Modern contraceptive use and associated factors among reproductive-age women in Ethiopia: multilevel analysis evidence from 2019 Ethiopia mini demographic and health survey

Abstract Background Despite the high fertility and population growth rates, the use of modern contraceptives remains low in low- and middle-income countries. Different pocket-sized studies on the use of modern contraceptive methods conducted in various parts of Ethiopia have been extremely varied and ambiguous. Therefore, this study aimed to assess modern contraceptive use and its associated factors in women of reproductive age in Ethiopia. Methods Cross-sectional data from the Ethiopia Interim Demographic Health Survey (EMDHS) 2019 in a stratified, two-stage, and cluster sampling study. Multilevel binary logistic regression analysis was used to fit the associated factors. The interclass correlation (ICC), median odds ratio (MOR), proportional change variance (PVC), and deviance were used for model comparison and fitness. The adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to identify the significant factors of modern contraceptive use. Result The multilevel analysis demonstrated that Orthodox religion [AOR = 1.7; 95%CI: 1.4–2.10] protestant religion [AOR = 1.2; 95%CI: 0.93–1.62], married [AOR = 4.2; 95%CI: 1.93–9.07], primary education [AOR = 1.5; 95%CI: 1.26–1.76], secondary education [AOR = 1.36; 95%CI: 1.04–1.77 [AOR = 1.89; 95%CI: 1.37–2.61], middle [AOR = 1.4; 95%CI: 1.14–1.73], rich [AOR = 1.3; 95%CI: 1.06–2.68] were positively associated with modern contraceptive utilization, while the age group of 40–49 [AOR = 0.45, 95% CI: 0.34–0.58], and high community poverty [AOR = 0.62; 95%CI: 0.46–0.83] were negatively associated with modern contraceptive utilization. Conclusion The prevalence of modern contraception in Ethiopia remains low. Maternal age, religion, maternal education, marital status, wealth index, region, and community poverty were significant predictors of modern contraceptive utilization in Ethiopia. Governments and non-governmental organizations should expand their public health programs to poorer communities to increase the use of modern contraception in the country.


Introduction
Modern contraceptive methods play a significant role in reducing the consequences of unintended pregnancies, which can result from the nonuse of contraceptives [1][2][3].It protects the lives of women and children and improves the quality of life for all [4][5][6].Unintended pregnancy occurs when no child or children are desired (unwanted) or when it is not expected (mistimed) [7].The common consequences of unintended pregnancies are unsafe abortion, economic burden, and maternal mental health problems, including depression, stress, and lower levels of psychological welfare [7,8].Improvements in healthrelated consequences, such as reduced maternal mortality and infant mortality, are not the only importance of modern contraceptive methods, but also improve economic growth and schooling, especially for girls and women [9].
Most countries have seen a rise in the demand for and use of modern contraceptives globally [10].Despite its enormous advantages, its acceptance rate is still low, and there is a continually high unmet need for family planning among women in developing nations [11,12].According to current data, only a significant fraction of women in Africa used modern contraceptives, with estimates ranging from 23.9% in 2012 to 28.5% in 2017 [13].In comparison to the target set on the Health Sector Transformation Strategy (HSTP)-I among women aged over 39, the most recent Ethiopian interim Demographic and Health Survey revealed insufficient uptake of contraceptive methods and substantial unmet needs [14].According to the survey, just 28% of women aged 15 to 49 used modern contraceptives, whereas 29% of all women used any form of contraception (whether traditional or modern) [15].
According to various studies, modern contraceptive utilization is significantly associated with age, marital status, education level, partner rejection, servicerelated problems, accessibility, counseling on contraceptive methods, postnatal care follow-up, being a housewife in occupation, feeling of husband toward modern contraceptive methods, knowledge about modern contraceptive methods, and availability are a few contextual and individual factors that affect access to and use of contraceptives [2,9,[16][17][18][19][20].
Over the past 10 years, a range of tactics have been used in Ethiopia to promote the usage of contraceptive techniques.The development of health extension activities to alter community attitudes and raise awareness was one of the measures taken to boost contraceptive use [20,21].The health system modernized primary healthcare facilities and extended health centers and health posts to remove obstacles to the use of contraception [21].Despite these governmental initiatives, the percentage of women who use contraceptive methods is still low [22].Moreover, our study included information that readers may use to decide whether or not modern contraception use has improved since the last EDHS and its findings were drawn.Therefore, this study aimed to examines both individual and community level factors associated with the use of modern contraceptives among women of reproductive age in Ethiopia based on the 2019 mini-EDHS data.The results of the study will be expected to help policymakers create strategies that will decrease maternal mortality and morbidity by promoting the use of modern contraceptives.

