December 2007 - Volume 1, Issue 6

CONTRACEPTIVE BEHAVIOR AMONG MARRIED ADOLESCENTS IN SOME SELECTED AREAS OF BANGLADESH

Md. Mosfequr Rahman (1), Md. Aminul Hoque (2) Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi-6205, Bangladesh Department of Statistics, University of Rajshahi, Rajshahi-6205, Bangladesh Correspondence to: Md. Aminul Hoque, Ph.D., Associate Professor, Department of Statistics, University of Rajshahi, Rajshahi-6205, Bangladesh. Mobile: +88-1914254017, Fax: +88-0721-750064 (off.) Email: mdaminulh@gmail.com

ABSTRACT Adolescents ranging from 10 to 19 years constitute the largest population of the world. They number over one billion and the number is increasing. The behavioral patterns of contraceptive acceptance and use differ significantly between adolescents and adults. Considering the importance of the contraceptive behavior of married adolescents, an attempt has been made in this study to investigate the contraceptive use and pattern of married adolescents in some selected areas of Rajshahi district, Bangladesh. This study is based on the data collected under the project of UNFPA entitled "Strengthening the Department of Population Science and Human Resource Development". It has been observed from this study that family planning practices among adolescents is lower than other groups of women. The current use of contraception among adolescents is 65.3 percent. The pill appears to be the most popular method among the adolescents. Rural and urban differences are still high in the current use of contraception (60.9 percent and 69.9 percent). Logistic analysis shows that respondent's education, husband's education, place of residence, religion, husband's occupation, visit of family planning worker, desire for more children and having radio or television in the household are supposed to be most influential factors on the current use of contraception.

Key words: Married adolescents, contraceptive, family planning, logistic analysis, influential factors.

INTRODUCTION

Any deliberate practice to reduce the risk of conception is considered as contraception, i.e., contraception is the prevention of conception by which a woman can prevent unwanted pregnancies. Contraceptive use is one of the crucial factors mediating between sexual activities and conception and it is one of the oldest methods of fertility reduction. The use of contraceptives is the most important factor that directly affects fertility.

Both married and unmarried adolescents face the added obstacles of legal and cultural restrictions which limit their access to family planning services. However, unwanted pregnancies resulting from lack of contraceptive use have led to an increasing number of abortions among young women. In many part of the world, despite the fact that young women are often denied access to legal abortion services, both the number and the proportion of abortions performed for young women have been increasing over time (Islam and Mahmud, 1995). Aside from external influences at the socio-cultural and policy levels that affect an adolescent's contraceptive behavior, factors which vary at the individual level are also important, such as whether or not contraception occurs within a stable relationship, and whether or not either partner has had previous experience with contraception.

In our society, adolescent girls often face unwanted pregnancy either through failure of contraceptive methods or by non-use. Moreover, because of early marriage, childbearing is the common norm; unintended pregnancies are not deemed very unusual (Pachauri, 1998). The decision for the pregnancy termination depends on husband or on other family members. As the socio-cultural beliefs regarding abortions are very restrictive in terms of the existing general abortion law of the country, induced abortion is viewed as a shameful act because it is frequently done to end illicit pregnancy (Maloney, Aziz and Sarker 1981).

In society, there are no special contraceptive services for adolescent groups (Pachauri, 1998). The country's social norm, tradition, and legislation has tended to disapprove and restrict contraceptive uses by adolescents (WHO, 1975). In Bangladesh, where 66 percent of adolescents are married, only 9 percent of them use contraceptives, compared to 19.1 percent of married adults (Senanayake et al., 1994). According to Bangladesh Demographic Health Survey (1996-1997), 1 in 3 married women aged between 15 and 19 are using contraceptive methods (BDHS, p. 49). It is widely believed that modern contraceptive methods, especially, the oral pill may lead to infertility. As a result, without any practice of contraception they want to have their first baby soon after marriage. Jejeebhoy states "contraceptive use depends, to a large extent, on a woman's age, fertility, and duration of marriage; the education contraception relationship should ideally be viewed with these factors controlled" (Jejeebhoy, 1995). A Matlab study findings indicate that "contraception discontinuation was 73 percent higher among parents with no surviving sons and 72 percent higher among parents with no surviving daughters, compared with parents who have children of both sexes (Rahman et al., 1992). Adolescents tend to be begin contraceptive use 1.5 years after marriage, or at an average of 17 years old (Islam-MM et al., 1998).

