Contraception decision-making autonomy among adolescent girls and young women in Uganda

Globally, teenage pregnancies continue to be a major public health problem, particularly in low- and middle-income countries¹. Estimates show that about 16 million girls aged 15 to 19 years and two million girls under the age of 15 give birth every year¹ with an estimated 13% of adolescent girls and young women globally believed to have given birth to their first baby before age 18. In Uganda, teenage pregnancy rates have stagnated at 24–25% since 2006, with higher rates in rural compared to urban areas and among adolescent girls with no or primary education compared to those with secondary or higher education². Teenage pregnancies have implications on the educational opportunities, population growth and ill-health of women³, stressing the need for interventions aimed at reducing them. Contraception is an effective approach to reduce teenage and unwanted pregnancies⁴. However, many adolescent girls and young women (AGYW) lack access to modern contraceptives and continue to have an unmet need; i.e., although many AGYW would like to use contraception to delay or space-up childbirths, many of them, especially in low- and middle-income countries, are not using any method of contraception^5,6.

Uganda has the lowest contraceptive prevalence rate in East Africa among in union/married women of reproductive age⁵ and data from the 2022 Uganda Demographic and Health Survey show that only 21.8% of 15–19-year-old married adolescent girls and 37.2% of 15–19-year-old sexually-active unmarried adolescent girls use a modern contraceptive method². Several factors contribute to the suboptimal use of contraceptive methods among sexually-active adolescent girls and young women in Uganda. These factors can be grouped into individual^6,7,8,9, environmental^{7,10,11,12,13} and gender-related factors^14,15. Regarding the individual-level factors, Ahinkorah et al.⁷, showed that adolescent girls aged 15–19 years were less likely to use modern contraceptives compared to those aged 20–24 years. Other studies also show that issues related to awareness, knowledge, decision-making power about contraception⁸, fear of contraceptive side effects, contraceptive preferences and acceptability of available contraceptive methods impact contraceptive uptake by AGYW^6,9.

Several environmental factors, including strict national guidelines, few service providers with the required level of training, a limited range of available contraceptive methods⁷ and high costs of modern contraceptive services^10,11,12,13 also affect uptake. Additionally, previous studies have shown that extreme gender inequities, husband’s Quranic education, gender ideology, attitudes towards violence against women-where the male partners are the ones in charge of contraceptive decision^14,15 affect contraceptive uptake.

Provision of self-care-oriented family planning (FP) services is an innovative strategy that can increase reproductive autonomy (a key reproductive empowerment construct) among young women, with the potential to reach young women with contraception without total reliance on the conventional health sector¹⁶. The term ‘self-care-oriented FP’, as used in this paper, refers to the use of FP methods by a person at risk of getting pregnant, with minimal or no support from a health provider. Self-care products, such as emergency contraceptive pills, condoms, and self-injection injectables have had a considerable effect on young people’s health¹⁷. These products have the potential to lessen unintended pregnancies by overcoming access barriers to FP services such as prohibitive financial costs associated with transportation and concerns around confidentiality^13,18. In Uganda, short-term contraceptive methods with the potential for self-care (injectables, oral pills, emergency contraception and condoms) are the most widely used methods among young women who are currently married or sexually-active but unmarried^2,19. In addition, some self-care-oriented FP methods such as emergency contraception, oral pills and condoms can be purchased and used without the support of a health provider²⁰. Self-care-oriented FP can easily be delivered through the existing channels preferred by young people in their respective communities, such as the private sector (drug shops, pharmacies)²¹ and through community-based models such as community health workers and peer educators²². These approaches have the potential to overcome inequities based on age, education and geographic coverage due to the increases access at community level.

While self-care-oriented FP services can potentially help AGYW to achieve reproductive autonomy²³, the ability to use self-care options can be influenced by one’s reproductive autonomy which is also influenced by several factors such as empowerment for contraception decision-making²⁴, partner involvement, the health system and socio-cultural issues. Women who are empowered to make reproductive health decisions are often in position to use contraceptives when compared to those who are not²⁵. In many sub-Saharan African countries, research has shown that women’s right to health including sexuality has been infringed due to socio-cultural barriers where most decisions are taken by men^24,26. Some studies have shown that the likelihood of using modern contraceptives increases when both the husband and wife jointly participate in decision-making²⁷. However, it is not clear to what extent women maintain their autonomy during joint decision-making. Moreover, in many instances, the male partners are in charge of the final decision about FP use, while women choose the method²⁵.

