Presented during a January 2018 webinar.

1. Use of Family Planning and
Maternal and Child Health Services by
Adolescents and Young Women
in 5 Sub-Saharan Countries
Mahua Mandal, PhD
Paul Brodish, PhD
MEASURE Evaluation, UNC-Chapel Hill
January 9, 2018
USAID/Washington, DC

2. Background
Adolescents and Young Women
• Pregnancy and childbirth: leading causes of death for 15- to
19-year-olds in developing countries
• One-third of adolescent pregnancies is unintended
• Reproductive health (RH) of 15- to 24-year-old women is
especially important
o Adolescents and young women make up one-third of
the population in developing countries

3. Background
Use of Family Planning (FP) and Maternal
and Child Health (MCH) Services
• Use of FP contributes to lower maternal morbidity and mortality
• Use of MCH services lowers poor maternal and infant outcomes
• Demographic and Health Survey (DHS) trend data over 25 years is
encouraging
○ Women in sub-Saharan Africa (SSA) have increasingly used FP,
antenatal care (ANC), health facilities for delivery, skilled birth
attendants, and immunized their children
• Unclear whether use of services among sexually active adolescents
and young women has followed similar trend

4. Background
Research Questions
1. Have adolescent girls and young women increased their
use of FP and MCH services in the past decade?
2. If use of FP and MCH services increased, is the rate of
increase similar to that of 25- to 29-year- old women?
3. To what extent do predictors of use of FP and MCH services
differ among adolescent girls and young women
compared to women ages 25-29 years?
• Especially interested in interaction with health workers

5. Family planning
and reproductive
health outcomes
• Use of modern
contraceptives
• Age
• Marital status
• Age of
marriage
• SRH knowledge
and attitudes
• Fertility
awareness
• Self-efficacy
• Parity
• Desired fertility
• Age difference
• Couple
communi-cation
• Shared sexual
and
reproductive
decision making
• Partner’s desired
fertility
• Violence and
coercion
• Quality of
sexual and
reproductive
health (SRH)
services
• FP provider
bias
Conceptual Framework
• Policies and
laws
• Methods mix
• Equitable
gender norms
• Economic
opportunities
• RH education

6. Demographic and Health Surveys
• Democratic Republic of the Congo (DRC): 2007, 2013−2014
• Uganda: 2001, 2006
• Mali: 2006, 2012−2013
• Zambia: 2007, 2013−2014
• Ghana: 2008, 2014
Subset sample of females ages 15−24 who had at least one child at time of survey
Numbers range from 1,180 (Ghana, 2009) to 6,595 (DRC, 2013−2014)
Methods
Data and Sample

7. a) Current use of modern method of FP
• Pill, IUD, injectables, diaphragm, condoms, sterilization,
implants, foam, jelly, lactational amenorrhea method
(LAM), and other country-specific (yes vs. no)
b) Use of ANC for most recent birth
• ≥4 ANC visits for most recent birth (yes vs. no)
c) Use of immunization for most recent child born
• 3 doses of diphtheria, pertussis, and tetanus (DPT) for
most recent born child (yes vs. no)
Methods
Dependent Variables

8. • Age (15−19 years; 20−24 years; 25−29 years [ref])
• Survey year (Year 1; Year 2)
• Respondent visited by FP worker or any health facility staff
talked to respondent about FP in 12 months preceding
interview (yes vs. no)
• Respondent reported ≥4 ANC visits for most recent birth
(yes vs. no)
• Respondent reported 3 doses of DPT vaccination for most
recent born child (yes vs. no)
Methods
Primary Independent Variables: FP

9. • Age (15−19 years; 20−24 years; 25−29 years [ref])
• Survey year (Year 1; Year 2)
• Respondent visited health facility in past 12 months (yes vs.
no)
• Distance to facility was perceived problem for getting care
for oneself if sick (yes vs. no)
Methods
Primary Independent Variables: ANC
and Child Immunizations

10. • Urban/rural residence
• Highest level of education
• Religion
• Wealth quintile
• Marital status
• Employment status
• Knowledge of ≥ 3 modern FP methods
• Ideal number of children
Methods
Control Variables: FP

11. • Urban/rural residence
• Highest level of education
• Religion
• Wealth quintile
• Marital status
• Employment status
• Last child wanted
Methods
Control Variables: ANC and Child
Immunization

12. • Accounted for clustered and stratified design of DHS and
used weighted data
• Separate analysis by country
• Examined demographic characteristic of sample by each DV
and by age group
• By age group: Pearson’s chi-square tests to compared each
DV by survey year
Methods
Analysis

13. • Entire sample: Multivariable logistic regression, regressing
each DV on age; survey year; and age x survey year
• Entire sample and stratified by age group: Multivariable
logistic regressions regressing each DV on primary IVs,
controlling for demographic variables
Methods
Analysis