Although the contraceptive use rate is gradually increasing in Bangladesh, it is still very low compared with any developed country and many developing countries. Since the average age at marriage in Bangladesh remains one of the lowest in the world, a large proportion of the potential acceptors of contraception are married adolescents. Unfortunately little exclusive and comprehensive study on the contraceptive behavior of married adolescents in Bangladesh has been undertaken; therefore, in view of the importance of this matter, an attempt has been made in this study to investigate their contraceptive behavior. For comparison purposes we consider the contraceptive behavior of married young adults along with that of adolescents.

METHODS AND MATERIALS

The data of this study was collected under the project of UNFPA entitled "Strengthening the Department of Population Science and Human Resource Development" of University of Rajshahi, Bangladesh. The individual questionnaires collected information on the respondent's fertility behavior and intentions, knowledge and practice of contraception, and availability and accessibility of contraceptives. Information on socio-demographic characteristics, such as education, religion, husband's occupation, household assets, and modern health care practices, among others, were also collected in the individual questionnaire. These data were collected from the three residential areas, which are rural, urban and sub-urban areas of Rajshahi district, Bangladesh. We collected information of 6000 ever-married women, we found 426 married adolescents (6.39%). All this information was taken by purposive sampling method. The data of this study was collected in June 2004. Univariate tables and logistic regression analysis were used for data presentation and interpretations.

LINEAR LOGISTIC REGRESSION ANALYSIS

When we examine each independent variable individually, it can only provide a preliminary idea of how important each variable is by itself. So the relative importance of all the variables has to be examined simultaneously by some multivariate methods. There are varieties of multivariate statistical techniques that can be used to predict a binary dependent variable from a set of independent variables. Multiple regression analysis and discriminant analysis are two related techniques but these techniques are applicable only when the dependent and independent variables are measured in interval scale under the assumption that they are normally distributed with equal variances. However, in most applications, the dependent variable may be a dichotomous one and one or more explanatory variables are qualitative or measured in nominal or ordinal scales and the assumption of normality is violated. To overcome this problem, a very interesting and appropriate technique is the linear logistic regression method developed by Cox (1970), which does not require any distributional assumption. This regression is useful when the dependent variable is dichotomous. Since it does not require any distributional assumptions, unlike many other multivariate techniques (i.e. the variables are normally distributed with equal variances), it can appropriately handle situations in which the independent variables are qualitative or measured in nominal and ordinal scale. The logistic regression model can be used not only to identify risk factors but also to predict the probability of success. This model expresses a qualitative dependent variable as a function of several independent variables, both qualitative and quantitative (Fox, 1984).

Let Yi denote the dependent variable for the 1st observation and Yi = 1, if the 1stith individual is a success and Yi = 0, if the 1stith individual is a failure. Suppose that for each of the individuals k independent variables Xi1, Xi2,…,Xik are measured. These variables can be either qualitative such as residence, religion, education etc. or quantitative such as age, number of living children etc. in logistic regression model, it is assumed that Yi's are normally distributed with mean Pi and variance s², and Pi is defined as the probability of success, that is,

And

Estimation of the parameters of ßj's from equation (1) and (2) seems to be very complicated. However, the logit transformation of Pi turns out to be a linear function of Xij, that is

which express the log odds of occurrence of an event (i.e. dependent variable) as a linear function of the independent variables. Thus logarithm of the value of "success" (P) to "failure" (1-P) are relating it to the independent variables, the logistic parameters can easily be interpreted in turns of odds ratios. Relative odds can be estimated for the categories of each independent categorical variable or combination of such variables.

In logistics regression the parameters of the models are estimated using maximum likelihood method. The contribution of individual variables in logistics regression depends on the other independent variables and the interpretation is difficult when they are highly correlated. A statistic that is used to look at the partial correlation between the dependent variable and each of the independent variable is the R statistic.

RESULTS

Current Use of Contraception

The term "current use" refers to the method that was being used by an individual client at the time of the survey. Thus, any respondent (or her spouse) using a family planning method at the time of survey was regarded as a current user.

Table 1.1 summarizes the current level of contraceptive use among the adolescents and young adults who were currently married. The results indicate that about 65.3 percent of adolescent women are currently using contraception methods. On the contrary, the corresponding figure for the young adults and for over all ever married women is 87.0 and 75.0 percent respectively. The comparable figure for adolescent women as obtained from 1989 BFS was 15.3 percent (Islam and Mahmud, 1995). The current overall contraception using rate in Bangladesh is 58.1 percent (BDHS, 2004).

From the 1.1 we also see that, among the individual methods, oral pill is the most used method of contraception for adolescent women (79.6 percent), young adults (74.7 percent), and all ever married women of reproductive age (68.2 percent).

