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want to consider the heterogeneity of adolescents' risks for unintended pregnancy and tailor programs to align with the profile of adolescents in their settings.
CON-09075; No of Pages 5 Contraception xxx (2018) xxx–xxx

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Original research article

Developing strategies to address contraceptive needs of adolescents: exploring patterns of use among sexually active adolescents in 46 low- and middleincome countries Amanda M. Kalamar a, Özge Tunçalp b, Michelle J. Hindin c,⁎ a b c

Population Services International, 1120 19th St. NW Suite 600, Washington, DC 20036 World Health Organization, Department of Reproductive Health and Research, 20 Avenue Appia, 1211 Geneva 27, Switzerland The Population Council, 1 Dag Hammarskjold Plaza, New York, NY 10017

a r t i c l e

i n f o

Article history: Received 16 May 2017 Received in revised form 8 March 2018 Accepted 8 March 2018 Available online xxxx Keywords: Adolescents Contraceptive use Contraception Low- and middle-income countries

a b s t r a c t Objective: We explore the patterns of adolescents' need for contraception in 46 low- and middle-income countries. Methods: Using data from the Demographic and Health Surveys, we estimate the prevalence of never-use, everuse and current contraceptive use of sexually active adolescent girls ages 15–19. We use weighted fixed-effects meta-analytic techniques to estimate summary measures. Finally, we highlight country profiles of adolescent contraceptive use. Results: More than half (54.4%) of sexually active or girls in unions report never using contraception, while 13.3% report having used contraception but not currently doing so. Nearly a third report currently using a contraceptive method: 24.6% are using a modern short-term method, 2.5% are using a most effective method, and 5.2% are using a traditional method. Conclusions: We find significant heterogeneity across countries as well as within countries based on adolescents needs for spacing, limiting and method preference. With more than half of sexually active adolescents having never used contraception, the potential for unwanted pregnancies is high. Implications: While there is no single strategy to address adolescents' contraceptive needs, country programs may want to consider the heterogeneity of adolescents' risks for unintended pregnancy and tailor programs to align with the profile of adolescents in their settings. © 2018 Elsevier Inc. All rights reserved.

1. Introduction Adolescents (10–19 years) comprise nearly a fifth of the global population, and the adolescent population is projected to continue to grow over the next 15 years, with the largest growth in sub-Saharan Africa [1]. Each year, 12 million girls aged 15–19 in low- and middle-income countries (LMICs) give birth, with half of all these pregnancies being unintended, and among adolescent unintended pregnancies, nearly half end in induced abortion, while the other half end in a birth [2]. It is estimated that a lack of access to contraception leads to 6 million unintended pregnancies among adolescents, and in LMICs, 60% of adolescent 15–19-year-old girls who would like to avoid an unintended pregnancy are not using modern contraception [2]. Unmet need for contraception is highest in West and Central Africa among both married and unmarried young women, although the proportion is substantially higher among unmarried young women [3]. Across all regions, ⁎ Corresponding author. E-mail address: [email protected]. (M.J. Hindin).

adolescents 15–19 have higher unmet need than do women ages 20– 24 [3]. The most commonly cited reasons for not using contraception among unmarried sexually active adolescents in LMICs include not being married, infrequent sex and fear of side effects or health concerns, while among in-union adolescents, reasons include breastfeeding and postpartum abstinence [4]. Infrequent sex and experience of side effects are also cited as common reasons for method discontinuation and high rates of method switching among adolescents [5]. We explore patterns and types of adolescents' contraceptive use in 46 LMICs using data from the Demographic and Health Surveys (DHS). Previous research on adolescent contraceptive use has focused on topics such as contraceptive knowledge and access [6,7], and several recent multicountry analyses have described levels of adolescent contraceptive use [8,9]. Despite these contributions, they do not provide information on the patterns of use or types of contraceptive users. Understanding adolescents' patterns and types of use can help inform programs to address adolescents' heterogenous contraceptive needs that can inform the choice of appropriate strategies to ensure that they can prevent unintended pregnancy.

https://doi.org/10.1016/j.contraception.2018.03.016 0010-7824/© 2018 Elsevier Inc. All rights reserved.

