1 BACKGROUND

Adolescent sexual and reproductive health care seeks to educate and give medical assistance to young women to aid in their understanding of their sexuality and to safeguard them against unintended pregnancy.¹ Despite the sexual and reproductive health guidelines implemented by the World Health Organization (WHO) for safe sexual practices and the freedom to choose the rate of reproduction, it remains a major concern in low -and middle-income countries.² Sub-Saharan Africa (SSA) has the worst reproductive health indices and has not improved in the statistics on the prevalence rate of contraception, adolescent birth rate, antenatal care coverage, and unmet need for family planning, unlike high-income countries.^{3, 4}

Contraceptive usage is a major challenge in  SSA because of cultural restrictions on sexual interaction. Given that marriage is the only premise for sexual intercourse, contraceptives use and information were solely available to members of a specific group.^{5, 6} However, studies indicate that knowledge of contraceptive use can translate into its practice without any barriers.^{3, 4} Amdist education, modernization, and mixed intercontinental practices in SSA, its influence on knowledge of contraceptive usage is still low.⁵ In addition, policymakers have propagated family planning services in response to the growing population and the economic downturn in SSA⁷

In SSA, there is low usage and minimal knowledge of modern contraceptives.⁸ This is because, in many African countries, postpartum abstinence is considered the sole approach to family planning. Though postpartum abstinence has waned in most African countries due to contemporary methods of contraception, it is still accepted as a more efficient way to achieve intended birth outcomes.⁶

Barriers such as lack of access, cultural considerations, religious objections, fear of health risks, and side effects may hinder the use of contraceptives.⁹ A study has shown that misconceptions about the accessibility and safety of using contraception are widespread among women in SSA.⁶ However, most of these barriers can be dealt with if users have a solid knowledge of the types, sources, and appropriate use of contraceptives available to them. With the growing knowledge of the types of contraceptives, most women of reproductive age in SSA only know of condoms with just a few using them.^{5, 10, 11} Considering the high fertility rate of women of reproductive age in SSA, the growing population, and the complexities regarding the use of contraceptives, there is a need to disseminate quality information to raise awareness for a reliable reproductive health guide.¹² This will also improve the knowledge and concerns regarding unsafe abortion, teenage pregnancy, and maternal mortality rate from unintended pregnancies.^{13, 14}

Knowledge and use of contraceptives among women is a concern for health organizations when it comes to assessing family planning as women bear almost all the responsibility for regulating fertility.⁷ In Nigeria, 82% of childbearing women knew at least one method of contraception, yet 82% had never used any contraceptive method.¹⁵ The probability of using any contraceptive method was high among those with knowledge of contraceptives.¹⁵ Similarly, in Ghana, although Beson et al. found high level of knowledge on contraception, this did not translate to current use of modern contraception.¹⁶ In other sub-Saharan African countries, research has consistenly showed a low prevalence of modern contraceptive use, contributing to the high incidence of unitended pregnancies, unsafe abortions, and maternal mortality.^17-19

Despite the knowledge of contraceptive usage from social media, clinicians, peer groups, and pharmacy counter staff^{12, 20} amidst the many benefits including preserving and enhancing lives through properly planned pregnancies, SSA has not fully come to terms with this. The types of modern contraceptives and its associated drawbacks are not fully understood.^21-23 Although, the United Nations has determined that one of the key indicators for measuring global progress towards achieving universal access to reproductive health should be the prevalence rate of contraception,²⁴ this goal remains unmet in SSA. This study examined whether knowledge of contraceptives is associated with actual usage. 

2 METHODS

2.3 Statistical analyses

We used Stata version 17 to carry out the statistical analyses. We used a forest plot to present the proportion of women who use any contraceptive method (Figure 1). Next, the Pearson's χ² test of independence was used to examine the variables with a significant relationship with contraceptive use. This was followed by a multilevel binary logistic regression analysis. Before the regression analysis, we used the variance inflation factor (VIF) to determine the extent of collinearity among the studied variables. We found the minimum, maximum, and mean VIF to be 1.01, 5.89, and 2.36, respectively. Hence, we found no evidence of high collinearity among the variables. A five-modelled multilevel logistic regression analysis was used to examine the association between knowledge of contraceptives and their use. Model O was an empty model and it showed the variance in contraceptive use attributed to the primary sampling unit (PSU). Model I included only the key explanatory variable. Model II included Model I and the individual-level covariates. Model III consisted of Model I and the contextual level variables. Model IV contained variables in Model II and the contextual level covariates. The results were presented as adjusted odds ratio (AOR) with their 95% confidence interval. We used Akaike's Information Criterion (AIC) to assess model fitness, with the last model being the best-fitted model due to its least AIC value. All the analyses were weighted. Statistical significance was set at p < 0.05. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines in writing this paper.³⁰

3 RESULTS

4 DISCUSSION

Using the most recent DHS data of 21 sub-Saharan African countries, the present study examines the association between contraceptive knowledge and the actual use of any method of contraception. Overall, only 24.32% of sexually-active women aged 15–49 used any method of contraception in SSA. The proportion observed in this study mirrors that of a study conducted in South Nigeria¹⁵ that found only 18.3% use any method of contraception. However, the observation is lower when compared to high-income countries like the United States where there is a 61.4% use of any method of contraception.³¹ While the proportion of using any method of contraception was low across SSA, Zimbabwe reported the highest usage (66.81%) while Chad reported the least usage (5.07%). The reasons accounting for the varied proportions in contraceptive use may be due to the differences in contraceptive accessibility and a reflection of how sociocultural belief systems in the respective countries affect women's use of any method of contraception.