While reproductive autonomy is recognized as a component of self-care, there is a gap in evidence on decision-making with regard to method choice among AGYW and there is a dearth of information on their level of interest in self-care-oriented FP methods. This study, therefore, assessed contraception decision-making autonomy and its associated factors among sexually-active AGYW who were current users of contraception as well as AGYW’s interest in self-care-oriented FP services.

Characteristics of adolescent girls and young women

Table 1 (column 2) shows the characteristics of 2109 sexually-active AGYW included in this analysis. Fifty-eight per cent (n = 1216) of the AGYW were aged 20–24 years, 64.7% (1385) were married or in a sexual relationship but not married, 51.8% (n = 1092) had post-primary education; 70.9% (n = 1495) were out-of-school while 45.5% (n = 959) could not read text prepared in their local language. Thirty-three per cent (n = 692) of AGYW lived with a husband/sexual partner; 23.7% (n = 500) lived with both parents, 24.6% (n = 518) lived with only one parent while 4.6% (n = 97) lived alone or with their friends. Fifty-two per cent (n = 1091) owned a mobile phone.

Current contraceptive use

Table 1 (columns 3 and 4) also shows the percentage of ever and current users of contraception, stratified by selected socio-demographic characteristics. Overall, 59.1% (n = 1246) of AGYW had ever used any form of contraception while 54.8% (n = 1155) reported current use of contraception. Current contraceptive use increased with increasing age from 40% (n = 70) among those aged 10–16 years to 59.4% (n = 722) among those aged 20–24 years, and was higher among those in a sexual relationship but not married (61.1%, n = 446) and those that were currently married (55.9%, n = 355) compared to those that were widowed or separated/divorced. Of current contraception users, 80.2% (n = 926) were using modern contraceptive methods while 19.8% (n = 229) were using traditional methods. Among current users, the most currently used modern FP methods were: male condoms (39.8%, n = 460), injectable injection (27.3%, n = 318), contraceptive implant (14.0%, n = 162) and contraceptive pills (6.0%, n = 69) while the most commonly used traditional method was withdrawal method (11.4%, n = 132). Only 2.2% (n = 25) reported current use of emergency contraception.

Contraception decision-making processes

Table 2 shows the percentage of current contraceptive users stratified by the type of person who made the decision about their use of contraception and background characteristics. In response to the question, ‘Would you say that using contraception is mainly your decision, mainly your husband/partner’s decision or did you both decide together?’ 26.8% (n = 310) reported that it was mainly the respondent’s decision, 8.7% (n = 100) reported that the decision was made mainly by the husband/partner while 64.5% (n = 745) reported that the decision to use contraception was a joint decision between the respondent and their husband/partner. Across all socio-demographic characteristics, the decision to use contraception followed a similar pattern. For instance, while 22.1% (n = 139) of those with post-primary education reported that use of contraception was mainly their decision, the percentage of those reporting that the decision was made jointly between and their partners was three times higher (69.8%, n = 440). Similarly, while 22% (n = 74) of in-school AGYW reported that the use of contraception was mainly their decision, the percentage of those reporting that the decision to use contraception was made jointly was three times higher (69.7%, n = 234).

Table 3 shows the percentage of current contraceptive users stratified by the person who made the decision on the specific FP method that they were currently using. A majority of current users reported that they made the decision on the specific FP method to use jointly with their partners (59.2%, n = 684). Only 4.2% (n = 49) reported that it was the partner that made the decision while 27.8% (n = 321) reported that they made the decision on their own. Interestingly, the percentage of those who made the decision on their own increased with increasing age (from 20% [n = 14] among those aged 10–16 years to 30.1% [n = 217] among those aged 20–24 years) but decreased with increasing education and ability to read text prepared in the local language. In-school current contraceptive users (17.9%, n = 60) were nearly two times less likely to report that they made the decision on the specific FP method to use on their own than their out-of-school counterparts (31.9%, n = 261).

