Special Analysis: Youth and Contraceptive Use
This special analysis is excerpted from the FP2020 Commitment to Action: Measurement Annex 2015.
FP2020’s goal of empowering 120 million additional women and girls to use modern contraception must be attained in a way that is inclusive of all women, including young people.
The analyses presented in this section give a snapshot of contraceptive use and non-use among married and unmarried sexually active young women. It is clear that patterns of use among young women vary greatly by country; some countries seem to have much more equitable use and knowledge of family planning by both married and unmarried young women, whereas in other countries, large discrepancies exist.
FP2020 is often asked what percentage of additional users of family planning since the London Summit can be attributed to youth. Unfortunately, given data limitations and the methodology used to estimate additional users, it is not possible to disaggregate this global number by age. However, where recent survey data are available, we can look at contraceptive use and non-use among youth aged 15 to 24 in specific countries.
While we don’t have a reliable estimate of unmet need among all youth (married and unmarried), it is clear that the need for contraception is pervasive. Comprehensive sexuality education can ensure that young people have the knowledge and tools to make informed decisions about using contraception, preventing unwanted pregnancies, and protecting themselves from sexually transmitted infections, including HIV. In some countries, policies restrict young people’s fundamental right to sexual and reproductive health information, services, and supplies. Even when policy barriers have been removed, stigma and provider bias often prevent young people from seeking or receiving information and services.
The following analysis will look at the available evidence regarding contraceptive use, knowledge, and attitudes among both unmarried and married young women aged 15 to 24.
UNMARRIED YOUTH
Are unmarried youth using modern methods of contraception? Modern contraceptive prevalence among unmarried women is measured among those who are sexually active (defined as women who reported having had sex in the four weeks prior to the survey). The following analysis looks exclusively at sexually active unmarried young women aged 15 to 24.
Of the 41 countries with data collected since the time of the London Summit on Family Planning, 13 countries have usable data on sexually active unmarried youth.43 The graph below shows that in these 13 countries, levels of contraceptive use among this group vary widely, from just under 20% in Indonesia, to nearly 60% in Sierra Leone and Nigeria.
Current levels of use are important, but it is also useful to see how contraceptive use among this group is changing over time. In the chart below, countries have been categorized based on changes between the last two surveys in mCPR for sexually active unmarried young women, and how these changes compare to changes in mCPR among married young women.44
Countries fell into one of four groups: mCPR increase in both married and unmarried sexually active youth; mCPR decrease in both populations; and the opposites of both groups.
In the majority of countries, increases in mCPR among both unmarried and married young women were observed. Of these countries, Sierra Leone is notable because mCPR for unmarried young women grew nearly four times faster than mCPR among married young women.
Four countries experienced declines in mCPR among unmarried young women, and in most of these countries this decline happened despite increases in mCPR among married young women.
Nigeria also stands out in this analysis: while there was no increase in mCPR for married young women, a very large increase among unmarried young women was seen.
MARRIED YOUTH
Does marriage lead to improved access to contraception for young women? It is sometimes assumed that once women are married, barriers to contraception will be removed. However, in some places, young married women still face barriers to contraceptive use.
One way to look at this is by examining the ratio of unmet need for contraception among young married women age 15-19 compared to all married women of reproductive age. A ratio of 1 would mean that their levels of unmet need are identical. Anything less than 1 indicates young married women have lower unmet need, and anything greater than 1 indicators young married women have higher unmet need.
As can be seen in the graph below, in more than half of the 30 countries with sufficient recent data, unmet need is higher among young married women.
In Nepal, the unmet need among married 15- to 19-year-old women is nearly twice that of the total unmet need for all married women of reproductive age.
There are many complex factors that drive these different patterns in unmet need among young unmarried women. To fully understand why countries have a low or high ratio of unmet need among young married women compared to all married women of reproductive age would require further study at the country level regarding the cultural context and other drivers of these issues. However, we can begin to analyze some of the underlying dynamics.
