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Abstract
Objective Improving reproductive health requires access to effective contraception and reducing the unmet need for family planning in high-fertility countries, such as Yemen. This study investigated the utilisation of modern contraception and its associated factors among married Yemeni women aged 15–49 years.
Design and setting A cross-sectional study was conducted. Data from the most recent Yemen National Demographic and Health Survey were used in this study.
Participants A sample of 12 363 married, non-pregnant women aged 15–49 was studied. The use of a modern contraceptive method was the dependent variable.
Data analysis A multilevel regression model was used to investigate the factors associated with the use of modern contraception in the study setting.
Results Of the 12 363 married women of childbearing age, 38.0% (95% CI: 36.4 to 39.5) reported using any form of contraception. However, only 32.8% (95% CI: 31.4 to 34.2) of them used a modern contraceptive method. According to the multilevel analysis, maternal age, maternal educational level, partner’s educational level, number of living children, women’s fertility preferences, wealth group, governorate and type of place of residence were statistically significant predictors of modern contraception use. Women who were uneducated, had fewer than five living children, desired more children, lived in the poorest households and lived in rural areas were significantly less likely to use modern contraception.
Conclusions Modern contraception use is low among married women in Yemen. Some individual-level, household-level and community-level predictors of modern contraception use were identified. Implementing targeted interventions, such as health education on sexual and reproductive health, specifically focusing on older, uneducated, rural women, as well as women from the lowest socioeconomic strata, in conjunction with expanding availability and access to modern contraceptive methods, may yield positive outcomes in terms of promoting the utilisation of modern contraception.
- reproductive medicine
- primary care
- maternal medicine
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study used nationally representative data.
Secondary data analysis was a prudent choice for this research given the ongoing conflict in Yemen.
This study is based on a cross-sectional survey; hence, causal relationships between the study’s variables cannot be established.
There is the possibility of reporting bias on the part of women in responding to the survey question on contraceptive use.
The use of secondary data for analysis limited the study’s variable selection.
Introduction
A significant number of women still die each year from pregnancy complications, childbirth or unsafe abortion in low-income and middle-income countries.1 The 1987 Safe Motherhood Conference (Nairobi, Kenya), the 1994 International Conference on Population and Development (Cairo, Egypt), the 1995 Fourth World Conference on Women (Beijing, China) and the 1997 Safe Motherhood Technical Consultation (Colombo, Sri Lanka) all identified and discussed maternal mortality.2 Considerable progress has been made in women’s sexual and reproductive health between 1990 and 2020, particularly since the 1994 International Conference on Population and Development, including increases in contraceptive use globally. Contraceptive prevalence increased from 42.0% in 1990 to 49.0% in 2019, although with regional variations. For example, the use of contraception among women of reproductive age in sub-Saharan Africa (SSA) increased from 13.0% in 1990 to 29.0% in 2019. On the other hand, it increased from 26.0% to 34.0% in Western Asia during the same period.3
More recently, the international community took a giant step forward towards a world of equity and inclusion, health, including sexual and reproductive health and reproductive rights, education and greater equality with the adoption of the 2030 Agenda for Sustainable Development Goals (SDGs).4 Access to effective contraception and the reduction of the unmet need for family planning are critical components of improving reproductive health and remain important today as they did in 1994. It is important to note that the definition of modern contraceptive methods may vary slightly depending on the source or context, but generally, they refer to medically approved and effective methods of contraception that are in line with current scientific and clinical standards.5 The use of a modern contraceptive method is associated with improvements in health-related outcomes such as reduced unplanned pregnancies, high-risk pregnancies and abortions, which most often than not are unsafe.6–8 It also facilitates birth spacing, which provides both health and social benefits to mothers and their children.
