The Role of Spousal Socio-Demographic Differences and Decision-Making Power Dynamics on Contraceptive Use Among Married Female Adolescents in Rural Ethiopia

doi:10.21203/rs.3.rs-5206980/v1

Background:

Ethiopia has one of the largest populations of married female adolescents in sub-Saharan Africa. These young women face challenges related to gender roles, socio-economic factors, and reproductive health, impacting their access to family planning services. This study examines how spousal socio-demographic differences and decision-making dynamics affect contraceptive use among these adolescents in rural Ethiopia.

Methods:

In January 2022, a household survey was conducted as part of the RISE intervention program, involving 2,125 married female adolescents aged 15–19 from rural areas. Multi-stage cluster sampling was used to select participants. Multivariate logistic regression models analyzed the effect of spousal characteristics on contraceptive use.

Results:

The average age of respondents was 17.9 years, with 56.5% having given birth and 84% having completed at least elementary education. The modern contraceptive prevalence rate (mCPR) was 38.5%, with injectables being the most used method. Husbands were on average eight years older, and a husband-wife age gap of 10 + years significantly reduced contraceptive use (AOR 0.69). Higher education levels among wives (AOR 1.69) and similar education between spouses (AOR 1.76) increased contraceptive use. Women involved in financial (AOR 1.94), healthcare (AOR 1.42), and family size decisions (AOR 1.35) were more likely to use contraception.

Conclusion:

Contraceptive use among married adolescents in rural Ethiopia is shaped by spousal age differences, education, and decision-making dynamics. Addressing gender power imbalances, promoting female education, and involving men in family planning are critical for improving outcomes.

Sexual & Reproductive Medicine

Married Adolescents

Family planning

Decision-making dynamics

Ethiopia

Female adolescents face significant challenges due to their ongoing physical, mental, emotional, and social development [1]. Early marriage often exacerbates these challenges, particularly in relation to gender roles, socio-economic status, health, education, and overall well-being. These young individuals are frequently ill-prepared—physically, emotionally, and socially—for the demands of marriage and parenthood [2]. In many traditional societies, prevailing gender norms heavily influence household power dynamics, often disadvantaging young brides, particularly when their husbands hold more authority [3]. Cultural expectations commonly place women in subordinate roles, focusing on domestic responsibilities and childcare [4]. These social norms further entrench gender roles, expecting young wives to be obedient to their husbands, thereby reinforcing patriarchal systems that restrict their economic independence and limit their ability to voice opinions or challenge decisions [3]. This patriarchal structure often supports male dominance in decision-making, leaving young wives with minimal power in negotiations, especially concerning critical matters such as finances, healthcare, and family planning [5].

Ethiopia, home to the second-largest adolescent population in Africa, has over six million female adolescents, 17% of whom are married [6]. More than 13% of Ethiopian girls become mothers before the age of 18, facing significant health and socioeconomic challenges, including a heightened risk of maternal mortality [7]. Complications such as anemia, eclampsia, and sepsis during pregnancy and childbirth pose severe risks to these young mothers, making early pregnancy one of the leading causes of maternal deaths in the country [8]. Gender, cultural, and economic barriers often hinder adolescents' access to essential reproductive health services, including family planning and maternal healthcare [9]. Existing research highlights the importance of gender roles, cultural norms, and traditions in influencing attitudes and behaviors toward family planning [10, 11].

In Ethiopia, as in many sub-Saharan African countries, there is a notable gap in research on the reproductive health and family planning needs of married adolescents. Most existing studies focus on factors such as education, religion, economic status, and the number of children when analyzing family planning service use among this demographic [12–14]. However, these studies often fail to consider the impact of socio-demographic differences between spouses and the decision-making dynamics within marriages on access to and use of family planning services. This is particularly important because, in many rural Ethiopian households, husbands are generally older, relatively more educated, and have a higher socio-economic status than their wives, which often gives them greater decision-making authority. Understanding the dynamics between spouses, especially the influence of husbands, is essential for designing interventions that effectively meet the unique family planning needs of married adolescents and couples.