One potential driver of this pattern could be discrepancies in knowledge of modern contraception. Overall, the knowledge level of modern methods is fairly similar across all age groups. However, when looking at knowledge of at least one long-acting contraceptive method (IUD or implant), large discrepancies can be seen.45 In fact, in all countries included in this analysis, a lower proportion of non-users age 15 to 19 could name at least one long-acting method, compared to all married women of reproductive age (graph below).
This pattern does not match to the ratios of unmet need, meaning it cannot explain all of the difference in unmet need between young married women and all married women of reproductive age. However, it suggests that in some countries, more work is needed to ensure that all married women have the same access to information about contraceptives.
COMPARING MARRIED AND UNMARRIED YOUTH
What similarities and differences are there between married and unmarried sexually active youth? Understanding differences in the reasons for not using contraception and exposure to family planning health care providers may help to explain some of the differences in levels of use between these two groups. This analysis includes six countries that have had a recent DHS survey with a sufficient number of unmarried sexually active women to allow for further analysis.
Do the reasons for non-use of contraception vary for married and unmarried sexually active youth? To answer this, responses to four selected questions about reasons for non-use are shown. Young women were able to respond “yes” to more than one reason, meaning that the same women may be counted under different reasons.
As might be expected, we see that infrequent sex is more commonly cited as a reason for non-use among unmarried sexually active young women than among married young women (28.2% vs. 8.9%, on average). And similarly, we see that many more married young women cited breastfeeding as a reason for non-use (40.1% vs. 3.1%, on average).
For some reasons for non-use, we see less distinction between responses from married and unmarried young women. Non-use due to fear of side effects varies largely across countries, and between married and unmarried young women.
Non-use due to lack of access or services too far is generally low, but, some differences between married and unmarried women can be seen. This is especially true in Sierra Leone, where four times the percentage of unmarried young women cited this as a reason for non-use than did married young women.
Do married and unmarried sexually active young women have the same access to family planning service providers? To answer this, three questions related to interactions with service providers were examined. For both unmarried sexually active and married young women, visits by family planning health workers are fairly low (10.3% and 11.8%, on average).
More variation is seen in terms of visiting health facilities (31.3% and 53.1%, on average), and for those visiting facilities being told about family planning (31.6% and 44.8%, on average). Comparing the ratio between married and sexually active unmarried young women highlights gaps in exposure to family planning services. Aside from Sierra Leone, in all five of the other countries, exposure to family planning information and services is considerably lower for unmarried sexually active young women than married young women, regardless of the venue in which this exposure happens (visit with family planning worker or at a facility).
AN UNFINISHED AGENGA
To better understand what is driving these trends, the country context and more country-specific knowledge is needed. For example, what can be learned from countries such as Nigeria and Sierra Leone, which have seen large increases in modern contraceptive use by unmarried sexually active young women? And, what can be learned from countries such as Haiti and Egypt, which have been able to ensure that young married women have the same levels of contraceptive knowledge as do their older married counterparts?
Download the full FP2020 Commitment to Action: Measurement Annex 2015
43. The following countries collected data on unmarried youth, but had to be excluded from the analysis for the reasons noted: DHS surveys in Cambodia, Niger and Tajikistan were excluded from the analysis due to too-few sexually active unmarried women in the sample. DHS surveys in Ghana, Kenya and Lesotho were excluded because at the time of writing, only the Key Indicator Reports were available for these countries, which do not provide data on unmarried sexually active contraceptive users by age. PMA2020 surveys were excluded due to an inconsistency in the calculation of recent sexual activity. This inconsistency has been corrected, and PMA2020 data will be included in the next youth analysis, where sample sizes permit.
44. Note: Gambia and Indonesia were excluded from this analysis because no prior estimate of sexually active unmarried mCPR was available for comparison.
45. Note: some countries are excluded from this analysis because their full data sets were not available.