Continued rapid population growth presents a challenge for achieving the 2030 Agenda for Sustainable Development. However, the world has seen a decline in fertility rates since 1990, from 3.2 live births per woman in 1990 to 2.5 in 2019, although the extent and rate of decline for individual regions and countries continue to vary greatly.3 Yemen, one of the poorest countries in the world, and West Asia reportedly had a fertility rate of 6.5 children per woman in 1997. Data suggest that the early age of marriage and low level of education may have contributed to the high fertility rate in Yemen, particularly in rural settings.9 Nevertheless, the most recent national survey indicated that fertility had declined to 4.4 children per woman in 2013 in Yemen, which corresponded with an increase in the use of contraception over the same period.10
To achieve universal access to sexual and reproductive healthcare services, information and education by 2030 in Yemen, increased support for family planning will be required, including knowledge about factors that influence contraceptive use among married women. This will be a critical step towards meeting population policy objectives. Maternal age, level of education, occupation, place of residence, region, fertility desire, decision-making autonomy and the number of living children have all been identified as critical determinants of the use of a modern contraceptive method in Asia.11–15 However, evidence suggests that contraception use varies greatly across and within regions, implying that, while regional patterns exist, country-level factors are also important determinants that may vary. Little is known about the prevalence and determinants of the use of modern contraception among married women in Yemen.
The purpose of this study was to determine the prevalence of modern contraceptive use and its determinants among married Yemeni women of childbearing age (15–49 years).
Methods
Data source and sample size
The data analysed in this study were obtained from the 2013 Yemen National Health and Demographic Survey (YNHDS). The Ministry of Public Health and Population collaborated with the Central Statistical Organization to implement the 2013 YNHDS. Inner City Fund International provided technical assistance through the United States Agency for International Development (USAID)-funded Monitoring and Evaluation to Assess and Use Results (MEASURE) Demograpic and Health Survey (DHS) project, which provides support and technical assistance for population and health survey implementation in countries worldwide. The sample was selected from 800 clusters (213 clusters in urban areas and 587 in rural areas). The 2004 General Population Housing and Establishment Census was used as the sampling frame. The dataset contains information about the women’s background characteristics, such as age, education, type of place of residence, governorate, wealth quintile and contraceptive use pattern. A total of 19 517 households were selected for inclusion, and of these, 18 027 were occupied. The details of the survey methodology, including the questionnaire used for data collection, are contained in the final report.10
Participants
A total of 25434 women were interviewed. Of these, 16656 reported being married. The women’s file was used for this study. The present study included 13483 women who were not pregnant at the time of the survey for analysis because the focus of the study is the contraceptive use. However, the authors ensured that all the women had information on all the explanatory variables examined in the study. As a result, observations with missing data on any of the included explanatory variables were excluded, yielding a final sample of 12363 married, non-pregnant women for analysis. To ensure that the analyses adequately accounted for the complex survey sample used by the DHS, specialised procedures for design-based analyses, such as weighting and clustering, were used.16 Figure 1 depicts a flow chart of how the current study’s final sample was determined.
Flow chart illustrating the final sample selection for the current analysis. YNHDS, Yemen National Health and Demographic Survey.
Variables
Dependent variable
The dependent variable in the study was the use of a modern contraceptive method, obtained from respondents’ self-report. Modern contraceptives in the current study included injectables, male and female sterilisation, vasectomy, contraceptive pills, intrauterine devices, implants, emergency contraception, female and male condoms, diaphragms and the lactational amenorrhoea method as used commonly in DHS surveys.17 A dummy variable was created for the dependent variable (1=use of a modern contraceptive method; 0=not using a modern contraceptive method). Women who were not using contraception as well as those who were using traditional or folkloric methods were classified as not using a modern contraceptive method.