Table 4 shows the percentage of current contraceptive users stratified by whether or not they discussed the decision to delay or avoid pregnancy with their partners/husbands prior to using their most recent or current FP method. Overall, two-thirds (66.5%, n = 768) of current contraceptive users reported that they discussed the decision to delay or avoid pregnancy with their partners/husbands. Discussing the decision to delay or avoid pregnancy with husband/partner prior to using the current or most recent FP method increased with increasing age (from 54.3% [n = 38] among those aged 10–16 years to 68.4% [n = 494] among those aged 20–24 years) and education level (from 42.3% [n = 11] among those with no education to 69.2% [n = 436] among those with post-primary education). A higher percentage of current contraceptive users who were married (73.8%, n = 262) reported discussing the decision to delay or avoid pregnancy with their male partners than users in other marital-status categories.e out-of-school were two-and-a-half times more likely to report that they discussed the decision to delay or avoid getting pregnant.

Factors associated with contraception decision-making autonomy

Table 5 shows the crude and adjusted prevalence ratios of the factors associated with contraception decision-making autonomy among current contraceptive users. At the bivariate analysis, all variables were significantly associated with contraception decision-making autonomy and were thus entered into the final, multivariable model as potential confounders. After adjusting for these confounders, the factors that remained significantly associated with contraception decision-making autonomy were: discussion with husband/partner prior to the use of contraception (adjusted prevalence rate ratio [adj. PR] = 0.39; 95% Confidence Interval [95%CI]: 0.32, 0.48) and being currently married (adj. PR = 0.74; 95%CI: 0.56, 0.98).

Interest in self-care-oriented family planning

Overall interest in self-care-oriented family planning

Table 6 shows the overall and method-specific level of interest in self-care-oriented FP methods among 2109 sexually-active AGYW, stratified by age-group. To assess the overall level of interest in self-care-oriented FP methods, respondents were asked: ‘Would you be interested in ways to access information on the range of ways or methods that you can use to delay or avoid pregnancy without seeing a provider or a VHT?’ Individuals who responded in the affirmative were then asked about their levels of interest in receiving information on how to access or use specific FP methods. Overall, 57.5% (n = 1213) of all sexually-active AGYW reported that they would be interested in accessing information on or being told about how to use self-care-oriented FP methods.

Interest in specific self-care-oriented FP methods

Overall, interest in specific self-care-oriented FP methods ranged from 70.7% (n = 858) for diaphragm to 85.4% (n = 1036) for safe days method (also known the calendar method). Of all the modern short-acting self-care-oriented FP methods considered, emergency contraception (ECP) had the highest level of stated interest [80.8% (n = 980)]; higher than pills, condoms, and the diaphragm. Also, interest in fertility awareness methods had the highest level of stated interest (safe days method – 85.4% (n = 1036); rhythm – 84.7% (n = 1028)); higher than interest in the other modern FP methods. Across FP methods, the proportion reporting that they were interested in getting information on how to access or use a FP method was slightly lower among those aged 10–16 years but increased with increasing age. However, although interest in getting information on how to access or use self-administered injectable injections was high (79.5%, n = 965), only 8.9% (n = 86) of those who expressed interest in getting information on how to access or use self-administered injectable injections reported that they were willing to self-inject if a provider or member of the VHT showed them how to do it. Willingness to use self-administered injectable injections was slightly higher among those aged 10–16 years (15.4%, n = 10) but decreased to 7.5% (n = 23) among those aged 17–19 years and 8.9% (n = 53) among those aged 20–24 years.

Interest in self-management of FP side effects and bleeding changes

When asked about their interest in self-management of FP side-effects, 86.8% (n = 1053) of AGYW were interested in receiving information on how to manage side effects of FP use without seeing a provider or a member of the VHT. However, only 53.9% (n = 561) of current contraceptive users were told about side-effects of FP methods by a health provider. Regarding interest in self-management of bleeding changes due to FP use, 87.0% (n = 1055) of the respondents expressed interest in receiving information on how to manage bleeding changes as a result of FP use without seeing a provider or a member of the VHT. Interest in self-management of bleeding changes increased with increasing age from 83.5% (n = 76) among those aged 10–16 years to 88% (n = 643) among those aged 20–24 years.

