Trends in Contraceptive Knowledge and Use Among Adolescent Married Women in Malawi

There is a growing interest in adolescent reproductive health. Teenage pregnancies are an important public health issue because they are associated with maternal, fetal, and neonatal adverse outcomes. Teenage girls who get pregnant are likely to drop out from school and teenage parents are unlikely to have the social and economic means to raise children. These, and many other reasons, justify the promotion of sexual abstinence among teenagers and/or contraception. In the United States, it has been estimated that 82% of pregnancies in women aged 15 to 19 years are unintended (1). There is an interest in the prevention of pregnancy among unmarried adolescents, but much less in married ones.

Young married women may not use the most appropriate pregnancy prevention (2). Young women usually prefer certain types of contraceptives, usually relying on less effective methods. Santelli et al (3) found that overall hormonal method use among teenagers in the United States barely changed in the period from 1993-2001. There was, however, a decline in the pill use (from 25% to 20%) that was offset by a decreased use of injectable contraceptives. Much research on adolescent contraceptive use and reproductive health assumes that adolescent women are unmarried, which makes married adolescent women not recognized by researchers and not included in the design, implementation, and evaluation of reproductive health programs. The present article aims to explore the trends in contraceptive knowledge and use among married adolescent women in Malawi between 1992 and 2004.

The Malawi Demographic and Health Surveys (MDHS) 1992, 2000, and 2004 and the Knowledge, Attitudes and Practices in Health Survey 1996 (MKAPHS 1996) (4-7) are nationally representative studies using multi-stage cluster sampling techniques. The prevalence of different estimates was obtained and reported. In the present study, the prevalence data on the knowledge and use of contraception among married adolescent women were analyzed to obtain odds ratio first with the 1992 results as the referent and then with the immediately preceding survey data as the referent.

A total of 206 married adolescent women participated in the MKAPHS 1996, 388 in the MDHS 1992, 934 in MDHS 2000, and 788 in MDHS 2004. The adolescents were defined as persons under the age of 20 years. The percentage of married adolescent women who knew about at least one method of modern contraception was 84.5% in 1994, 97.2% in 1996, 96.3% in 2000, and 95.3%in 2004. Compared with 1992, the percentage of women with the knowledge of contraception was significantly increased in subsequent survey years (P<0.05). However, when each survey was compared with the preceding one, a significant improvement was noticed in the period between 1992 and 1996 (P<0.001). Thereafter, there has been no significant change, suggesting that knowledge levels have been maintained or reached saturation. Modeling suggested that significant increase from the 2004 level will only be reached if knowledge levels will rise to at least 96.9% (P = 0.040) (Table 1 and Table 2).

Table 1.

Odds ratios and 95% confidence intervals for “ever” used contraceptives among married adolescents in Malawi

Data comparison	1996	2000	2004
1992 data as referent value:
any method	21.3 (0.7-1.0)	28.1 (1.0-1.5)	32.9 (1.2-1.9)
modern method	12.8 (0.8-1.0)	24.1 (1.8-2.9)	29.3 (2.4-3.8)
contraceptive pill	4 (0.7-1.7)	2.8 (04-1.2)	3.7 (0.6-1.5)
intrauterine contraceptive device	0	0	0.1 (0.8-8.0)
injectable contraceptives	2.5 (0.7-2.1)	11.6 (3.8-9.8)	16.7 (5.9-14-9)
condom	10 (1.0-1.9)	7.2 (0.7-1.4)	11.2 (1.2-2.2)
female sterilization	0	0	0
Previous survey as referent value:
any method	21.3 (0.7-1.0)	28.1 (1.2-1.8)	32.9 (1.0-1.5)
modern method	12.8 (0.8-1.0)	24.1 (1.7-2.7)	29.3 (1.1-1.6)
contraceptive pill	4 (0.7-1.7)	2.8 (0.4-1.1)	3.7 (0.8-2.2)
intrauterine contraceptive device	0	0	0.1
injectable contraceptives	2.5 (0.7-2.1)	11.6 (3.3-8.0)	16.7 (1.2-2.0)
condom	10 (1.0-1.9)	7.2 (0.5-1.0)	11.2 (1.2-2.1)
female sterilization	0	0	0

Table 2.

Odds ratios and 95% confidence intervals currently used contraceptives among adolescent married women in Malawi

Data comparison	1996	2000	2004
Malawi Demographic and Health Survey 1992 as reference:
any method	10.7 (1.1-2.1)	15.2 (1.7-3.1)	18.9 (2.2-3.9)
any modern method	6 (1.2-2.8)	12.9 (2.9-6.2)	16.6 (3.9-8.3)
pill	2.6 (1.4-6.3)	1.2 (0.6-3.2)	1.3 (0.6-3.4)
intrauterine contraceptive device	0	0	0
injectable contraceptives	1.5 (1.1-8.4)	8.1 (7.1-43.5)	11.8 (10.8-65.5)
condom	1.9 (0.5-1.8)	2.8 (0.8-2.5)	3.4 (1.0-3.0)
hormonal implants	0.1	0	0.1
Previous survey as referent value:
any method	10.7 (1.1-2.1)	15.2 (1.1-1.9)	18.9 (1.0-1.6)
any modern method	6 (1.2-2.8)	12.9 (1.7-3.2)	16.6 (1.0-1.7)
pill	2.6 (1.4-6.3)	1.2 (0.2-0.9)	1.3 (0.5-2.4)
intrauterine contraceptive device	0	0	0
injectable contraceptives	1.5 (1.1-8.4)	8.1 (3.3-10.1)	11.8 (1.1-2.0)
condom	1.9 (0.5-1.8)	2.8 (0.8-1.9)	3.4 (0.7-2.0)
hormonal implants	0.1	0	0.1

The proportion of “ever used” modern contraceptives increased for about two and half times (12.1% to 29.3%) between 1992 and 2004. Much of the increase was attributable to injectable hormonal contraceptives, the use of which increased from 2.1% to 16.7%. The use of the pill declined over the period, while intrauterine contraceptive devices, condoms, and hormonal implants were unpopular in this age group. The increased popularity of injectable contraceptives deserves further study. In a study by Meekers et al (8) youths who believed that condoms were effective against conception had a higher likelihood of using them than those who did not believe so. It is worrying that adolescent married women in Malawi had little experience with condoms, since the country has an HIV prevalence of 14% among adults 14-49 years old (9). This could be a manifestation of the low acceptability of condoms in marital situations, as Chimbiri found that condom was considered “an intruder” within marriage among rural Malawians (10).

Lema and Mpanga (11) reported that the most commonly chosen method of contraception among women after abortion were oral pills (45.3%), injectable depo-provera (21.8%), and male condoms (20.7%). In 1994, Lema et al reported in a hospital-based study among family planning clients that the oral pill was the most commonly chosen method (42.0%), followed by injectable depo-provera (31.0%), and sterilization (21.0%) (12). MDHS 1992 also showed that contraceptive pill was used more than injectable contraceptives, both “ever”(0.9% vs 0.5%) and “currently” (3.8% vs 2.1%).

Injectable contraceptives were used more than the pill from 2000 to 2004. This could be because pills were introduced before injectable contraceptives in Malawi. Many health professionals promote injectable contraceptives as they are perceived to be more effective, especially since they do not require daily adherence. However, there is a need for systematic research to explore the reasons behind the wider use of injectable contraceptives compared with pills.