Explanatory variables
The authors reviewed the existing literature and identified some variables that have been reported to have a relationship with the use of contraception among married women.18–22 The authors included maternal age in five categories, level of education of the woman and her partner, respondent’s employment status, respondent’s decision-making ability (whether the woman participates in decision-making regarding her health), governorate, type of place of residence (rural or urban), fertility preference (whether the respondent desires another child or more children, is undecided, or wants children no more), number of living children, wealth group (poorest, poorer, middle, richer and richest) and exposure to media (whether the respondent reads newspaper or magazine, listens to the radio or watches television (TV)). The factors investigated in this study were chosen based on their availability in the dataset. In other words, the authors acknowledge that not all factors known to be associated with the use of modern contraceptive methods were investigated in the current study due to their absence in the dataset used for the current analysis.
Statistical analysis
A design-based analysis approach, specifically weighting, was used in the current analyses to account for the unequal probability sampling design of the DHS programme in surveys to increase the number of cases and reduce sample variability for specific areas or subgroups. All the statistical analyses were performed using Stata V.13.0 SE (StataCorp LP, College Station, Texas, USA). The authors calculated the percentage of women who used contraception and modern contraception. The authors then used a χ2 test to examine the bivariate relationship between the explanatory variables and the use of a modern contraceptive method. A multilevel regression model was constructed using the explanatory variables that were statistically significant in the bivariate analyses. Our multilevel regression analysis included four models. First, an empty model (model 0) was built without explanatory variables to investigate the variation in using a modern contraceptive method due to clustering of the primary sample units. Model 1 was created with variables at the individual and household levels. Model 2 examined variables at the community level. Model 3 was fitted to include all statistically significant explanatory variables from the bivariate analyses and included individual-level and household-level factors, as well as community-level factors. The results of the multilevel binary logistic regression analysis were presented as adjusted ORs and their corresponding 95% CIs. Multicollinearity of the explanatory variables was checked using the variance inflation factor test; we did not find evidence of collinearity. To compare and assess the fitness of the models, the authors used the intraclass correlation coefficient (ICC), the likelihood ratio test and the Akaike information criterion (AIC). All the analyses were weighted. A probability value of less than 0.05 was deemed statistically significant.
Patient and public involvement
No patient involved.
Results
Sociodemographic and obstetric characteristics of married women included in this study
The mean age of the women was 30.7 (±8.2 years; range 15–49). The results of descriptive statistics showed that a total of 6544 (52.9%) women had no formal education, 11 095 (89.7%) were unemployed, 8331 (67.4%) resided in rural areas, 6879 (55.6%) married before the age of 18 and 6864 (55.5%) were involved in decision-making concerning their health. Regarding exposure to media, the results showed that 84.8% of the total sample reported not reading newspapers/magazines at all, 74.7% did not listen to the radio and 58.6% reported watching TV almost every day (table 1).
Background characteristics of respondents included in the present study (N=12 636)
Prevalence rate of the use of modern contraception among married women of childbearing age in the study setting
Results on the use of contraception among the study sample are presented in figure 2. The authors found that among the 12 363 women included for analysis, 4692 reported using any form of contraception, giving us a prevalence rate of 38.0% (95% CI: 36.4 to 39.5) for the use of any form of contraception among married women of the reproductive age (figure 2A). The authors estimated that 32.8% (95% CI: 31.4 to 34.2) of the 12 363 women (n=4054) were using a modern contraceptive method (figure 2A).
Distribution of respondents by; (A) general use of contraception (any form of contraception) and (B) use of a modern contraceptive method (N=12 363).
Bivariate analyses of the factors associated with the use of a modern contraceptive method among married women from univariate analyses
Table 2 shows that almost all the explanatory variables investigated were significantly associated with the use of a modern contraceptive method, except age at first marriage and frequency of listening to the radio. A higher proportion of women in the age group of 30–34 (40.0%) were using a modern method compared with the other age groups. Similarly, a significantly higher percentage of women with at least a secondary education (44.6%) and those whose partners had at least a secondary education (41.7%) reported using a modern contraceptive method compared with their counterparts. The use of a modern contraceptive method was relatively higher among women who were involved in making decisions regarding their own health (34.8%) and women who reported reading a newspaper or magazine (47.6%) or watching TV almost every day (38.4%). The use of a modern contraceptive method differed significantly by household wealth group, governorate and type of place of residence.