This study explores the impact of socio-demographic differences between female adolescents and their spouses on contraceptive use in rural Ethiopia. It also examines the decision-making dynamics within marriages, with a focus on how power imbalances between husbands and wives influence young women's ability to access and use family planning services. By addressing the socio-demographic factors and power dynamics, this research aims to fill a significant gap in the existing literature. The findings will also offer valuable insights for family planning programs, highlighting the role of men within the context of young girls' marriages in shaping reproductive health decisions and how their involvement can lead to better outcomes for married couples.

Data Sources

This study draws on data from a baseline household survey conducted in January 2022, in which female married adolescents aged 15–19 were interviewed. The survey was part of the evaluation for the Roadmap for Integrating Smart Start in Ethiopia (RISE) project. Implemented between 2022 and 2024, the RISE project targets married adolescents aged 15–19 across approximately two-thirds of rural Ethiopia, covering over 465 Woredas (districts). The primary objective of the RISE intervention is to improve family planning services for married adolescents in rural areas. RISE is a program led by the Ethiopia Federal Ministry of Health (FMOH) and regional governments, with support from the Children’s Investment Fund Foundation (CIFF) and Population Services International (PSI).

In January 2022 a baseline survey was conducted in the RISE program area using a two-wave, cross-sectional, population-based survey. The baseline survey, designed to capture pre-intervention data. The survey employed a multi-stage cluster sampling method, where clusters were defined at the woreda level, and the primary sampling unit (PSU) was the kebele, the smallest administrative unit in Ethiopia. In the first stage of sampling, 60 clusters (woredas) were selected using probability proportionate to size (PPS) methodology, ensuring that larger woredas had a higher probability of selection. In the second stage, three PSUs were randomly selected within each cluster. Within each PSU, households were randomly selected, with a comprehensive household listing conducted to identify all married adolescents within the selected PSUs. Data were collected from 2,125 married adolescents aged 15–19 through face-to-face interviews, providing information on both themselves and their husbands, with a response rate of 98.4%.

Study Variables

The primary outcome of interest in this study is the modern Contraceptive Prevalence Rate (mCPR), which is defined as the proportion of married female adolescents aged 15–19 years who are currently using, or whose partners are using, a modern method of contraception at the time of the survey.

Using the information provided by the women about themselves and their husbands, we constructed a set of independent variables. The key independent variables include differences between spouses in terms of age, education level, employment/work status, and decision-making dynamics in four key domains: household management, financial decisions, healthcare, and the number of children. These variables were selected to explore how disparities and dynamics within marriages influence contraceptive use among married female adolescents. Age differences between spouses were categorized into three groups: (1) husband less than five years older or younger than the wife, (2) husband 5–9 years older, and (3) husband 10 + years older. Educational differences were categorized into four groups: (1) both spouses have no education, (2) husband is more educated, (3) wife is more educated, and (4) both spouses have the same level of education. Work status differences were categorized into three groups: (1) both spouses are farmers with no other employment, (2) husband has off-farm employment, and (3) wife or both spouses have off-farm employment. Decision-making dynamics were assessed by asking respondents who primarily made decisions in their household regarding (1) spending money, (2) major household purchases, (3) healthcare for the family, and (4) the number of children. Responses were categorized into two groups: (1) decisions made by the wife alone or jointly with her husband, and (2) decisions made solely by the husband. A summary decision-making score was then constructed by summing the responses across these domains, and the resulting scores were classified into three levels: low, moderate, and high decision-making participation by the wife. At the individual level, independent variables included the woman’s age, her husband’s age, the education levels of both spouses, the employment status of both spouses, the number of children ever born, and the couple's religious affiliation.

Method of Analysis

The primary objective of the analysis was to examine the influence of socio-demographic differences between spouses and the dynamics of decision-making on the contraceptive use of married female adolescents. To achieve this, we conducted three separate multivariate logistic regression models. Model 1 included spousal differences in age, education, and employment status, as well as the individual socio-demographic characteristics of both the married female adolescents and their spouses. Model 2 expanded on this by incorporating variables related to decision-making for spending money, purchasing major household items, healthcare for the family, and determining the number of children the family will have. Model 3, instead of using individual decision-making variables, incorporated a summary decision-making score on top of the factors included in Model 1. The results from these models are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI) to provide a measure of the strength of associations.