This analysis assessed two primary outcomes: contraception decision-making autonomy and interest in self-care-oriented FP methods. Our findings show that: a) a majority of current contraceptive users jointly made the decision to use contraception with their male partners/husbands; b) only a small proportion of current contraceptive users made the decision to use contraception on their own; i.e., had contraception decision-making autonomy; and c) slightly more than half of AGYW were interested in receiving information on specific self-care-oriented FP options and self-management of FP side effects, with the highest level of interest among modern, short-acting FP methods being for emergency contraception and the highest overall level of interest being for fertility awareness methods. We found that prior discussion with partner about contraception and being currently married were negatively associated with contraception decision-making autonomy. In other words, contraception decision-making autonomy was lower among AGYW who discussed contraceptive use with their male partners than among those who did not – which signifies the role of the male partner in contraception decision-making in this population. Nevertheless, the finding that there is low contraception decision-making autonomy among AGYW suggests a need to increase access to self-care FP options and promote meaningful involvement of the male partner in contraception discussions while allowing women to make the final contraceptive decisions on their own.

Among the sexually-active AGYW, the overall prevalence of current contraception use (i.e. any modern or traditional FP methods used by AGYW to avoid or delay getting pregnant) among sexually-active AGYW was slightly higher (54.8%) than the total national average among sexually unmarried women aged 15–49 years (44.0%)². The use of contraception was higher among those who were not married compared to the married AGYW (61.1% versus 55.9%) and increased with age; lowest among the youngest adolescents aged 10–16 years. These results suggest that younger adolescent girls remain at a great risk of unintended pregnancies and their associated consequences^28,29,30,31. This therefore suggests the need more effective interventions to increase uptake of contraceptives most especially among the younger adolescents. Our study further showed that the proportion of AGYW using a contraceptive method increased with age; this finding could be attributed to increasing agency and reduced vulnerability among the AGYW as they get older³². Unlike the younger adolescents, older AGYW are more mature and knowledgeable about contraception as well as the importance of contraceptive use³³. The most common methods currently used by AGYW were the short-acting methods. This finding is in tandem with the results of the 2022 Uganda Demographic Health Survey². Our findings of higher contraception use among the non-married category compared to the married AGYW could be attributed to the role of patriarchy in a woman’s ability to decide which contraceptive method to use; married women may lose their decision-making autonomy probably due to the 1) cultural expectation of childbearing to prove their fertility and 2) reproductive coercion^1,34.

We found that approximately 1 in 4 AGYW made the decision regarding the current contraceptive method they used on their own with the majority reporting that they made the decision jointly with their partners. This finding is not in tandem with previous studies which show the low involvement of men in contraception use discussions^2,35, although findings from a previous study in Uganda show that joint decision-making was associated with less discontinuation of use³⁶. This suggests that AGYW rely on the male partner to make the decision on which contraceptive method to use. This resonates with the cultural norm which dominates women’s reproductive health decision-making in most low and middle income countries despite a high level of awareness of the various contraception methods by AGYW³⁷. We also found that joint decision-making for contraception is the practice; thereby stressing the importance of programs that bring men on board since most decisions are made jointly^38,39. Programs need to promote couple communication around contraception use and at the same time work to empower women’s decision-making autonomy^39,40.

If well accepted, contraceptive self-care options have the potential to reduce the inequities that propagate poor reproductive health outcomes and decision-making^{41,42,43,44,45}. We found a very high interest in getting information for self-care-oriented contraception options among the AGYW. About seven in ten respondents were interested in getting information for self-care-oriented contraception options including receiving information on how to manage side effects of FP use without seeing a provider or a VHT. This is a very promising finding as it has the potential to by-pass some of the barriers to FP access and use such as, constrained health care providers and infrastructure^46,47. Although our study only inquired about interest in getting more information on the subject matter, previous studies in Uganda and similar settings have found good acceptability and feasibility of self-care specific FP options^40,48,49,50. This finding strengthens the need to promote self-care specific options, including digital options, which could provide information and, in some cases, access to self-care family planning commodities, among AGYW.

Nevertheless, the low contraception decision-making autonomy in this population has implications for the promotion of self-care-oriented family planning, especially with regard to family planning methods that women may want to use and discontinue or change at their own discretion. Empowering adolescent girls and young women to be able to make their own contraceptive decisions is therefore essential for promoting what has come to be known as ‘contraceptive agency’ or women’s ability to make and act on decisions related to when and whether to avoid or delay pregnancy and what, if anything, to do when they are not actively trying to become pregnant⁵¹. Thus, the findings from this study suggest a need for empowering AGYW with the ability to not only make their own independent contraceptive decisions but also the ability to act on those decisions.