14. Results
Demographic Characteristics
Some secondary
school or higher
Married/living
together
Had more than 1 child
15−19
years
20−24
years
15−19
years
20−24
years
15−19
years
20−24
years
DRC, 2013−
2014
49.9 47.6 66.5 77.9 19.8 54.7
Uganda, 2011
2011
19.9 31.7 68.1 80.8 23.0 62.1
Mali,
2014
19.2 13.8 85.5 94.6 19.6 60.2
Zambia,
2013−
2014
46.4 49.8 55.6 70.9 8.7 55.3
Ghana, 2014 60.8 58.8 41.8 66.6 10.0 43.4

15. Results
FP and MCH Outcomes
Unmet need for
FP
Current use of
modern FP
≥4 ANC visits 3 doses of DPT
15−19
years
20−24
years
15−19
years
20−24
years
15−19
years
20−24
years
15−19
years
20−24
years
DRC,
2013−
2014
35.4 31.1 8.7 9.4 46.6 50.1 41.5 48.7
Uganda,
2011
26.8 32.1 19.0 22.2 50.9 49.1 54.2 61.5
Mali,
2014
28.2 25.1 9.5 11.5 42.0 42.2 49.1 50.4
Zambia,
2013−
2014
27.0 21.4 37.3 43.4 51.9 52.3 70.7 76.7
Ghana,
2014
45.7 32.0 21.4 26.8 81.9 83.8 59.4 69.3

16. Results
Did FP and MCH service use increase over time among female
parents ages15−24 years?
Current Use of
Modern FP
≥4 ANC Visits 3 Doses of DPT
15−19
years
20−24
years
15−19
years
20−24
years
15−19
years
20−24
years
DRC
Uganda
Mali
Zambia
Ghana

17. Results
Is the rate of increase of use of FP and MCH services among 15-
to19- and 20- to 24-year-old women similar to that of 25- to 29-
year-old women?
Yes, statistically, but…

18. Results
15- to 19-year-olds
• Completing 3
doses of DPT for
most recent born
child
• Knowledge of ≥3
modern methods
of contraception
• Being visited by an
FP worker or staff
at health facility
talking to
respondent about
FP
• Completing 3 DPT
doses for children
20- to 24-year-olds
• Completing 3
doses of DPT for
most recent born
child
• Knowledge of ≥3
modern methods
of contraception
How do predictors of use of modern FP differ between
adolescent and young women and 25- to 29-year-olds?
25- to 29-year-olds

19. Results
15- to 19-year-olds
• Order of survey
(3 countries)
• Visited
healthcare facility
in past 12 months
(2 countries)
• Order of survey (3
countries)
• Visited healthcare
facility in past 12
months (3
countries)
• Distance to health
facility perceived as
problem (3
countries)
20- to 24-year-olds
• Order of survey
(3 countries)
• Visited
healthcare facility
in past 12 months
(2 countries)
How do predictors of use of ANC differ between adolescent
and young women and 25- to 29-year-olds?
25- to 29-year-olds

20. Results
15- to 19-year-olds
• Survey year
(Uganda,
Zambia, Ghana)
• Survey year (Uganda,
Zambia, DRC)
20- to 24-year-olds
• Survey year
(Uganda and
Zambia)
How do predictors of child’s immunization differ between
adolescent and young women and 25- to 29-year-olds?
25- to 29-year-olds

21. Summary of Results
Overall Changes in FP and MCH Over Time
• Use of FP and MCH services among adolescent girls and
young women have improved over time, albeit
inconsistently
• Increase in use of modern FP driven by implant use (all
age groups) and injectables (15- to 19- year-olds)
• Unmet need for contraception has decreased over time
but remains high: 21% to 46%
• ≥4 ANC visits increased over time in 2 countries
• 3 DPT doses increased over time in 4 countries

22. Discussion
Differences in Predictors of Use of FP and
MCH Services
• Implicit or explicit bias among healthcare staff regarding
FP communication with adolescent girls and young
women
• Value of girls and young women determined by their
fertility
• Distance to health facility not reported as a barrier by
adolescent girls and young women – more likely to rely
on others for transportation and don’t get sick as often as
other women
• Predictors of DPT similar across age groups

23. Discussion
Limitations
• Analysis does not include variables measuring gender
norms or inequities
• Sample sizes too small to include measures of
experience of intimate partner violence or partners’
controlling behaviors
• Variables related to adolescent and young women’s
interaction with healthcare staff do not measure the
quality of interactions and communication

24. Discussion
Programmatic and Policy Considerations
• Address social and cultural biases against youth in healthcare
settings, including improving provider attitudes and healthcare
policies
• Increase access to private sector (Example: youth voucher
program in Madagascar)
• Reach adolescents and young women in their communities
(Example: Promoting Change in Reproductive Behavior of
Adolescents (PRACHAR) program in India)
• Increase education; increase age of marriage

25. Thispresentationwas produced with thesupportof the United StatesAgency for International
Development(USAID)underthe termsof MEASUREEvaluationcooperativeagreementAID-
OAA-L-14-00004.MEASUREEvaluationis implementedby theCarolinaPopulationCenter,
Universityof NorthCarolinaat Chapel Hill in partnershipwith ICFInternational;JohnSnow,Inc.;
ManagementSciences for Health;Palladium; and TulaneUniversity.Viewsexpressedare not
necessarilythoseof USAID or the United Statesgovernment.
www.measureevaluation.org

26. Questions?