All data management and statistical analyses were performed using Stata version 17 (Stata Corporation, College Station, TX, USA). The Survey command in Stata was utilized to define strata and primary sampling units (PSUs), enabling appropriate adjustments for the sampling design in all calculated proportions, rates, and odds ratios.

Characteristics of married female adolescents and their spouses

Table 1 presents background characteristics of married female adolescents (wives) and their husbands. The distribution of age for the wives indicates that most fall within the 18–19 age group, accounting for 63.9% of the total. Adolescents aged 15–17 years comprise the remaining 36.1%. The mean age for the wives is 17.9 years, indicating a predominantly adolescent demographic. The wives reported that none of their husbands were aged 15–17, and only 2.1% were in the 18–19 age group. Most of the husbands, according to the wives, were aged 25–29 (54.7%), followed by those aged 20–24 (29.2%), with 14% being 30 or older. The wives indicated that the mean age of their husbands was 25.5 years, highlighting a significant age gap between spouses.

A significant proportion of these female adolescents married early, with 86.3% having wed before reaching 18 years old. The mean age at marriage is 16.0 years, demonstrating a trend of early marriage. A minority (13.7%) were married at ages 18–19. Husbands typically marry later than their wives. Only 3% wed before the age of 18, while 8.9% did so between 18 and 19 years. The most common age range for marriage is 20–24 (41.5%), followed by 25–29 (27.9%). The mean age at marriage for husbands is 23.8 years. Literacy levels among the wives reveal disparities. About 16.1% cannot read or write, while the majority have some level of primary education. Specifically, 39% attained grades 1–6, 29% reached grades 7–9, and 15.8% progressed to grade 10 or higher. According to the wives, literacy is slightly higher among their husbands, with only 16.8% unable to read or write. Most husbands have completed primary education, with 30.5% reaching grades 1–6, 28.1% attaining grades 7–9, and 24.6% achieving education at grade 10 or higher.

The majority of the wives (83.1%) engage in non-paying farming activities, highlighting their primary involvement in subsistence agriculture. A smaller portion (16.9%) has off-farm employment that provides wages. The husbands predominantly engage in non-paying farming (79.1%), though a notable 20.9% are employed in off-farm jobs that provide wages. This split indicates a reliance on both subsistence agriculture and paid labor.

Almost equal numbers of wives have either no child (43.5%) or a single child (44.2%). Only 12.2% have two or more children. Most had their first birth between ages 15 and 17 (83.4%), with only 1.1% giving birth under 15 years of age.

Table 1

Percent (%) distribution of key background characteristics of female married adolescents (Wives) and their husbands (Reported by Wives), Rural Ethiopia, 2022
	Wife (female)		Husband (male)
	N	%	N	%
Age
15–17	767	36.1	0	0.0
18–19	1358	63.9	45	2.1
20–24			620	29.2
25–29			1162	54.7
30+			298	14.0
Mean age (95% CI)	2125	17.9 (17.8–18.0)	2125	25.5(25.3–25.7)
Age at marriage
< 18	1833	86.3	64	3.0
18–19	292	13.7	190	8.9
20–24			881	41.5
25–29			593	27.9
30+			397	18.7
Mean age at marriage (95% CI)	2125	16.0(15.8–16.1)	2125	23.8(23.6–24.0)
Education
Cannot read/write	343	16.1	358	16.8
Grade 1–6	829	39.0	645	30.5
Grade 7–9	617	29.0	598	28.1
Grade 10+	336	15.8	522	24.6
Type of work
Farming (non-paying)	1765	83.1	1682	79.1
Off farm employment (paying)	360	16.9	443	20.9
Number of children ever born (wife)
0	925	43.5
1	940	44.2
2+	260	12.2
Age at first birth (Wife)
<15	20	1.1
15–17 years	1,567	83.4
18–19 years	292	15.5

Contraceptive use among married female adolescents

Figure 1a shows that the overall modern contraceptive prevalence rate (mCPR) among married female adolescents in rural Ethiopia was 38.5%. Two methods—injectables and implants—dominated the contraceptive choices, together comprising 92.7% of total contraceptive use. About a quarter of the adolescents used injectables, while just over one-tenth opted for implants.