Factors associated with the use of modern contraception among married women from univariate analyses (N=12 363)
Mixed effects analyses of the factors associated with the use of a modern contraceptive method among married women of childbearing age in Yemen
Fixed effects results
Table 3 presents the results of our multilevel analysis of the factors associated with the use of a modern contraceptive method. The authors found that factors, namely maternal age, educational level of the respondent and her partner, number of living children, the respondent’s fertility preference, frequency of watching TV, household wealth group, governorate and type of place of residence, were associated with reporting the use of a contraceptive method. The authors found that women with a fundamental (aOR=1.39; 95% CI: 1.23 to 1.56) or at least a secondary level of education (aOR=1.81; 95% CI: 1.52 to 2.16) as well as women whose partners had attained at least a secondary level of education (aOR=1.19; 95% CI: 1.02 to 1.39) were more likely than their colleagues to report using a modern contraceptive method. The odds of reporting use of a modern contraceptive method were higher among women from poorer, middle, richer or richest households compared with women from the poorest households. Women who watched TV almost every day were more likely than those who did not watch at all to report using a modern method of contraception (aOR=1.16; 95% CI: 1.01 to 1.33). According to governorate, higher odds of modern contraceptive method use were reported among women from Sanaa and Amran, while lower odds were reported among women from Hajjah, Al-Hodeidah, Shabwah, Al-Mahwit, Al-Mahrah and Reimah compared with Ibb. Women residing in rural areas were also less likely than their urban counterparts to report using a modern method of contraception (aOR=0.75; 95% CI: 0.62 to 0.92).
Fixed-effects analyses of the factors associated with the use of a modern contraceptive method among married women of childbearing age
Random effects results
The empty model (model 0), as shown in table 4, shows that there was variation in the use of a modern contraceptive method in the study setting across the clusters. The variation between clusters accounted for about 21% of the prevalence rate of using a modern contraceptive method (ICC=0.210). In model 1, there was a significant variation in modern contraceptive method use, with differences between clusters accounting for approximately 18% (ICC=0.179) of the variation. Model 3 had the lowest ICC, log likelihood and AIC values. Furthermore, it had the highest Wald χ2 value. Model 3 was thus selected as the best model for identifying the factors associated with the use of a modern contraceptive method in the study setting.
Random effects analyses of the factors associated with the use of a modern contraceptive method among married women of childbearing age
Discussion
The authors estimated that about one-third of married women used a modern method of contraception to limit or space childbirth. The current study’s rate of modern contraceptive use is lower than rates reported by previous studies in other parts of the world, such as 46.9%–71.9% in Ethiopia23 24 and 43% in rural Zambia.20 It is also lower than the 48% reported in India25 and the 45.7% among the poorest countries in the world.26 The observed variation may be attributable to differences in the socioeconomic status of the studied populations, methodologies and healthcare interventions across geographical locations.
The study found that sociodemographic and economic factors such as maternal age, maternal educational level and partner’s educational level, number of living children, women’s fertility preferences, household wealth group, governorate and type of place of residence were significantly associated with the use of a modern contraceptive method. These factors have been reported in other studies.20 21 23–25 The authors found that, compared with the age group of 15–19 years, women older than 30 years were significantly less likely to use a modern method of contraception. This is in accordance with some existing studies. A study among high fertility countries in SSA reported that older women were less likely to use modern contraception.27 However, the finding also contrasts with the findings of a study in Sierra Leone where married women aged 15–19 years were less likely to report using a modern contraceptive method.21 The decreased likelihood of using modern contraception with older age can be attributed in part to infrequent sexual activity and the belief that there is no risk of pregnancy.23 28 Women aged 15–19 years, on the other hand, may be in their early stages of their reproductive lives and are likely still in school. Because of their education and unreadiness to start a family, they may use contraception to accomplish the academic goals. The policy implication of this finding is that there is a need to specifically target and address the lower use of modern contraception among women older than 30 years. This may involve developing and implementing targeted interventions such as age-specific health education programmes, outreach efforts and policy initiatives that aim to improve awareness and access to modern contraceptive methods for women in this age group.
