Abstract
OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.