This study had a number of limitations and strengths. The cross-sectional nature of this study that relied on self-reported information may have introduced in reporting bias. Furthermore, the study relied on recall of information by the respondents and this could have introduced recall bias, especially on questions that were about the time when an event happened. For instance, while we found that discussion with male partner lowered contraception decision-making autonomy, it is difficult to tell with certainty if the discussion actually happened before or after AGYW had started using their current contraceptive methods. Some AGYW may have forgotten the order in which things happened, and may have, inadvertently reported that the discussion took place before when it happened after they had started using their current/most recent contraceptive methods. However, we think that the clarity in the questions regarding ‘before you started using your recent/current contraceptive method’ could have helped to improve women’s recall about the timing of the discussion. Nevertheless, we acknowledge that the inquiry on the decision-making processes for the recent/current contraceptive method would have potentially benefitted from a detailed description of the joint decision-making process between the couple but this was not explored by our study. In addition, self-reports on interest for information on self-care specific FP options may not always translate into use. Also, if adolescents are interested in self-care but don’t have decision-making autonomy, the interest may not translate into use. Self-care methods avoid certain barriers (such as needing to find a provider) but they do not necessarily avoid the barrier of having to make a decision with a partner. Therefore, not exploring the relationship between self-care method interest/use and decision-making autonomy may also be a limitation to this study.

Our definition of contraception decision-making autonomy could also have been limiting in some way given that we focused on the proportion of AGYW who made the decision to use contraception on their own. We did not assess if some of the women who discussed contraception issues with their male partners actually went ahead to make decisions to use contraception on their own. While our findings show that contraception discussion with partner negatively affected contraception decision-making autonomy, it is also possible that following the discussion, some AGYW may have had the liberty to make the decision on their own. If this was the case, then, our definition could have under-estimated the proportion of AGYW who had contraception decision-making autonomy. Also, given that some contraceptive methods such as male condoms may not require a discussion with partner, it is likely that our definition of contraception decision-making autonomy may have been over- or under-estimated. Thus, further research should assess the dynamics of women’s contraception discussions with their partners to determine whether or not some women proceed to make contraceptive decisions on their own after the joint discussion with their male partners. Further research should also help to tease out if the definition of contraception decision-making autonomy should incorporate aspects where the contraception method in question may not require discussion with partner, as in the case of condom use by the male partner. This will help to refine the definition and measurement of contraception decision-making autonomy as used in this study.

Finally, given that our study was conducted in districts that were purposively selected because of their high HIV prevalence levels, it is likely that the findings may not be generalizable to AGYW in districts with low HIV prevalence in particular or to other girls in the other districts in the country in general. It is also important to note that since this was a secondary analysis of data on contraception which wasn’t the primary aim of the study, we were not able to weight the data to cater for the complex survey design, and this is likely to affect the interpretation of the findings. However, given that the selection of households in which the study was conducted and indeed the selection of AGYW in those households was done using random selection methods, we think that the findings can apply to AGYW in other contexts in Uganda. The strength of this analysis is that the primary study from which the findings are drawn was conducted in districts selected across the different regions of the country (which improves applicability of the findings across regions) and the study had a large sample size which helps to improve the precision of our findings.

Our findings suggest that most adolescents and young women do not have contraceptive decision-making autonomy and the decision to use contraceptives is made jointly with their partners. Discussing with husband/partner prior to contraceptive use and being currently married were inversely associated with decision-making autonomy. However, given that AGYW are interested in accessing information on self-care-oriented FP methods, these findings suggest the need for interventions aimed at empowering AGYW in contraceptive decision-making and to promote self-care specific options among AGYW.