Data source
This study used cross-sectional data from the (EMDHS) 2019.Ethiopia is the second most populous country in Africa, located at (3o-14oN, 33 -48 E).The EMDHS is a country-representative sample survey conducted between the five-year Ethiopian demographic and health survey.The country has nine regions and two city administrations (Amhara, Benishangul-Gumuz, Gambela, Harari, Oromia, Southern Nations, Nationalities, and People Region (SNNPR), and Tigray, Afar, and Somali) and city administrations (Addis Ababa and Dire-Dawa).We retrieved the data for this study from the DHS website (www.dhsprogram.com)after authorization was granted via online request by explaining the purpose of our study.We extracted dependent and independent variables from the woman record (IR file).DHS is a nationally representative household survey conducted by face-to-face interviews on a wide range of populations.Study participants were selected using a two-stage stratified sampling technique.Enumeration areas (EAs) were randomly selected in the first stage, while households were selected in the second stage.Women those who were pregnant were excluded from this study.Therefore, the final study sample included a weighted total of 8,885 reproductive-age women.The detailed sampling procedure is presented in a full EMDHS 2019 report .

Dependent variable
Modern contraceptive use: In the current study a woman was considered a modern contraceptive method utilizer if she had been using at least one of the modern contraceptives (female sterilization, male sterilization, IUCD, injectable, implants, pills, male condom, female condom, emergency contraception, and standard days method) during EMDHS data collection period.A woman was considered to be using modern contraception if she used any of the modern contraceptive methods code as 1 "Yes" if not use any kind of modern methods (No method, Folkloric method, Traditional method) coded as 0 "No"
The aggregate community-level explanatory variables (community women's poverty and education) were constructed by aggregating individual-level characteristics at the community (cluster) level.They were dichotomized as high or low based on the distribution of computed proportion values.

Multilevel analysis
As data from the EMDHS were nested (hierarchical), we used multilevel logistic regression.The random effect was measured using intra-community correlation (ICC), calculated as ICC ¼ r Va 1 , where Va 1 is the variance of the empty model and Va 2 is the neighborhood variance in the subsequent model).Model comparison was performed using the Likelihood Ratio (LR) test, and goodness of fit was assessed using deviance (À2LL)).

Socio-demographic characteristics of the study population
We analyzed 8,885 reproductive-age women from a cross-sectional survey of the EMDHS 2019.Of these, 3347 (37.7%) were from the Oromia region and 27 (0.3%) were from the Harari region.The majority (67.80%) of the respondents were rural residents.The majority of study participants (60.30) were aged 15-29 years.Regarding educational status (41.65%) of the respondents had primary education.The majority of participants (67.5%) were married (Table 1).

Random effect analysis
The null model indicated that the ICC of 21% total variability for modern contraceptive use was due to changes between clusters, and the remaining unexplained was attributable to within-cluster variability.In addition, a MOR of 5 in the null model presented a difference in modern contraceptives between clusters.Finally, the PCV of the multilevel model showed that 48% of the variability in modern contraceptive use could be explained by the full model.The best-fit model was compared by deviance, and the best fit was Model 3, as it had low deviance (Table 2).3).