Furthermore, the authors found that, compared with women with no formal education, educated women had an increased likelihood of using a modern contraceptive method. Similarly, women whose partners had at least a secondary level of education were significantly more likely than those whose partners had no formal education to report using modern contraception. A study in India reported that having at least 10 years of schooling increased the use of modern contraception and was negatively associated with the unmet need for contraception.25 Having a formal education has been associated with modern contraceptive method use among married women in SSA countries.21 23 The association of higher maternal and partner’s levels of education with the use of modern contraception in the current study may be due to the direct and indirect effects of education on the individual and health-seeking behaviour, including economic and social empowerment, improved knowledge and awareness about the benefits of effective contraception and access to health services.19 29–31 Nearly 1 in 10 women of reproductive age in Yemen has no formal education. As a result, strategies to promote female education may impact positively on women’s use of contraception.
In this study, women with fewer than five children alive were less likely to use modern contraception. Similarly, women’s fertility preferences predicted the use of a modern contraceptive method. Specifically, women who desired another child or more children were less likely to report using a modern contraceptive method compared with those who had no desire for children any more. The association of the number of living children and fertility preference with modern contraceptive use can be explained by the desire for more children or otherwise. When couples have their ideal number of children, modern contraception may be used to stop childbearing. The common reason for the non-use of contraception among Pakistani married women was a desire for more children.32 It is established that women who desired more children or had pregnancy intent were less likely to use a contraceptive method.23 33 34 According to one study, childbearing desire not only influences the non-use of contraception but also results in contraceptive discontinuation.35 Addressing fertility preferences and family size desires of women can be crucial in promoting modern contraceptive utilisation. Additionally, efforts to address cultural norms and societal expectations related to fertility preferences and family size desires, through community-based education and awareness programmes, may help empower women to make informed choices about their reproductive health.
In Yemen, the TV is the most common source for information on family planning for ever-married women of reproductive age.10 In the current study, exposure to TV was associated with the use of modern contraception. Specifically, women who watched TV almost every day were more likely to use a modern contraceptive method than those who did not watch at all. Information on contraception disseminated through TV can increase women’s knowledge of modern contraception, including the benefits and types of methods, as well as the side effects associated with their use, creating a demand for its use. Receiving information on contraceptive use from sources such as TV has been associated with the use of modern contraception among Ghanaian women of reproductive age.36 However, in another study where only about 7% of married women reported hearing information on family planning on TV, a lack of statistical association was documented.21 Women from the wealthier households had increased odds of using modern contraception compared with their counterparts from the poorest households in the study setting. The positive effect of wealth on contraceptive use may be largely reflected in improved access to various sources where the method can be found. Furthermore, wealthy women can afford modern methods of contraception, whether from government facilities or the private sector. Indeed, about 44% of modern contraceptive users in Yemen obtain their commodities from the public sector.10
The study found that community-level factors such as the governorate and type of place of residence were associated with modern contraceptive use. Women from Sanaa and Amran had higher odds of use, while those from Hajjah, Al-Hodeidah, Shabwah, Al-Mahwit, Al-Mahrah and Reimah had lower odds of use when compared with women from Ibb. Yemen’s conflict has had varying degrees of negative impact on households' socioeconomic status and access to basic health services, lending support to this observation. For example, Al-Hodeidah is suffering from a lack of health services as a result of the destruction of several hospitals and health centres.37 Rural women were less likely to use a modern contraceptive method due to poor access and low socioeconomic factors. These findings emphasise the importance of considering contextual factors at the community level, such as governorate and type of place of residence, in designing and implementing family planning programmes and policies. Tailoring interventions to address regional differences and rural-urban disparities can help improve modern contraceptive utilisation and ultimately contribute to better reproductive health outcomes for women in Yemen.