Study site and design

This secondary analysis uses data collected as part of a large survey conducted among 5223 in- and out-of-school AGYW aged 10–24 years in 14 purposely selected districts between September 3 and 27, 2020. Data were collected by simultaneously (by seven survey teams) during this period. The survey was conducted as part of repeat cross-sectional surveys conducted among AGYW in selected priority districts in Uganda with funding from the Global Fund. A detailed description of the main survey methodology is documented elsewhere⁵². In brief, both in- and out-of-school AGYW were interviewed at household level. We had initially planned to interview in-school AGYW at the respective schools that they attended but this was not possible at the time because schools were still closed due to COVID-19 (data were collected at a time when schools in Uganda were still closed but travel restrictions had been lifted). Because interviews for both in- and out-of-school were conducted at household level, we opted to define ‘in-school AGYW’ as those who were attending school immediately before schools were closed in March 2020 due to COVID-19 while ‘out-of-school AGYW’ were considered as AGYW of school-going age who had been out of school (for any other reasons, other than completion of studies) for at least one year prior to the survey. This was done to avoid confusion between AGYW who were at home because the schools were still under COVID-19 lockdown or because they completed their studies and those who were at home because they dropped out of school. At most, two AGYW were interviewed (one in- and the other one out-of-school, where both categories existed) per household, for up to 35 in-school and up to 35 out-of-school AGYW interviewed per village. Adjustments in the number of AGYW interviewed at household level were varied depending on whether or not it was possible to get both categories of girls in the same household.

We used a multi-stage sampling approach to select villages within each district and households within each village. Using a list of villages obtained from the Uganda Bureau of Statistics, the study team randomly sampled up to twenty-two villages per district. Upon obtaining administrative clearance to conduct the survey in a district, teams visited selected villages and, working with the local leadership in each village, generated lists of households that were presumed to have AGYW aged 10–24 years. Teams visited the selected households to screen AGYW for study eligibility and eligible girls were invited to participate in the study after providing written informed consent. Interviews were conducted at private venues within the home or at any other agreed-upon location, with strict observance of COVID-19 prevention measures, including use of a face-mask and ensuring appropriate distances between the interviewer and the respondent. These measures were included into the our COVID-19 risk mitigation plan that every member of the study team had to adhere to.

Study population

This analysis uses data collected from AGYW aged 10–24 years, resident in the surveyed districts. The data were collected as part of a large survey conducted to assess HIV, sexual and reproductive health and gender-based violence status among AGYW in 14 priority districts that were part of the districts supported by Global Fund-supported implementing partners in Uganda. AGYW were considered to be sexually-active if they reported that they had engaged in penetrative vaginal-penile sex with a male partner in the 12 months preceding the survey. This analysis uses data for 2109 sexually-active AGYW (aged 10–24 years) who were interviewed as part of the above-mentioned survey.

Data extraction

AGYW data in the large survey were collected using an interviewer-administered, structured questionnaire, configured in the KoboCollect tool and loaded on mobile phones. The large survey questionnaire included questions on socio-demographic and behavioral characteristics, contraception, menstruation hygiene management, and intimate partner violence, among other sections. For this analysis, we extracted data on socio-demographic characteristics (e.g., age in completed years, highest level of education, current marital status, readability and household possessions, among other characteristics), behavioral characteristics (e.g., ever had sex, sexual intercourse in the past 12 months, among others), contraception history (ever and current use), discussion with husband/partner prior to contraceptive use, who made the decision about the use of contraception, who made the decision on the specific FP method that the AGYW were currently using, and interest in self-care-oriented family planning methods.

Measures of variables

We assessed two primary outcomes: a) contraception decision-making autonomy (defined as the proportion of AGYW who made a decision to use contraception on their own) among sexually-active AGYW, and b) interest in self-care-oriented FP methods among AGYW (i.e., interest in obtaining FP methods that AGYW can use with minimal or no provider interaction). Contraception decision-making was assessed among sexually-active AGYW who were current contraceptive users while interest in self-care-oriented FP was assessed among all sexually-active AGYW. We defined the term ‘contraception’ in the generic sense to refer to any modern or traditional FP methods used by AGYW to avoid or delay getting pregnant. Contraception decision-making autonomy was assessed with the question: ‘Would you say that using contraception is mainly your decision, mainly your husband/partner’s decision or did you both decide together?’ which was coded ‘1=Mainly my decision’, ‘2=Mainly my partner’s decision’, or ‘3=Joint decision’. If a girl had more than one partner at the time of interview, it was up to them to decide if, in their opinion, using contraception was mainly their own decision, any of their partner’s decision, or jointly decided by them and any of their partners.