Please cite this article as: Kalamar AM, et al, Developing strategies to address contraceptive needs of adolescents: exploring patterns of use among sexually active adolescents i..., Contraception (2018), https://doi.org/10.1016/j.contraception.2018.03.016

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A.M. Kalamar et al. / Contraception xxx (2018) xxx–xxx

2. Materials and methods We use the most recently available data (2008–2016) from the DHS [10] in 46 countries that have information for all relevant questions. Over the last 3 decades, the DHS has produced nationally representative, comparable, cross-sectional, surveys for many developing countries. Six countriesi with surveys since 2008 were excluded due to low frequency of sexual activity among adolescents and one countryii because information on never-use of contraception was missing. The analytic sample was limited to adolescent girls between the ages of 15 and 19 who reported having sexual intercourse in the past 3 months or were married or in a union, and who were not pregnant during the survey. The following questions from the DHS are relevant to this analysis: (1) Have you ever used anything or tried in any way to delay or avoid getting pregnant? (2) Are you currently doing something or using any method to delay or avoid getting pregnant? (3) Which method are you using? Using these three questions, we construct the following five categories of use among sexually active or in-union adolescents: never-users, past users, current users of traditional methods, current users of modern short-term methods, and current users of the longerterm or permanent modern methods. Current users of traditional methods report using folkloric or traditional methods; current users of modern short-term methods report using injectables, pill, male or female condom, diaphragm, foam/jelly, standard days method or lactational amenorrhea method; and current users of longer-term or permanent methods report using intrauterine devices, implants, or sterilization (female or male). We conducted this analysis in three components. First, we calculate 46 country-specific contraceptive prevalence estimates, weighted to be nationally representative, overall and by each of the five categories of use among adolescent girls based on their reports of current use. Next, we provide summary measures for each of these five categories of use across all 46 countries using country-level fixed-effects meta-analytic techniques, weighted by each country's sample size. This technique is widely used to estimate effect size across multiple studies or settings and has become a standard methodology with the DHS [11,12]. Finally, we provide examples of different country-level patterns of use. All analyses were conducted using Stata 13.0 [13]. 3. Results 3.1. Patterns of use We show country-specific demographic information and current contraceptive prevalence by type (never-use, ever-use and current use of any method) in Table 1. Based on the average across all 46 countries, the majority of adolescent girls (54.4%) have never used a method of contraception, while 13.3% have used contraception in the past but were not current doing so at the time of the survey. Close to a third (32.4%) reported current use of any method at the time of the survey. In Fig. 1, we present three specific patterns of contraceptive use: high never-use (Senegal), mixed-use (Lesotho) and high current use (Colombia). These profiles are illustrative and were selected to highlight the heterogeneity that can exist and does exist in many countries. Even when a particular category of use is dominant, no country was wholly homogenous. The 46 countries included in this analysis fall along a spectrum of different combination of use patterns, in between Senegal, with the highest proportion in the never-use category, to Colombia, with the highest proportion of current users. Some countries closely mirror these use profiles, and those are highlighted below, while others' use profiles are more mixed. Countries were fairly distributed across the three use patterns, with the fewest number of countries in the high ever-use pattern. In Senegal, nearly 90% of adolescent girls report never having used i ii

Bangladesh, Egypt, Gambia, Jordan, Maldives, Tajikistan. Mozambique.

Table 1 Demographic characteristics and contraceptive use among adolescent girls (15–19), by country⁎ Among sexually activea or in-union adolescents Country

Survey year

Albania 2008/09 Armenia 2010 Benin 2011/12 Bolivia 2008 Burkina 2010 Faso Burundi 2010 Cambodia 2014 Cameroon 2011 Chad 2014 Colombia 2010 Comoros 2012 Republic of 2011/12 the Congo Cote 2011/12 d'Ivoire Democratic 2013/14 Republic of the Congo Dominican 2013 Republic Ethiopia 2011 Gabon 2012 Ghana 2014 Guinea 2012 Guyana 2009 Haiti 2012 Honduras 2011/12 Indonesia 2012 Kenya 2014 Kyrgyz 2012 Republic Lesotho 2014 Liberia 2013 Madagascar 2008/09 Malawi 2010 Mali 2012/13 Namibia 2013 Nepal 2011 Niger 2012 Nigeria 2014 Peru 2012 Philippines 2013 Rwanda 2014 2008/09 Sao Tome and Principe Senegal 2014 Sierra 2013 Leone Tanzania 2015 Timor-Leste 2009 Togo 2013/14 Uganda 2011 Zambia 2013 Zimbabwe 2015 Weighted averageb