Table 1.2 presents the current level of contraception by the currently married women's husband. Among the married adolescent's husband 25.6 percent use contraception, while the corresponding figure for young adult's husbands and all ever married women's husbands is 14.7 and 14.3 respectively. This indicates that husbands are less interested in using contraception, rather they may want their wife's to use the method of contraception. That is the husbands of adolescents are using contraception more than their counterparts of young adults' husbands. Among the various methods of contraception, condom appears as the most popular method of contraception used by the husband of the married women. About 99.1 percent of adolescents' husbands are using condoms as contraception, while the corresponding figure for young adults and all ever married women's husbands are 97.3 percent and 93.3 percent respectively.

Discussion about Family Planning

The women in Bangladesh still feel shy about their needs and especially about their family planning needs. Whatever methods they use, almost all of them do not decide on their own. They take the decision from those closely relatedto them. Table 1.3 presents the percentage of women who are currently using contraceptive methods taking the decision from various close relatives. The table indicated that about 93.5 percent of adolescents who are currently using contraceptive methods are taking the decision after discussion eith their husband. The corresponding figures for young adult women is 85.2 percent and for overall women it is 80.3 percent.

That is, husbands are the most reliable person with whom women are taking the decision about family planning. We found that young adult women are more reasonable toward discussong it with a family planning worker. This may be because they are more mature and feel the need of them. Some small percentages were also found about those who discussed family planning with their mothers, mother in law and other close relatives.

Differentials in Current Use of Family Planning

Current use of family planning varies by various socio-economic variables. Table 1.4 summarizes various socio-economic, demographic and geographic differentials in current use of contraception in terms of percentages using any method at the time of survey. They are useful to identify among other things the sub-groups of population that may be in need of more care and attention in the delivery of family planning devices. The current use of contraception was found to be directly associated with respondent's and their husband's education, number of living children, desire for more children, place of residence and religion.

Among all the characteristics, education of both the respondents and their husbands seem to have the strongest and most positive effect on current use of contraception. The results suggest that the higher educational levels of the respondents are associated with higher contraceptive use i.e., as educational level increases, the percentage of women using contraceptiin increases rather rapidly. However, this effect is more pronounced in the case of adolescent women than of the young adult women. The current use of contraception is 49.6 percent among adolescents who have no education and reached to a high of 56.0 percent for those who have primary education, 62.3 percent for those who have secondary education and reached to 65.8 percent for those who have higher level of education. While for young adult women the corresponding figure is 81.8 percent, 88.9 percent, 89.1 percent and 89.1 percent respectively.

For adolescent women current contraceptive use shows strong variation by the place of residence. Adolescent women who are from rural areas have the percentage of currently using contraception at 60.9 percent and the respective figure for urban and sub-urban places is 69.9 percent and 63.6 percent respectively. However, for young adult women and for all currently married women, place of residence shows moderate variation on current use of contraception; and urban area shows higher use of contraception than sub-urban and rural areas.

Household assets index also shows a significant variation in the current use of contraceptives for adolescents. The result indicates that current use of a contraceptive method is 74.5 percent among adolescents who were form upper classes and reached to a low of 61.5 percent for middle class adolescents and 55.5 percent for lower class adolescents. While for young adult women the corresponding figure is 88.6 percent, 87.4 percent and 82.8 percent respectively.

Number of living children has shown some differential effect on current use of contraception. The result shows that adolescent women who have no living children are less likely to use any method. Use of contraception among adolescents increases to a maximum of 75.6 percent for those adolescents with 3 or more living children and then descended to 65.1 percent for those having 1 or 2 living children. For young adult women and overall women the use of contraception is the maximum when they have three or more living children, and then declines.

Contraceptive use increases with regular visits of family planning workers, indicating a positive relationship between family planning workers who visit a couple regularly and contraceptive use. The use of contraception is higher (about 60 percent) for adolescent women who have been contacted by family planning workers regularly than those who have been contacted irregularly by the women (57 percent) and who have not been contacted by the women (53 percent). The same picture is also seen for both young adults and overall women.

Husband's occupation appears to make a difference in contraceptive practice. The result suggests that contraceptive use is highest among those whose husbands are servicemen followed by businessmen, farmers, laborers and others. The higher level is related to higher education of husbands. The lower level represents husbands living in rural areas and consequently who may have a lower level of education.

Those who do not desire additional children are more likely to be current users than those who desire additional children. The contraception use is considerably higher, 72.1 percent, for adolescents who do not desire more children than for adolescents who desire additional children (62.9). This is also true for young adult women.

Experience of child loss also has a negative effect on contraceptive use for both adolescents and young adult women.