Discussion
In this analysis, we included 8,885 women of reproductive age regarding modern contraceptive use and found a prevalence of 2495 (28%).The current prevalence was higher than that reported in previous studies in Ethiopia (20.42%) [28] and Gahan (21%) [29].However, the findings of this study were lower than those of studies conducted in Northwest Ethiopia [30] and Kenya [31].This disparity could be attributed to the lack of information on modern contraceptive methods.The variation could also be due to sociocultural differences across countries, which could have a significant impact on contraceptive utilization.The average contraceptive prevalence rate in four emerging regions of Ethiopia in 2021 was 22.2%, and it was 11.7%, 38.6%, 25.5%, and 8.8% for the Afar, Benishangul Gumuz, Gambela, and Somali Regions, respectively [32].
The multilevel analysis demonstrated that the age group of 40-49, and high community poverty were negatively associated with modern contraceptive utilization, while Orthodox religion, protestant religion, married women, educational status, and middle and rich wealth index were positively associated with modern contraceptive utilization.
Women in age group 40-49 years were less likely used modern contraceptive method compared to those in age group 15-29 years.This study finding was supported by study conducted in Malawi [33], Ethiopia [27].The discrepant outcome may be the consequence of variations in the sample size, study design, setting, and study population.Younger women were also less likely to have married and were more likely to take contraceptives during sexual gratification to avoid unexpected pregnancies, according to one study.
The positive relationship between the Orthodox Christian religion and contraceptive use was also supported by another study [34].This might further strengthen the use of religious leaders to increase service utilization.In our analysis, married women had more contraceptive use than single women.This finding was consistent with that of another studies in Ethiopia [26,32], West African .It is more global than married women reporting contraception use, while a single might not be due to cultural factors.Our study also revealed that the educational status of a woman positively influences modern contraceptive utilization This study finding was supported by studies conducted in Africa [25,26,28,29].The rationale might be that educated women would be aware of the advantages of modern contraception through reading newspapers, watching television, and using various social media.Moreover, educated women could exhibit positive health-seeking behavior and utilize health services, such as family planning options.In this study, women from middle-and high-income households used modern contraception higher than women from low-income homes.This finding was supported by studies conducted in Ethiopia [35], Rwanda [36], and Nigeria [37] This may be due to the fact that women from rich household may be more educated and have employment (there may be significant obligations there), allowing them to further develop their business issues and agendas.In this study, contraception use rates were lower among women in high community poverty than low community poverty group [35,38].The rationale might be that poorer communities will not make as much of an investment in women's empowerment and education.These communities may also have few cultural boundaries within them.Moreover, modern contraception methods varied by region.Women who lived in Amhara, Oromia, Benishangul, and SNNPR were more likely used modern contraceptive compared to those women in Tigray region.The finding was in line with study in Ethiopia [39].The implementation of family planning services varies among areas, which could be the cause of this regional disparity.
This study had several strengths and limitations.We used the national survey data and a relatively large sample size.It utilizes internationally validated and nationally adapted surveys.Therefore, the current findings can be generalized to the entire country and yield accurate estimates.We used weighting to handle the disproportionate nature of the data, and multilevel analysis to account for the hierarchical nature of the data.The study limitations and cross-sectional study design (cross-sectional) does not allow us to establish causality between the factors.The second limitation of this study was the lack of data on some variables.

Conclusion
The prevalence of modern contraception in Ethiopia remains low.Maternal age, religion, maternal education, marital status, wealth index, region, and community poverty were significant predictors of modern contraceptive utilization in Ethiopia.Governments and nongovernmental organizations should expand their public health programs to poorer communities to increase the use of modern contraception in the country.Furthermore, reforming the health system and promoting reproductive health education through mass media to raise awareness of the benefits of modern contraceptive use are effective strategies to increase modern contraceptive use among Ethiopian women.
2 a r 2 a þr 2 b ; where r 2 a is the community-level variance and r 2 b indicates individual-level variance.Individual variance (r 2 b ) is equal to p 2 =3 which is a fixed value.The median Odds Ratio (MOR) was estimated as MOR ¼ MOR ¼ e0:95Ã ffiffiffiffiffiffiffi Va 1 p , where Va 1 is the variance in the empty model, and Proportional Change in Variance (PCV) was estimated as PVC ¼ Va 1 ÀVa 2

Table 2 .
Random effect analysis result.