Contraceptive decision-making and its association with contraceptive use among married adolescent girls in Niger

TL;DR

This study explores how married adolescent girls in Niger make contraceptive decisions and how these decisions relate to their contraceptive use, often without their husbands' knowledge.

Contribution

The study introduces a nuanced analysis of contraceptive decision-making, distinguishing between overt and covert use among married adolescent girls in Niger.

Findings

Over half of the participants reported ever using a contraceptive, with most reporting their husbands as the sole decision-makers.

Adolescents' participation in decision-making was positively linked to covert contraceptive use and negatively linked to overt use.

Women who had final say in contraceptive decisions were more likely to use contraceptives covertly.

Abstract

Niger has among the highest rates of child marriage and lowest rates of modern contraceptive use in the world. This study analyzes the association between contraceptive decision-making and contraceptive use among married adolescent girls in rural Niger, including multiple assessments of decision-making and consideration of overt vs. covert contraceptive use.

We analyzed cross-sectional survey data collected from married adolescent females (n = 823) participating in the third round of data collection (October–November 2019) for the cluster-randomized controlled trial of a family planning intervention study. Contraceptive decision-making measures assessed participants’ (a) participation in contraceptive decision-making, (b) final say in decision-making in case of spousal disagreement, and (c) satisfaction with participation in decision-making. Outcomes include contraceptive use ever categorized based on whether use was overt (with husband’s knowledge) or covert (without husband’s knowledge). Adjusted multinomial logistic regression models were used to test the associations between each decision-making item and each type of contraceptive use.

Over half of participants reported ever using a contraceptive (59%) and that their husbands were the sole decision-makers regarding contraceptive use (60%). Adolescents’ participation in decision-making was negatively associated with overt contraceptive use (ARRR = 0.41; 95%CI = 0.19–0.91) and positively associated with covert contraceptive use (ARRR = 8.76; 95%CI = 2.45–31.30). Women reporting joint decision-making were more likely to report covert use vs. no use (ARRR = 3.20; 95%CI = 1.14–8.99). Women having final say in contraceptive decision-making in case of disagreements were more likely to report covert contraceptive use over no use (ARRR = 9.14; 95%CI = 3.17–26.40). Women’s satisfaction with decision-making was positively associated with contraceptive use ever (AOR = 2.72; 95%CI = 1.80–4.16), and overt (ARRR = 2.68; 95%CI = 1.75–4.01) and covert contraceptive use (ARRR = 10.9; 95%CI = 2.16–54.80).

Male control over decision-making and female satisfaction with decision-making are associated with greater contraceptive use. Findings indicate that women’s control over decision-making, and its relation to contraceptive use, is complex and requires more nuanced understanding for married adolescents.

Niger is a country with one of the highest prevalence of child marriage in the world, with three in four girls marrying before the age of 18 years. Use of modern contraceptives remains low in this context with little known about the role of married adolescents in decisions regarding such use, or their control over or satisfaction with these decisions. In this study, we analyze data from a large representative sample of married adolescent girls in the Dosso region of Niger to access their participation in contraceptive decision-making, whether they or their husbands have the final say over such decisions in cases of disagreement, and how satisfied they are with the level of control they have over these decisions. In addition to describing agency regarding contraceptive use, we also assessed whether these aspects of decision-making are related to married adolescent girls’ reports of contraceptive use, and whether this use was with or without the knowledge of their husband. The results show that girls who participated in contraceptive decision-making alone or with their husbands, who had the final say in decision-making in cases of disagreement, and who reported being satisfied with their level of control over these decisions were more likely to use a contraceptive than others, but to do so without their husbands’ knowledge. The findings highlight the complexity of married adolescent girls’ reproductive autonomy in this context and indicate that measuring multiple aspects of contraceptive decision-making may advance a more nuanced understanding of their agency regarding these critical decisions.