Figure 1b indicates that mCPR increases with age, with 34.7% of adolescents aged 15–17 years using modern contraceptives, compared to 40.4% of those aged 18–19 years. This suggests that older adolescents are more likely to adopt modern contraceptive methods. As illustrated in Fig. 1c, there is a positive and linear relationship between education level and contraceptive use, ranging from 30% among those with no education to 50% among those who completed Grade 10 or higher. In Fig. 1d, the highest mCPR (46.7%) was observed among adolescents with one child, followed by those with two or more children (32.3%) and those with no children (31.6%). These findings collectively emphasize the variations in contraceptive use among married female adolescents in rural Ethiopia, influenced by factors such as age, education level, and parity.

Figure 1a-d. modern Contraceptive Prevalence Rate (mCPR), Married adolescents, Rural Ethiopia, 2022: (a) total and by type of contraceptive methods, (b) by age, (c) by education, and (d) by number of children

Spousal socio-demographic differences and decision-making dynamics

Table 2 highlights the demographic and socioeconomic differences between married couples, with a particular focus on age, education, and employment status, as reported by the wives. The mean age difference between spouses is 7.6 years, reflecting a common age gap norm in rural communities. The majority of couples (58.8%) have husbands who are 5–9 years older than their wives, while nearly a quarter have husbands who are at least 10 years older. A significant portion of couples (36.3%) have husbands with more education than their wives, which reflects traditional gender norms in education access in rural Ethiopia. Interestingly, a similar portion of couples (32.8%) share the same education level and a quarter of couples have wives who are more educated than their husbands. Most couples (72.75%) work as farmers without additional employment, highlighting the agricultural dependence of rural Ethiopian households. The remaining couples have diversified employment where the husband has off-farm work (13.8%) or the wife/both partners are engaged in off-farm employment (13.5%).

The decision-making dynamics in households reveals that while a majority of households (55.0%) involve the wife (alone or jointly) in decisions regarding spending money, 45.0% have the husband making these decisions alone, reflecting a notable level of male dominance in financial matters. In decisions concerning major household purchases, a significant 70.5% of couples involve the wife either alone or jointly with the husband. This high participation rate suggests that many couples recognize the importance of collaborative input in significant financial decisions. However, almost a third of households (29.5%) still have the husband deciding on these matters alone. When it comes to healthcare decisions, women's influence is even more pronounced, with 88.8% of wives participating alone or jointly in decisions regarding the health of their families. Conversely, only a little bit over a tenth of households report the husband as the sole decision-maker for healthcare. The data indicates that in the majority of cases (80.1%), decisions about the number of children are made jointly with the husband or either by the wife alone, suggesting a significant level of female involvement or shared decision-making in family planning. On the other hand, in 19.9% of the couples, the husband alone makes this decision.

A composite decision-making score, summarizing decision-making influence across these various domains, shows that while 26.5% of couples report low decision-making influence for wives, a similar proportion (24.7%) falls into the moderate category. Almost half of the couples have high decision-making participation from the wife.

Table 2

Percent (%) distribution of Socio-Demographic Differences and Decision-Making Dynamics Among Spouses, Rural Ethiopia, 2022
	Number	%
Spousal socio-demographic differences
Age difference between spouses
Husband < 5 years older or younger	349	16.42
Husband 5–9 years older	1,249	58.78
Husband 10 + years older	527	24.8
Mean age difference (95% CI)		7.6 (7.4–7.8)
Education difference between spouses
Both have no education	131	6.16
Husband more educated	771	36.28
Wife more educated	526	24.75
Both have same education level	697	32.8
Employment/work differences between spouses
Both are farmers, no other job	1,546	72.75
Husband has off farm employment	293	13.79
Wife or both have off farm employment	286	13.46
Decision making dynamics
Who makes decision on how to spend money ?
Wife alone /jointly	1168	55.0
Husband alone	955	45.0
Who makes decision on big household purchases?
Wife alone /Jointly	1496	70.5
Husband alone	626	29.5
Who makes decision on health care of the family ?
Wife alone /Jointly	1885	88.8
Husband alone	237	11.2
Who makes decision on the number of children ?
Wife alone /Jointly	1682	80.,1
Husband alone	419	19.9
Summary composite decision making score
Low	563	26.5
Moderate	524	24.7
High	1035	48.8

