Contraceptive use and associated factors among sexually active female adolescents in Atwima Kwanwoma District, Ashanti region-Ghana

Introduction Unintended pregnancies and adolescent childbearing are on the increase in Sub-Saharan Africa. In Ghana, 14% of adolescents aged 15-19 are already mothers or pregnant with their first child. Most of these pregnancies are associated with poor outcomes such as miscarriages, stillbirths, unsafe abortions and other complications that might result in infant or mortality. In addition, sexually-active adolescents (16-19 years) are at higher risk of contracting STIs. Evidence suggest that contraceptive use help reduce fertility rate and adolescent reproductive health. This study therefore sought to understand the magnitude and associated factors that influence female adolescents' use of contraceptive in the Atwima Kwanwoma District, Ghana. Methods A descriptive and analytic cross-sectional study design was used for this study. Using a structured questionnaire, data were collected from randomly sampled 200 sexually active female adolescents; aged 16-19 for a three month period; June to September 2017. The questionnaire elicited data on the socio-demographic characteristics of respondents, their knowledge and perception, use of contraceptives and factors influencing their contraceptive use. Data were analyzed using STATA version 12.1 software. Results Ninety-five percent of the respondents exhibited some knowledge about contraceptives, but this high knowledge did not translate into its use as the prevalence rate was 18%. Condom was the most widely used contraceptive (33%) and perceived side effects of contraceptives was found to be the main reason for not using the contraceptives (53.66%). Marital status and the participants who were staying with both parents were found to be associated with contraceptive use with their p-values of 0.023 and 0.002 respectively. Conclusion Considering the fact that contraceptive knowledge does not necessarily translate into use, further studies (qualitative), are needed to understand why high knowledge levels are not associated with high usage patterns.


Introduction
It is anticipated that, the world population will reach 8.5 billion in 2030, 9.7 billion in 2050 and 11.2 billion by 2100 [1]. Much of the population growth occurs in the least developed parts of the world, which is Sub-Saharan Africa and Asia. The additional 2.4 billion people expected to be added to the global population between 2015 and 2050; 1.3 billion will be added in Africa [1]. According to [2] Ghana's population increased by 30.4% from 18,912,079 in 2000 to 24,658,823 in 2010. This rapid population growth causes constraints on future economic growth and the ability of a country to provide for the welfare of its citizens and achieve its national development objectives. To help address the issue of rapid population growth, strategies need to be put in place to reduce the fertility rate. A major method of reducing fertility rate is through the use of contraceptives [3]. The Government of Ghana and its development partners as well as international NGOs have been implementing activities to improve the use of contraceptives for several decades.
Although some progress has been made especially in the area of knowledge, a large number of Ghanaian female adolescents rarely use modern contraceptives [3]. Education on contraceptives need to be intensified among adolescents to enable them protect themselves from unplanned pregnancies, unsafe abortions and STIs.
In Ghana, 14% of adolescents aged 15-19 are already mothers or pregnant with their first child [4]. Despite the numerous economic, social and health challenges of adolescent childbearing, several unmarried adolescents in the Atwima Kwanwoma District have two or more children and some others who use many kinds of concoctions to induce abortion. However, the incidence of unwanted pregnancy and STI acquisition among adolescents can be reduced by effective access and use of modern contraceptives [5]. With a very low (13%) contraceptive prevalence rate among female adolescents, the researcher therefore sought to understand the magnitude and the associated factors influencing contraceptive use among this population in the Atwima Kwanwoma District. In doing so, the female adolescents' knowledge about contraceptives, perception about contraceptive use and the factors affecting the utilization of contraceptives were determined. Effective application of this study's recommendations will improve the reproductive health of adolescent girls in the country, which will increase their contribution to the social and economic development of the country.