Factors Affecting the Current Contraceptive Use among the Adolescents
and Young Adults

In this section, we apply logistic regression technique to estimate the effects of selected socio-demographic and programmatic factors on current contraceptive use among adolescents and young adults.

The logistic model is fitted by considering current use of contraception as the dependent variable, which we dichotomized by assessing 1 if the respondent is using any method of
contraception and 0 for not using any method. The explanatory variables considered in the model are as follows: respondent's education, husband's education, place of residence, religion, husband's occupation, visit of family planning worker, want more children, number of living children, respondent's working status, having radio or TV, experience of child death.

Table 1.5 gives the estimates of logistic regression coefficient (ß) corresponding the independent variables, partial R and relative odds calculated for each category of the categorical variables. The inference regarding statistical significance is based on chi-square statistics. The p-value is used to identify the significant effects to assess the relative importance of the selected variables in the model. The odds ratio has a clear interpretation and is straightforward. An odds ratio of greater than 1.00 suggests an increased likelihood of the event occurring (i.e. currently using), while odds less than 1.00 indicate a decreased likelihood of the event occurring. The category with the relative odds of 1.00 represents the reference category for that categorical variable.

Among adolescent women, according to the model, seven variables appeared as the significant predictors of current contraceptive use. These variables are: place of residence, husband's occupation, education of the respondents, husband's education, want more children, visit of family planning worker and having radio or television. The rest of the explanatory variables are found statistically insignificant. For young adult women the significant predictors of current use of contraceptives are: respondent education, husband's education, husband's occupation, desire for more children, number of living children, place of residence and working status of the respondent.

From the results of logistic regression analysis, it appears that respondent's education have very strong and positive independent effects on contraception with the likelihood of current use increasing significantly for the women of primary, and secondary and higher education. From our data we found that, the adolescent women with primary level of education were 1.016 times as likely to practice contraception as those who had no education and adolescent women of secondary education are found 1.464 times as likely to use a contraceptive as those who are illiterate. As expected, education increases receptivity to "new technologies", including awareness and use of contraception.

Educated women also may desire fewer children than their less educated counterparts because of incompatibility between formal-sector employment and child care (Choe and Tsuya, 1991). Again among young adult women who have primary education are found more likely (odds ratio 1.043) to use contraceptives than their illiterate counterparts and young adults who have secondary and higher education are also found more likely to use contraceptive (odds ratio 1.572) than those who have no education or are illiterate.

Husband's education also exerts a positive significant effect on current use of contraceptive behavior among both adolescent and young adult women. It is observed that the adolescent wives of secondary and highly educated husbands are 1.869 times as more likely to use a contraceptive as those adolescent wives of illiterate husbands. But the adolescent wives of primary educated husbands shows a negative effect on practicing contraception. While young adult wives of primary educated husbands are 1.279 times higher and of secondary and higher educated husbands are 1.936 times higher as likely to use contraceptive as those young adult wives of illiterate husbands

While considering the place of residence, the result shows that sub-urban adolescent women are 0.536 times less likely to use a contraceptive than in rural areas, and urban women are 4.305 times more likely to use a contraceptive than those women in rural areas. The same picture is also observed for young adult women.

Husband's occupation also has a significantly positive effect on the behavior of both adolescent and young adult users of contraceptives. From the table we see that wives of husbands employed in the service sector were 2.848 times more likely to practice contraception than the adolescent wives of agricultural laborers or farmers. We also found that adolescent wives of businessmen and laborers or other categories were 1.573 and 1.231 times higher than their adolescent wives of farmer counterparts. For young adult women we also observe that the young adult wives of servicemen, businessmen and laborers were more likely to use contraceptives; the respective odds ratios are 1.948, 1.759 and 1.333 with respect to the current contraception use with reference category of farmer husbands.

Religion has an insignificant and positive effect on current use of contraception of the adolescent women. The result shows that Muslim adolescent women are more likely to use contraception than their Non-Muslim counterparts. The same picture is also shown for adolescent women.

The analysis further indicates that frequency of visits by field workers is significantly and positively related to current use of a contraceptive method among adolescent women but insignificantly associated for young adult women. Adolescent mothers are more likely to use family planning methods when the field workers visit them regularly or several times, than those who are not visited at all by the field workers.

The multivariate analysis indicates that the probability of being a current contraceptive user is also 0.845 as low among adolescent women who did want more children compared with those who wanted no more. The corresponding odds ratio for young adult women is 0.346.
Number of living children is another important and significant factor affecting the use of contraceptives among females; adolescent women have 0-1 children, 0.596 times less likely to use contraceptive than that of having 2 or more living children, and for young adult women having 0-1 children 0.607 times less likely to use contraception than of young adult women having 2 or more children.