The findings from this study support the hypothesis that there is a strong positive association between contraceptive knowledge and the actual use of any method of contraception among women of reproductive age in SSA. That is, the higher the knowledge level of a woman, the more likely she is to use any method of contraception. This is similar to what has been reported in Ukoji et al.¹⁵ and Yaya et al.'s³² study where high contraceptive knowledge was significantly associated with higher odds of actual use of any method of contraception. One possible explanation for the observed association could be an increase in the perceived self-efficacy to use contraception. For instance, Tomaszewski et al.³³ have shown that contraceptive use tends to be high when there is high contraceptive self-efficacy arising from a high contraceptive knowledge. Furthermore, being knowledgeable about contraceptives can enlighten women about the benefits of using contraceptives, hence, facilitating and informing healthcare decision-making. Also, we posit that high contraceptive knowledge can improve women's sexual empowerment to have communications with their partners regarding contraceptive use.

An inverse association was established between age and contraceptive use. This finding is corroborated by Yaya et al.'s³² study that found lower odds of contraceptive use among women aged 35–49 compared to adolescent girls. It is possible that older women might have a higher desire to have children, and therefore, would be less motivated to use any method of contraceptives. From a cultural perspective, most countries within the sub-Saharan African region frown on pregnancy out of wedlock and pregnancy when one is an adolescent.³⁴ Adolescents who get pregnant are often stigmatized and ostracized by society.³⁵ Hence, contraceptive use provides an avenue for adolescents to escape shame and reproach from society, and still be able to fulfill their sexual desires.³⁶ Another perspective to this could be that younger women are more likely to be sexually active and may therefore be at a higher risk of experiencing unintended pregnancies. Hence, informing the high use of contraceptives among this cohort.

Higher educational attainment of the woman and her partner was associated with a higher likelihood of using any method of contraception. Similar findings have been reported in Nigeria¹⁵ and Kenya.³⁷ Higher educational attainment enables both the woman and her partner to have greater access to health information including information on contraceptives. The information received helps to dispel myths and misperceptions surrounding contraceptive use, thereby informing their decision to use it. Relatedly, we found that exposure to the media was associated with higher odds of using any method of contraception—a result that is consistent with what has been reported in Uganda³⁸ and India.³⁹ Thus, highlighting the opportunities that the mass media provide to promote contraceptive use among women of reproductive age in SSA.

Women who were currently working and those in the richest wealth index were more likely to use any method of contraception compared to those who were not working and those in the poorest wealth index. These results were expected because, besides the traditional methods of contraception, all other types of contraceptives must be purchased. However, in many sub-Saharan African countries, the cost of contraceptives is not covered by health insurance. This means that individuals from poorer households and those who are not working might not be able to afford contraceptives, thereby reducing their likelihood of using them. On the other hand, women from affluent households and those working have the financial resources to access any method of contraception. The result is corroborated by previous studies conducted in SSA³² and Uganda.³⁸

Compared to nulliparous women, those who had one or more children were more likely to use contraceptives. The result aligns with the findings of a multicountry study of 73 low-and middle-income countries⁴⁰ that found lower contraceptive use among nulliparous women compared to other parities. Nulliparous women may have a high desire to bear children. Therefore, they may tend to avoid contraceptive use to increase their chances of getting pregnant. It is also possible that women with one or more children may have completed their desired family size. For that matter, they may want to use a contraceptive method to prevent unplanned pregnancies.

Rural-dwelling women were less likely to use any method of contraception compared to those in the urban areas. This agrees with a study conducted in India³⁹ that found urban-dwelling women to be more likely to use any method of contraception. The result may be explained by the point that rural areas often lack access to healthcare and family planning services,⁴⁰ limiting contraception options. Another plausible explanation could be that women in rural areas may be more inclined to adhere to traditional and conservative perceptions about contraceptives which tends to be a barrier to their actual use of any method of contraception. Finally, the study found significant differences across the geographical subregions, with women in the Central, Eastern, and Western regions reporting the least likelihood to use any method of contraception. This picture may reflect the lapses in the current family planning regimes across the various sub-regions.

5 CONCLUSION

Our study has shown that the use of contraceptives among women in SSA is low. Women's knowledge of any contraception method increases their likelihood of using contraceptives in SSA. Enhancing contraceptive use in SSA requires targeted interventions to specifically reach women with lower wealth status, those residing in rural areas, nulliparous women, and older women of reproductive age. Furthermore, implementing tailored subregional strategies is essential to address and reduce existing disparities within the subregions. Recommendations for improvement include developing initiatives that focus on education and awareness campaigns in underserved communities, increasing accessibility to contraceptive resources in rural areas, and designing programs that cater to the unique needs of nulliparous and older women.

AUTHOR CONTRIBUTIONS

Irene Esi Donkoh: Formal analysis; methodology; writing—original draft. Joshua Okyere: Formal analysis; methodology; writing—original draft; writing—review & editing. Abdul-Aziz Seidu: Formal analysis; investigation; writing—review & editing. Bright Opoku Ahinkorah: Methodology; supervision; writing—review & editing. Richard Gyan Aboagye: Formal analysis; methodology; writing—original draft. Sanni Yaya: Conceptualization; investigation; supervision; writing—review & editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

TRANSPARENCY STATEMENT

The lead author Sanni Yaya affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.