptive use and non-use is the desired family size as presented in the demand-supply theory by Easterlin. Evidence showed that women who want more children use less contraception than those who want fewer children (Tawiah, 1997). If couples already have 6 more children than desired, there is a potential excess supply of children, which provides motivation for fertility control (Easterlin and Crimmins, 1985). Knowledge about family planning is one step ahead towards gaining access to and using suitable contraceptive methods in a timely and effective manner. In order to make choices about family planning individuals need to have adequate information about the available methods of contraception (CSA & Macro International: 2006). Knowledge of contraceptive increases the use of it (Gordon et al: 2011). Attitudes toward family planning depend on the safety and the feeling about specific contraception methods. Positive attitudes towards family planning encourage the use of it and vice versa. Contraceptive use, in developed countries, is determined by whether doctors are obliged to inform parents about an adolescent request for contraception service or not (Jones EF et al: 1985), adolescent’s attitudes towards contraceptive methods, fear of side effects, and parents’ support (Darroch JE et al: 2001) and differences in societal attitudes towards adolescent sexual activity. A restricted access of contraceptive methods has an impact on the individual’s method choice and hence results in a lower level of contraceptive use (Ross et al: 2001). Accessibility of family planning expressed in terms of time, cost and location and hence contraceptive prevalence is higher in countries where access to all methods is uniformly high (Ross et al: 2001). In some developed countries contraceptive methods are available freely or at low cost. Generally speaking, spousal communication either to limit or to space children can also encourages the use of contraception. Link (2011) found that both wives’ and husbands’ perception of communication encourages the adoption of contraception in rural Nepal. Communication is helpful for transforming attitudes into the physical act of using contraceptives and may lower the psychic cost of contraception use. In developed countries young women who discussed with their partner about contraception before first sex are more likely to use the method than those who don’t make any communication (Stone & Ingham, 2002). As cited by Crissman et al 2012, Malhotra and Mehtra (1999) said that many family planning initiatives focus on improving availability, prevalence and 7 knowledge of contraceptives and safe sex. These approaches are beneficial but are not necessarily sufficient to increase women’s control over their sexual and reproductive health unless women have sexual empowerment (Crissman et al, 2012). In other words, women with access and knowledge of contraception may not use it unless they are empowered in terms of decision-making on the desired number of children and choice of family planning methods. Increasing level of sexual empowerment is positively associated with the use of contraceptives. Bertrand et al (1993) explained that education affects the authority within households, whereby women may increase their autonomy with husbands, which has an effect on fertility preferences and use of family planning. In the next section, some of distal determinants are discussed in terms of effects on proximal determinants of contraception. Distal Determinants Contraceptive use increases when the number of living children increases. The higher the number of children, the more likely is family planning use (Okech et al: 2001; Tawiah: 1997; Islam et al: 1998 and Troitskaya & Andersson: 2007). The more the children a woman has, the more likely that the number of living children exceeds the desire number of children, thus increasing motivation to control unwanted pregnancy. The age of the women is another distal determinant in contraceptive use. Contraceptive use is relatively higher for younger women and decreases with age after 30 (Koc: 2000; Islam et al.: 1998 and Troitskaya & Andersson: 2007). Younger women have greater access to and knowledge about methods of contraception whereas at older age fecundity is low with less frequent sexual contact, reducing motivation to use. Increasing educational level has a positive effect on the use of contraceptives. Riyeni et al (2004) showed that education gives young women autonomy to make informed choices about their reproductive health and to avoid unsafe sex 8 which results in unintended pregnancy. Gupta (2000) said that women with higher education and higher standard of living are better off as they appreciate the health and social advantages of protecting themselves by delaying pregnancy. Young women tend to postpone pregnancy until they have completed their education and they feel that they are socially and economically secure. Education facilitates the acquisition of information about family planning, it increases husband-wife communication and increases couples’ income potential, making a wide range of contraception methods affordable (Khouangvichit, 2002). A study on women’s education and modern contraception use in Ethiopia found that the relationship between education and using family planning is indirect via clinic attendance (Gordon et al., 2011). Studies conducted in Ghana and Kenya found that married women with higher education were more likely to use contraceptives (Tawiah: 1997, Okech et al 2011 & Crissman et al: 2012). Women living in urban areas are more likely to use contraception because they have more information about and greater approval of family planning. In urban as compared to rural areas, people have better access to health services, educational institutions and media due to developed infrastructure and available facilities. Thus, higher adoption of contraceptive methods would be expected in urban areas. Besides, urban women have a higher access to school than those who live in rural areas; via schooling they can visit health institutions (Gordon et al, 2011). When a family planning provider is far away, there will be additional costs in terms of transport and transaction costs as well as waiting and traveling time, which may discourage a person from seeking the services (Okech et al: 2011). Occupational status of a woman has an effect on contraceptive use. Women’s decision making in using contraception will be higher for women who are active in the labor market. Occupation, like education, gives women more control over family planning decision-making including making a choice for 9