% 15–19 (among women 15–49)⁎

Married or in union (% 15–19)⁎

Had sex in Never use last 3 (%)⁎ months (% 15–19)⁎

Ever use (%)⁎

Current use (%)

19.5 14.5 17.5 20.8 19.4

7.4 7.9 13.8 13.4 31.5

10.0 7.6 28.3 18.1 30.9

15.2 76.9 63.1 32.0 83.1

28.0 2.0 13.1 24.5 2.3

56.8 21.1 23.8 43.5 14.6

25.1 16.5 23.3 22.2 17.0 24.7 20.3

8.5 15.6 24.2 38.7 13.7 16.4 18.8

10.4 13.8 34.6 35.7 38.5 15.5 47.9

87.1 60.6 53.5 94.2 5.2 70.0 28.6

2.9 10.6 14.2 1.2 31.7 5.5 12.4

10.0 28.7 32.3 4.6 63.1 24.5 59.1

20.1

20.7

46.8

64.4

9.8

25.7

21.5

21.3

35.1

65.4

9.3

25.3

19.4

20.5

38.9

16.7

28.0

55.3

24.3 21.2 17.3 22.1 20.3 23.5 22.2 15.2 18.7 19.9

19.1 13.5 6.4 33.3 16.3 12.1 22.6 12.8 11.9 9.6

17.9 47.7 23.7 33.2 26.9 28.0 28.5 11.1 8.5 8.7

63.9 39.7 60.7 85.2 35.1 61.9 13.9 40.7 46.6 93.5

11.0 9.4 9.3 5.1 24.1 11.1 33.6 12.3 13.1 0.3

25.1 51.0 29.9 9.7 40.8 27.0 52.5 47.0 40.3 6.2

21.7 22.5 22.8 21.7 18.1 20.8 21.7 16.4 20.1 18.5 20.0 20.5 21.2

17.7 14.4 33.7 23.4 43.0 5.4 28.8 61.0 28.8 11.2 9.7 3.1 19.9

24.7 52.6 40.2 26.4 42.8 25.3 21.1 45.9 34.1 17.8 9.9 7.6 35.6

38.5 66.7 59.9 51.3 85.3 23.9 66.6 87.8 83.1 6.6 53.9 73.9 40.3

15.9 6.9 15.1 20.6 4.7 16.2 15.7 5.1 2.7 28.0 10.4 4.6 26.1

45.7 26.4 25.0 28.1 10.0 59.9 17.7 7.1 14.2 65.4 35.6 21.5 33.6

21.5 23.3

22.8 18.8

19.8 47.1

83.1 56.8

3.4 6.6

13.5 36.6

21.9 23.9 17.9 23.6 22.1 22.1

23.0 7.7 12.7 20.0 16.9 19.6

34.1 5.7 31.6 27.5 30.3 22.7

69.1 91.1 65.9 64.9 63.1 44.2 54.4

7.9 1.3 6.4 15.2 8.7 12.6 13.3

23.1 7.7 27.7 19.8 28.2 43.2 32.4

Source: Demographic and Health Surveys. Ever and current use of any method: folkloric, traditional and/or modern. ⁎ Weighted percentages. a Sexually active in past 3 months. b Weighted by each country's sample size.

a method of family planning. Among the remaining 10%, more than half are ever-users and less than 5% report current use. Countries with a use profile similar to that of Senegal — high never-use and low current use

Please cite this article as: Kalamar AM, et al, Developing strategies to address contraceptive needs of adolescents: exploring patterns of use among sexually active adolescents i..., Contraception (2018), https://doi.org/10.1016/j.contraception.2018.03.016

A.M. Kalamar et al. / Contraception xxx (2018) xxx–xxx

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Fig. 1. Select family planning use profiles of sexually active or in-union adolescent girls.