Spousal Socio-Demographic Differences, Decision-Making, and Contraceptive Use

The results in Table 3 offer insights into the relationship between socio-demographic differences, decision-making dynamics between spouses, and modern contraceptive use, as examined across three separate models. In Model 1, which adjusts for women's age, education, religion, number of children ever born, and husband's age and education, significant associations with contraceptive use were found in relation to age and education differences between spouses. Couples where the husband was at least 10 years older than the wife had 31% lower odds of using modern contraceptives (AOR: 0.69; CI: 0.52–0.92) compared to couples with a smaller age difference (reference group: <5 years). Education differences highlighted that those wives who were more educated than their husbands had a 69% higher likelihood of using modern contraceptives (AOR: 1.69; CI: 1.11–2.58) compared to households where both partners lacked education. Similarly, couples with the same educational level showed increased odds of contraceptive use (AOR: 1.76; CI: 1.17–2.65). Model 2 incorporated decision-making dynamics in addition to all the variables included in Model 1. In this model, the significant influence of age and education differences between spouses on contraceptive use persisted. Regarding decision-making practices, the wife's involvement or joint decision-making in family money spending resulted in higher contraceptive use compared to the husband making decisions alone (AOR: 1.94; CI: 1.55–2.41). Decision-making on healthcare and the number of children also showed similar trends. Model 3 added summary decision-making score upon Model 1 while disregarding individual decision-making scores. As findings in the two models, age and education differences also remained significant predictors of contraceptive use. The summary decision-making score found to be associated with contraceptive use in t hat women who scored the highest in decision-making scores were 91% more likely than those score low to practice contraception (AOR: 1.91: CI: 1.37–2.63).

In summary, across the three models, several consistent trends emerged. A larger age gap between spouses, particularly when the husband is much older, consistently reduced the likelihood of contraceptive use. Educational disparities, specifically those favoring the wife, increased contraceptive use, while parity in education also remained a significant predictor. The most significant finding was the strong association between women's involvement in decision-making and contraceptive use. Women's participation in family money spending, major household purchases, healthcare, and family planning decisions were consistently linked with higher contraceptive use in all three models.

Table 3. modern Contraceptive Prevalence Rate (mCPR) (%) by spousal characteristics; and multivariate logistic regression adjusted odds ratio (AOR), and 95% confidence interval (CI) in the estimation of spousal differences in socio-demographics and decision making as factors influencing modern contraceptive use among married adolescents (15-19 years), rural Ethiopia, 2022

