title: Trends in contraceptive use and distribution of births with demographic risk factors in Ethiopia: a sub-national analysis.
abstract: BACKGROUND
  Evidence shows that family planning contributes to the decline in child mortality by decreasing the proportions of births that are considered high risk. The main objective of the present analysis was to examine the trends in use of modern contraceptives and their relationship with total fertility rate (TFR) and distribution of births by demographic risk factors as defined by mother's age, birth interval, and birth order at the sub-national level in Ethiopia.
  
  
  METHODS
  Analyses used data from three Demographic and Health Surveys in Ethiopia (2000, 2005, and 2011), which are nationally representative data collected through questionnaire-based interviews from women 15-49 using a stratified, two-stage cluster sampling. First, we examined the trends of and relationship between TFR (in the 3 years before each survey) and modern contraceptive use among currently married women in all administrative regions over the time period 2000-2011 using linear regression analysis. We also examined the relationship between birth risks and under-five mortality using the no-risk group as a reference. Finally, multiple logistic regression analysis was performed to estimate the relationship between the effect of being a resident in one of the regions and having an avoidable birth risk (which includes births to mothers younger than 18 and older than 34 years, birth interval of less than 24 months and birth order higher than third) after adjusting for select covariates including wealth, educational status, residence, religion and exposure to family planning information.
  
  
  RESULTS
  Sub-national-level regression analysis showed an inverse relationship between modern contraceptive use among married women and the TFR, with an average decrease of TFR by one child per woman associated with a 13 percentage point increase in modern contraceptive use between 2000 and 2011. A high percentage of births in Ethiopia (62%) fall in one of the risk categories (excluding first births), with wide regional variation from 55% in Gambela to 72% in the Somali region. The multivariate analysis showed women living in the Somali, Afar and Benishangul-Gumuz regions had significantly higher odds of having avoidable birth risk compared to those in Addis Ababa after controlling for observed covariates. The trend analysis showed there was a significant drop in the proportion of births from women above 34 years between 2000 and 2011. There was no significant decline in births to women less than 18 years between 2000 and 2011.
  
  
  CONCLUSIONS
  A majority of births in Ethiopia fall in one of the risk categories, with substantial region-to-region variation in the percentage of births with avoidable risk factors, Somali and Afar having the highest burden. The analysis indicated that births in the three regions had significantly higher odds of having one of the avoidable risk factors compared to Addis Ababa, and we suggest family planning programmes need to identify differentials of modern contraceptive use at the sub-national level in order to better address coverage and equity issues.
authors.affiliation: Department of Reproductive Health and Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia; solomonshiferaw@gmail.com.
authors.forename: Solomon
authors.initials: S
authors.lastname: Shiferaw
authors.affiliation: UNFPA - East and Southern Africa Regional Office, Johannesburg, South Africa.
authors.forename: Muna
authors.initials: M
authors.lastname: Abdullah
authors.affiliation: Mela Research PLC, Addis Ababa, Ethiopia.
authors.forename: Yared
authors.initials: Y
authors.lastname: Mekonnen
authors.affiliation: Institut Supérieur des Sciences de la Population, Ouagadougou University, Ouagadougou, Burkina Faso.
authors.forename: Abdoulaye
authors.initials: A
authors.lastname: Maïga
authors.affiliation: Department of Demography and Social Statistics, Obafemi Awolowo University, Ile Ife, Nigeria.
authors.forename: Akanni
authors.initials: A
authors.lastname: Akinyemi
authors.affiliation: UNICEF, New York, NY, USA.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
authors.affiliation: United Nations Population Fund (UNFPA), New York, NY, USA.
authors.forename: Howard
authors.initials: H
authors.lastname: Friedman
authors.affiliation: Federal University of Pelotas, Capão do Leão, Brazil.
authors.forename: Aluisio J D
authors.initials: AJ
authors.lastname: Barros
authors.affiliation: United Nations Population Fund (UNFPA), New York, NY, USA.
authors.forename: Sennen
authors.initials: S
authors.lastname: Hounton
mesh_terms: D000293:Adolescent; D000328:Adult; D001721:Birth Intervals; D001723:Birth Rate / Q000639:trends; D003267:Contraception / Q000706:statistics & numerical data*; D003268:Contraception Behavior / Q000639:trends*; D003906:Developing Countries; D005002:Ethiopia; D005260:Female; D006306:Health Surveys; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D011247:Pregnancy; D012307:Risk Factors; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Ethiopia; distribution of birth risks; modern contraceptive use; total fertility