Public health implications of the current study’s findings
The promotion of modern contraception in countries with high fertility rates, such as Yemen, has the potential to significantly impact maternal and infant mortality rates, empower women, promote education and contribute to long-term environmental sustainability.7 From the current study, about two-thirds of reproductive women who are married or in a union in Yemen do not use modern contraception to limit or space childbirth, which could result in increased unintended pregnancies and unsafe abortions, leading to higher maternal mortality rates and exacerbating poverty.
The findings of the present study suggest several determinants of modern contraceptive use at the individual, household and community levels that could be considered in family planning programmes. For example, our descriptive analysis shows that nearly 60% of Yemeni married women of reproductive age watch TV almost every day, suggesting that this medium could be used to disseminate information about family planning and increase women’s knowledge of modern contraception. This highlights the potential of media and communication channels in promoting contraception awareness and education. Furthermore, the study emphasises the importance of strategies to enrol and retain girls in school, preferably up to at least the secondary level. Education can delay early marriage, improve socioeconomic status and promote positive health-seeking behaviour, including the use of modern contraception. Investing in education for girls can have a significant and long-term impact on reproductive health outcomes, including increased contraceptive use and improved maternal and infant health.
Strengths and limitations of the current study
The study’s strength lies in the use of a nationally representative dataset and design-based models, which allow for the representation of estimates and generalisation of findings across all married women in the study setting. Nonetheless, some limitations must be noted. First, the dataset used is nearly a decade old, and it is expected that patterns of contraceptive use in the study setting may have changed since 2013. Nevertheless, it is the only and most recent DHS dataset available. Furthermore, while more recent data may be ideal, the social, cultural, economic and health system context of Yemen may not have significantly changed, making the findings from the 2013 DHS dataset still informative and relevant for decision-making. Second, because the results of this study are based on a cross-sectional survey, causal relationships cannot be established. Another potential limitation is the possibility of reporting bias on the part of women in responding to the survey question on contraceptive use. The use of secondary data for analysis limited the study’s variable selection. In other words, not all variables with a known association with modern contraceptive use were included as explanatory variables for the present analysis due to their unavailability in the dataset.
Conclusion
The findings of this study revealed that approximately one-third of married women aged 15–49 in the study setting are using modern contraception. This indicates that there is room for improvement in increasing the utilisation of modern contraception among married women in this context. Multilevel regression analysis indicated that individual-level, household-level and community-level factors, namely maternal age, maternal educational level, partner’s educational level, number of living children, fertility preference, wealth, governorate and place of residence, were statistically significantly associated with the use of modern contraception in the study setting. Interventions such as health education on sexual and reproductive health including; family planning utilisation targeting older, uneducated and poor women may have a positive influence in terms of increasing their use of modern contraception. Promoting contraceptive use in conflict-affected settings with fragile health systems, such as Yemen, requires innovative strategies such as expanding the basket of contraceptives, improving access to contraceptives in terms of affordability and physical availability and increasing knowledge and awareness among both providers and potential users. These strategies may help overcome barriers to contraceptive use and improve reproductive health outcomes in the population.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
Permission to use the dataset was obtained from the DHS program through ICF International. Since this study was a secondary analysis and individual considerations such as names and addresses were not included, the institutional review board’s approval was not required. The authors did not also have access to the participants in the original survey.
References
Footnotes
Twitter @boahmichael
Contributors MB and DH conceived and designed the study. MNA revised the initial study design and participated in the analysis and drafting of the manuscript. MB participated in the analysis and drafting of the manuscript. DH participated in drafting the manuscript. All authors read, revised, and approved the final version of the manuscript. MB is responsible for the overall content as guarantor
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.