	mCPR (%)	Model 1			Model 2			Model 3
		AOR	95% (CI)		AOR	95% (CI)		AOR	95% (CI)
		AOR	Lower	Upper	AOR	Lower	Upper	AOR	Lower	Upper
Age difference between spouses
Husband < 5 years older or younger (ref)	40.7	1			1.00			1.00
Husband 5-9 years older	40.6	1.02	0.80	1.30	0.97	0.76	1.25	1.04	0.77	1.41
Husband 10+ years older	31.5	0.69	0.52	0.92	0.68	0.51	0.91	0.71	0.50	2.39
Education difference
Both have no education (ref)	29.0	1.0			1.00			1.00
Husband more educated	34.6	1.30	0.86	1.95	1.11	0.73	1.69	1.26	0.78	2.03
Wife more educated	41.4	1.69	1.11	2.58	1.40	0.91	2.16	1.45	0.89	2.39
Both have same education level	41.9	1.76	1.17	2.65	1.57	1.11	2.51	1.65	1.12	2.67
Employment/Work differences
Both are farmers, no other job (ref)	39.0	1.0			1.00			1.00
Husband has off farm employment	40.3	0.92	0.75	1.14	0.89	0.71	1.12	0.81	0.60	1.11
Wife or both have off farm employment	42.0	1.12	0.87	1.46	0.87	0.68	1.17	1.03	0.76	1.40
Decision on family money spending
Wife alone /jointly (ref)	44.9				1.00
Husband alone	30.4				1.94	1.55	2.41
Decision on big household purchases for the family
Wife alone /Jointly (ref)	39.8				1.00
Husband alone	35.1				0.89	0.74	1.08
Decision on health care of the family
Wife alone /Jointly (ref)	39.8				1.00
Husband alone	27.4				1.42	1.02	1.98
Decision on the number of children
Wife alone /Jointly (ref)	40.2				1.00
Husband alone	31.5				1.35	1.10	1.72
Summary decision score (score)
Low (ref)	29.1							1.00
Moderate	32.1							1.14	0.81	1.62
High	46.3							1.91	1.37	2.63
AOR= Adjusted odds ratio; ref =reference category Models (1-3): adjusted for women’s age, women’s education, number of children ever born, husband’s age, husband’s education

This study emphasizes the influence of socio-demographic differences and decision-making dynamics between spouses on contraceptive use among married female adolescents in rural Ethiopia. The findings highlight the significant impact of spousal characteristics, particularly age difference, education level, and power distribution in decision-making, on family planning outcomes for young married women.

The observed link between substantial spousal age gaps and lower contraceptive use aligns with existing research from sub-Saharan Africa, which shows that age-related power dynamics often affect family planning decisions [10, 15–17]. Women married to much older men are less likely to use contraceptives, likely due to the power imbalance inherent in these relationships [15, 17, 18]. Studies have noted that in many sub-Saharan African contexts, an age gap of 10 years or more often reinforces traditional gender roles, where older husbands hold more decision-making power, limiting younger wives' autonomy in reproductive health decisions, including contraceptive use [17]. Similar trends have been documented in South Asia, where younger wives with older husbands often face reduced agency in making health decisions, including family planning [5]. Overall, the findings suggest that large age gaps in marriages can impede contraceptive use, particularly in cultures with strong traditional gender norms.

This study also reinforces the critical role of education in determining contraceptive use, a conclusion supported by a substantial body of existing research. Married female adolescents with higher education levels were significantly more likely to use modern contraceptives, with the highest usage among those who had completed grade 10 or higher. Couples with similar education levels were more likely to practice contraception, indicating that educational parity fosters mutual decision-making and empowerment. Interestingly, when wives were more educated than their husbands, contraceptive use was higher. In rural Ethiopia, where educational attainment remains low, this dynamic may create a supportive environment for educated women to exert influence within their marriages. As educational disparities continue to narrow, particularly in rural areas, the positive impact of female education on contraceptive use is likely to become even more pronounced, contributing to improved reproductive health outcomes [20]. This trend reflects broader patterns observed across other African countries, where higher educational attainment is associated with increased contraceptive prevalence [21–23].

Additionally, this study sheds light on the role of decision-making dynamics within marriages, particularly their impact on contraceptive use among married female adolescents in rural Ethiopia. Women’s involvement in decision-making, especially in areas like household spending, healthcare, and family size, is strongly correlated with higher contraceptive use. This aligns with existing literature that highlights the importance of female empowerment and joint decision-making in improving reproductive health outcomes [24–27]. In patriarchal societies, when husbands dominate decision-making, particularly regarding family size, contraceptive use tends to be lower, as women often lack the agency to influence decisions that directly impact their reproductive health [28]. These findings are consistent with studies in Asia, including rural India and Bangladesh, where increasing women’s decision-making power has significantly enhanced contraceptive use and other reproductive health outcomes [29, 30]. In the Ethiopian context, this study adds to the existing body of research by specifically focusing on married female adolescents and quantifying the impact of decision-making in specific areas, such as healthcare and household expenditures [31].