From the results we also observe that current contraception practice is likely to be 0.003 times lower among women who were working than those who were not working. Among the young adults the corresponding odds ratio is high, that is working young adult women are 1.158 time more likely to use contraception than their non-working counterparts. It has a significant effect on current use of contraception among young adult women.

Having radio and television in the household of adolescents is an important and significant variable; it contributes positively to the current use of contraception. The relative odds ratio are found to be 1.477 indicating higher prevalence of contraceptive use among adolescents who have radio or television in the household, as compared with those having no such facility.

The experience of child loss also has an independent effect on the current use of contraception. The negative sign of the regression coefficient suggests that, with every increase in the number of children lost, current use of contraceptives decreases among currently married adolescent women and young adult women.

DISCUSSION

This study examines the use of contraception among currently married adolescent and young adult women for comparison purposes in Rajshahi district, with particular focus on the extent to which socio-economic and demographic factors exert independent influence on contraceptive use. Low contraceptive use among married adolescents may be attributed to several socio-economic and cultural factors, such as education, religiosity, social conservativeness, husband-wife communication, occupation, economic condition etc. in addition, adolescents may face greater difficulties in obtaining contraceptive supplies and they may lack proper knowledge of the use of modern contraceptive methods. Most of the adolescent users get supplies of the methods from the field worker and other private sector sources. This may be due to their limited access to the commercial supplies or due to cultural reasons that they may feel embarrassed to obtain methods from commercial supplies. Most of the adolescent married females are economically poor and uneducated; moreover their status in the family and in society is very low. Because they are normally not very active economically outside the home, they have little say in decision making in the family.

From the differential analysis of the study, we found that, education of both respondents and their husband's have a strong and positive effect on contraception use for both adolescents and young adult currently married women. Urban currently married adolescent and young adult women use a higher percentage of contraception than their rural and sub-urban counterparts. Number of living children, desire for additional children, visit of health worker and experience of child loss has also great differences in the current use of contraception among adolescents and young adult currently married women.

With regard to the selected demographic and socio-economic factors related to contraceptive use the results of this study support the hypothesis that respondent's education is one of the most important factors. Evidence suggests that education not only increases awareness of social mobility and creates a new outlook and rationalism among couples, but also reduces desired family size by raising desired living standards, bringing about a better understanding of the reproductive process, better knowledge about health care and access to modern and effective means of birth control. Husband's education also has another most important factor affecting the current use of contraception among the adolescents and young adult married women. Current contraception use is found to increase with the increase in the level of husband's education.

The analysis shows that visits of family planning workers have significant and noticeable effects on the adolescents' and young adults' current contraceptive use. Visits of family planning workers to young couples may play a more important role in developing countries like Bangladesh, where educational level and socio-economic status is very low. Frequent visits by family planning workers and their counseling about family planning methods help to motivate adolescents to accept family planning methods and use them effectively. It also may ensure that the supply of contraceptive methods for adolescents is adequate.

Husband's occupation also shows a strong positively significant association with the current use. Desire for additional children and place of residence has emerged as successively important factors. All were found to be significantly and positively associated with current use of contraception. Although having radio or television in the household is also significant in terms of contraceptive use, it is less importantly so. Among the demographic and socio-economic factors, the number of living children, working status, religion and experience of child loss were not found to have any significant net effect on current use of contraception.

The findings of the study lead to the following policy recommendations, which hopefully can be proved valuable to the policy makers.

The family planning program of the government should be more effective and successful so that a hundred percent knowledge of the people about contraception might be converted to higher use rate. For this purpose family planning workers, and health workers should be introduced to make more effective home visits.

Adolescents need special counseling to dispel misconceptions about contraceptive side effects and health concerns and enhance their negotiating skills. This could be done through special information, education, communication campaigns, and mass media exposure.

Enhance access to information and services targeted to adolescents as a high priority. Adolescents also should be provided information on the availability of the family planning methods and their effective uses.

Provide education and empowerment for the women to increase their status in society.
Many women are afraid or unwilling to discuss with their husbands about limiting the size of their families. Efforts should be made to encourage greater participation of women in all family decisions. Women also should be informed about their rights and privileges.

Lastly, reproductive health and family life education should be included at least at the secondary level of education.

Thus, the results indicate that governmental efforts towards social and economic development as well as explicit attempts to provide widely diffused family planning services will contribute to a higher level of more effective contraceptive use in Bangladesh.

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Note: Reference category is in the parenthesis

 *** P<0.01, ** P<0.05, * P<0.1

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REFERENCES