— include Armenia, Burkina Faso, Guinea, Kyrgyz Republic, Mali and Niger. In Lesotho, there is higher current use but still a substantial proportion of never-use and ever-use. Countries which also have a similarly mixed profile of use include Bangladesh, Bolivia, Gabon and Malawi. In

contrast, in Colombia, only a very small percentage of adolescent girls have never used a contraceptive method, and more than half report current use of a method. Yet, we find a sizable percentage of adolescent girls that have used a method but were not doing so at the time of the

Fig. 2. Percentage of adolescent contraceptive nonusers and users in 46 countries, by method type.

Please cite this article as: Kalamar AM, et al, Developing strategies to address contraceptive needs of adolescents: exploring patterns of use among sexually active adolescents i..., Contraception (2018), https://doi.org/10.1016/j.contraception.2018.03.016

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A.M. Kalamar et al. / Contraception xxx (2018) xxx–xxx

Fig. 3. Select family planning profiles by method effectiveness among sexually active or in-union adolescent girls 15–19.

survey. Other countries where current use is high and never-use is low include Albania, Dominican Republic, Honduras and Peru. 3.2. Types of users In Fig. 2 we display the prevalence of contraceptive use by method effectiveness in each country as well as across all 46 countries combined. Based on the combined data, a quarter (24.6%) of girls are currently using a short-term modern method, and only 2.5% are using a longerterm or permanent method. Traditional method use is reported by 5.2%. In Fig. 3, we highlight types of users by whether they are currently using a method and, among those who are, the type of method: traditional, short-term modern, or longer-term or permanent method. Albania, Namibia and Sierra Leone are highlighted in this figure as they each have varying levels of current use, and within current use, the profiles by method effectiveness are very different. In Albania, the majority of adolescent girls report being current users, but the vast majority report relying on the least effective or traditional methods. Similarly, in Armenia, Democratic Republic of Congo and the Kyrgyz Republic, traditional methods are the most prevalent of the three use effectiveness categories. In contrast, in Namibia, there are a lot of current users; however, nearly all report using effective methods. Cameroon, Guyana, Togo and Zimbabwe show a similar pattern to Namibia. In Sierra Leone, the majority of adolescent girls have never used contraception; however, current users fall across all three levels of effectiveness. We find a similar pattern in Colombia, Indonesia, Kenya, Liberia and Zambia, among others. 4. Discussion Our analysis includes 46 countries with over 13.6 million sexually active adolescent girls ages 15–19. Our results point to significant heterogeneity across countries as well as within countries based on adolescents' needs for spacing, limiting and method preference. One of our most striking findings is that more than half of sexually active adolescents have never used contraception and a substantial proportion of ever-users have discontinued use. The six patterns we developed are illustrative of the heterogeneity of use profiles, although many countries closely mirror the patterns highlighted. These patterns may help to

indicate strategies that can be employed at the country level to help adolescent avoid unwanted pregnancies. For example, to address neverusers or those who have discontinued use, our analysis of the reasons for nonuse or discontinuation could be explored further with existing data [4]. Despite the large data sets and number of countries, there are several limitations to our analysis. First, we limit the sample to those adolescent girls who reported having sex in the past 3 months, and those who report last sex more than 3 months ago are not included. Second, as in all studies of sexual activity among adolescents, there is the potential for underreporting. Finally, our analyses do not take pregnancy intentions into account. We employ a more nuanced approach to understanding how to prevent unwanted pregnancies among adolescents by matching contraceptive methods and counseling to their current needs to prevent and space births. While both programmatic and policy efforts are trying to meet the needs of adolescents, a more tailored approach, considering country- or subregional-level contraceptive use patterns, may be more successful in many settings. Using already available data and analyzing future data using the contraceptive use patterns we describe in this paper, countries can reframe programs and offer context-specific approaches to meet the contraceptive needs of their adolescent populations.

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Please cite this article as: Kalamar AM, et al, Developing strategies to address contraceptive needs of adolescents: exploring patterns of use among sexually active adolescents i..., Contraception (2018), https://doi.org/10.1016/j.contraception.2018.03.016

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Please cite this article as: Kalamar AM, et al, Developing strategies to address contraceptive needs of adolescents: exploring patterns of use among sexually active adolescents i..., Contraception (2018), https://doi.org/10.1016/j.contraception.2018.03.016