One of the key strengths of this study is its focus on married female adolescents, a group often overlooked in family planning research. Unlike previous studies, our research specifically examines spousal socio-demographic differences and decision-making dynamics in this demographic, areas less explored in the literature. Additionally, the study’s robust sample size and use of standardized sampling methodologies strengthen its findings. However, one of the limitations include the reliance on wives' reports for husbands' socio-demographics and decision-making related information, which may introduce reporting bias. However, studies that examine the accuracy of spouse-reported data suggest that wives generally provide reasonably accurate information about their husbands despite some discrepancies [32, 33]. The cross-sectional design nature of our study precludes establishing causality. The results reflect associations between variables rather than cause-effect relationships. Furthermore, the study is limited to rural Ethiopian communities and may not be fully generalizable to urban settings where socio-cultural norms and economic structures differ.

This study identifies crucial programmatic priorities for improving contraceptive use among married female adolescents in rural Ethiopia. The findings highlight the need to address power imbalances in marriages with significant spousal age gaps, as these often limit young wives' autonomy in family planning decisions. The strong association between female education and contraceptive use underscores the importance of expanding educational opportunities to enhance reproductive health knowledge and informed decision-making among this demographic. Additionally, promoting joint decision-making within households, particularly regarding healthcare and family size, is vital. Male involvement in family planning, facilitated through couple counseling, is also crucial for fostering joint decision-making. A multifaceted approach that addresses power dynamics, encourages male involvement, expands education, and supports couple counseling is key to the success of family planning programs among married female adolescents in rural Ethiopia.

AOR, Adjusted Odds Ratio; APHI, Amhara Public Health Institute; CI, Confidence Interval; CIFF, Children’s Investment Fund Foundation; FMOH; Federal Ministry of Health, mCPR, Modern Contraceptive Prevalence Rate; PPS, Probability Proportionate to Size; PSI; Population Service International, PSU, Primary Sampling Unit; RISE, Roadmap for Integrating Smart Start in Ethiopia

Ethical approval and consent to participate

The study received ethical approval from the Amhara Public Health Institute (APHI) ethical board under approval number NoH/R/T/T/D/5/4. Informed verbal consent was obtained from participants, as approved by the APHI ethical board, and written consent was not required. Data collectors were specifically trained to emphasize the importance of informed consent, voluntary participation, and maintaining the privacy and confidentiality of respondents. No remuneration was provided to the women who participated. All data were securely stored, analyzed, and handled to ensure confidentiality. The study methods adhered to the ethical principles outlined in the Helsinki Declaration for medical research involving human subjects [34].

Consent to publish

Not applicable

Availability of data and materials

The raw data used in this study is not publicly available due to ethical restrictions. However, the raw data can be available upon request.

Point of contact: Dr. Yared Mekonnen, Mela Research, P.O. Box 34422, Addis Ababa, Ethiopia; E-mail: [email protected]

Competing interests

The authors declare no conflicts of interest.

Funding

Not applicable

Authors’ contributions

YM, TH, EW prepared the study protocol, designed the study, analyzed the data and wrote the manuscript. KY contributed to data collection monitoring, data quality assurance, verification, data management. All authors approved the final manuscript.

Acknowledgments

We sincerely thank the study participants for agreeing to provide valuable information. We also appreciate the technical and administrative support from the Ethiopia Federal Ministry of Health, as well as the Oromia, Amhara, and SNNP regional health bureaus. The survey zones, Woredas, and Kebeles facilitated fieldwork and data collection. The study's timely completion was made possible by the hard work and diligence of the field team and the support from Mela Research's central office.

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The authors declare no competing interests.

The Role of Spousal Socio-Demographic Differences and Decision-Making Power Dynamics on Contraceptive Use Among Married Female Adolescents in Rural Ethiopia

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Version 1

Abstract

Background:

Methods:

Results:

Conclusion:

Figures

BACKGROUND

METHODS

Data Sources

Study Variables

Method of Analysis

RESULTS

Characteristics of married female adolescents and their spouses

Contraceptive use among married female adolescents

Spousal socio-demographic differences and decision-making dynamics

Spousal Socio-Demographic Differences, Decision-Making, and Contraceptive Use

DISCUSSION

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1