Community-level variations in contraceptive use among women in union and those not in union: a comparative study of 35 sub-Saharan African countries.

backgroundGlobal fertility rates are nearing replacement levels, yet Sub-Saharan Africa continues to experience high fertility with slow declines. Modern contraceptive use is critical to fertility reduction, but comparative multi-country analyses remain limited, particularly for women not in union (never or formerly married). This study compares contraceptive use between women in union and those not in union across the region.

methodsPooled Demographic and Health Survey (DHS) data from 35 sub-Saharan African countries were analyzed to examine the determinants of modern contraceptive use. We incorporated sampling weights to ensure representativeness, and the final weighted analytic sample comprised 472,811 women. A multilevel random-intercept logistic regression model was employed to account for the hierarchical data structure, with women nested within communities and countries. Both individual- and community-level covariates were included, and analyses were stratified by marital status (in union, never married, and formerly married). Contextual variations in contraceptive use were assessed by estimating intraclass correlation coefficients (ICCs) at the community and country levels. To assess changes in community-level heterogeneity over time, multiple DHS survey waves were analyzed separately for each country, and intraclass correlation coefficients (ICCs) were synthesized using a meta-analytic approach.

resultsThe study found that among women in union, older women are less likely to use contraceptive methods, whereas among women not in union, older women are more likely to use contraceptives. Higher educational attainment, access to media, exposure to family planning information, better household socioeconomic status, and women's employment are positively associated with contraceptive use, regardless of marital status. Beyond individual and household factors, community-level variables, such as poverty rates, literacy levels, and health coverage, are also significantly associated with modern contraceptive use. Additionally, the study revealed substantial variation in contraceptive use across countries and communities. Countries with low contraceptive prevalence tended to show greater disparities in usage, whereas those with higher prevalence exhibited more consistent and uniform contraceptive use across communities.

conclusionWhile various individual and community-level factors are associated with contraceptive use in sub-Saharan Africa, there are significant contextual variations both across and within countries. Nations with low levels of modern contraceptive use, particularly in Western and Central Africa, often show inconsistent coverage across communities. In contrast, countries with higher contraceptive prevalence, particularly in Southern Africa and, to some extent, Eastern Africa, tend to exhibit more consistent and equitable coverage across their communities.