Methods
A descriptive, analytical cross sectional study design was used in carrying out this study. The study was conducted in the Atwima Kwanwoma District, one of the 27 districts in the Ashanti region of Ghana. The district has four sub-districts and 58 communities.
According to the District Health Management Team (DHMT), the district has a population of 103004 with a growth rate of 3% per annum. Most of the population are engaged in agriculture (62.6%).
Health care services are being delivered in 11 health institutions in the district with a total capacity of one hundred and twenty-three health personnel. These institutions are five (5) health centres, two adolescents between the ages of 16-19 years who were identified as sexually active and were residents in the Atwima Kwanwoma District for at least 6 months recruited for the study. However, adolescents within the age group of 16 and 19 who were not engaged in sexual activity and those who did not consent to participate in the study were excluded. A simple random sampling technique was applied to select sexually active female adolescents between the age groups of 16 to 19. Respondents were selected irrespective of their level of education. Three (3) communities were randomly selected from each of the four Sub-districts and then another random sampling of ten already labeled households from each of the twelve (12) selected communities was done. Any selected household which was found not to have adolescents aged 16 to 19 was replaced by another randomly sampled household. Once a household was selected, all adolescents aged 16 to 19 who consented or whose parents consented were considered for the study. In selecting the communities, the names of all the communities in each of the subdistricts were written on pieces of paper and folded (a sub-district at a time). The folded papers were kept in a plastic container and were well shaken to adequately mix them up. A volunteer was made to pick one folded paper at a time and the names of those communities picked constituted the chosen communities for the study. This same process was used in selecting the households.
Sample size: The sample size was determined with the following factors in mind; estimated prevalence of contraceptive use among female adolescents in the Atwima Kwanwoma District which was Page number not for citation purposes 3 13%, the desired level of confidence which was pegged at 95% (a standard value of 1.96) and an acceptable margin of error which was 5% with a standard value of 0.05. Using the sample size calculation formula below, a sample size of 174 was calculated.
Where N = minimum sample size required; Z = confidence level at 95% p = estimated proportion of female adolescents using contraceptives q = 1-p e = margin of error at 5% N = (1.96) 2 x 0.13(1-0.13) (0.05) 2 N = 174 A non-response rate of 10% was calculated and added, that made the sample size 191 and this was rounded up to the nearest hundred. Therefore, a total sample size of 200 was used. A structured questionnaire containing closed ended questions was used to collect the data in twelve communities in the Atwima Kwanwoma District after it was pre-tested. The questionnaire had sections that elicited the socio-demographic characteristics of participants, their knowledge and perception about the use of contraceptives. Moreover, data on whether participants had ever used contraceptive, the type of contraceptive used and factors influencing their usage were also obtained. The research team after explaining how to answer the items on the questionnaire administered them to eligible participants who consented or assented to partake in the study. Participants who could read and write answered the items themselves. For those who could not, the questions were explained to them in a language they understand for them to answer. The questionnaire was however, pre-tested on ten   Table   2.
Perception on contraceptive use: More than half of respondents (52.0%) reported that use of contraceptives among adolescents does not promote promiscuity, followed by 33.0% who believe it does. As shown in Table 3 below, participants who perceived that contraceptives have health risks constituted the majority (70%) Page number not for citation purposes 4 whilst 10% disagreed to that assertion. Regarding the process of acquiring a contraceptive, most of the respondents (47.0%) did not perceive the process of contraceptive acquisition as embarrassing.
Also most of the respondents (39.0%) disagreed that contraceptives use is only the responsibility of women while (13.0%) were indecisive. With religion prohibition of contraceptive use, majority (39.0%) agree to it whilst 7.0% strongly disagree.
Adolescents contraceptive use: An overwhelming majority of the respondents (82.0%) did not use contraceptives. Also, among the respondents who use contraceptives, a significant proportion of them (33.3%) use condoms with 11.1% of respondents using pills.
Out of the 164 respondents who do not use any type of contraceptives, majority (53.66%) stated that the side effects of contraceptive accounted for their non-usage whilst 3.66% attributed their non-usage to inconvenience associated with contraceptive use (Table 4). Association between socio-demographic characteristics of the respondents and the use of contraceptives: Table   6 indicates the use of Chi-square to test for the association between socio-demographic characteristics of respondents and contraceptive use among sexually active female adolescents. From the findings, there were only two variables which were statistically associated with contraceptive use; marital status and the person whom respondent stays (alone, with partner or with parents) with p-values as 0.023 and 0.002 respectively.

Discussion
The study assessed knowledge and perception about contraceptive and as well the factors that influence contraceptive use among sexually active female adolescents who were between the ages of 16-19 years at the Atwima Kwanwoma District.

Respondents' knowledge on contraceptives:
The results of the study revealed that most of the participants (96%) had heard about contraceptives. This however, differs from findings of a study by [6] which assessed the knowledge and practice of contraception among school going children in India. From their study, the percentage of participants who were unaware of contraceptives was higher (51.0%) than those who had heard something about contraceptives (49.0%). It was also discovered in this study that most of the participants had high knowledge on contraceptives; as 95.0% of them could tell how they understood contraceptives and were also able to mention at least a method of contraceptive and some of its benefits. This probably may be because more than half of the participants (52%) had above Primary School education. It was noted that condom as a method of contraception was known by majority of the respondents (30.0%) followed by injectable (25.0%). This finding is similar to that of a study by [7] which assessed the knowledge of contraceptive methods among adolescents and revealed that condoms were the most common (72%) contraceptive method known by participants.

Use of contraceptives:
The study showed that a small percentage of the participants (18.0%) had ever used contraceptive. This is far lower than the findings of a study by [8] at Asella Preparatory School in Ethiopia. The prevalence rate for contraceptive use among their participants was 61.0%. However, a study conducted by [9] revealed that contraceptive use among adolescents in Nairobi was lower than the current study ( contraceptive use make adolescents promiscuous, therefore, when they use them they will be tagged as bad girls and will also make them careless. It was further identified in this study that, 70.0% of the participants perceived contraceptives to be associated with fibroid and infertility as well as side effects like menstrual disorders.
Similar results was discovered by [14]. In their study, perceived health risks including effects on menstruation, weight and future fertility were shown to be primary barriers to contraceptive use.

Conclusion
The study revealed that the prevalence rate of contraceptives among sexually active female adolescents at the Atwima Kwanwoma  Table 1: Socio-demographic characteristics of the respondents