Independent variables included the factors that are likely to affect contraception decision-making autonomy including contraceptive discussion with partner prior to contraceptive use, schooling status (i.e. in- or out-of-school), highest level of education attained (coded as ‘no education’, ‘primary education’ or ‘post-primary education [secondary school education or higher]’), marital status (coded as ‘never married’, ‘in a relationship but not married’, ‘currently married’ or ‘divorced/widowed/separated’), ability to read health risk messages in the local language (as a measure of literacy), phone ownership, age-group (categorized as 10–16; 17–19, 20–24) and socio-economic status. A respondent was presumed to have discussed with their partner prior to using contraception if they answered the question, ‘Before you started using [most recent/current method], had you discussed the decision to delay or avoid pregnancy with your husband/sexual partner?’, in the affirmative. Current contraceptive users were asked about who made the decision about the specific FP method that they were currently using, which was coded as: ‘1=respondent alone’, ‘2=provider or partner’, ‘3=respondent and provider’, or ‘4=respondent and partner’. Age-group was categorized as 10–16 years; 17–19 and 20–24 based on available data. There were very few girls that were sexually-active and had ever used contraception in the category 10–14 years to allow for meaningful statistical analysis; thus, a special category, 10–16 years, was created.

We used household possessions (e.g., radio, television, bicycle, motorcycle, cell phone, running water inside the house or inside the compound, among other aspects) to construct a socio-economic status (SES) index. Each household item was assigned a weight ascertained through principal components analysis. Then, the scores were standardized in relation to a standard normal distribution with a mean of zero and a standard deviation of one. For each individual, the scores on household possessions were then summed up and individuals were ranked and sub-divided into wealth tertiles (i.e., lowest, middle, and highest), depending on their scores, with each tertile containing approximately one-third (33.3%) of the respondents.

To assess interest in self-care-oriented FP methods, all sexually-active AGYW (irrespective of current contraceptive use status) were asked: ‘Would you be interested in ways to access information on the range of ways or methods that you can use to delay or avoid pregnancy without seeing a provider or a member of the village health team (VHT)?’ coded as ‘1 = Yes’ and ‘2 = No’. AGYW that responded in the affirmative were asked if they were interested in accessing information on ways to obtain or use specific FP methods with minimal or no support from a provider or a VHT. Responses to these questions were used to measure interest in ‘self-care-oriented FP methods’, defined as those FP methods that the respondents could use on their own with minimal or no assistance of a health provider or a VHT. Respondents were also asked questions about their interest in self-management of FP side effects and bleeding changes as a result of FP use.

Data analysis

To assess contraception decision-making autonomy, we computed descriptive statistics to determine the percentage of current contraceptive users stratified by who made the decision to use contraception (i.e., respondent, partner, or both partner and respondent). We conducted bivariate analyses to determine the association between contraception decision-making autonomy and each independent variable; all variables (discussion with husband/partner about the need to delay or avoid pregnancy prior to contraception, marital status, age-group, wealth tertile, schooling status, highest level of education attained, one’s ability to read text prepared in the local language, and phone ownership) were considered for the final multivariable analysis. We used a modified Poisson regression model to identify the factors that were independently associated with contraception decision-making autonomy, after adjusting for potential confounders, and report the adjusted prevalence ratios (adj. PR) and 95% confidence intervals (95%CI) associated with these factors, using a p-value of 0.05 as a measure of statistical significance. We used a modified Poisson regression model rather than any other logit models given that the prevalence of our outcome (a binary outcome) was greater than 10%. In such cases, use of logit models is not recommended since it could result in biased estimates.

To assess interest in self-care-oriented FP methods (i.e., whether or not AGYW are interested in using FP methods that require minimal or no provider interaction), we computed descriptive statistics to determine the percentage of all sexually-active AGYW that were interested in receiving information about self-care-oriented FP methods in general and specifically for each method. We assumed that interest in self-care-oriented FP methods would vary by age (e.g., the very young adolescent girls might want to use a method that they can manage on their own, for fear that their parents might find out that they are already sexually-active), and therefore conducted cross-tabulations of interest in self-care-oriented FP methods by age-group. We also computed the percentage of those that were interested in receiving additional information on how to manage FP side-effects and bleeding changes due to contraceptive use. No inferential statistics were computed for this outcome.

Ethical considerations

The 2020 survey from which the data used in this analysis were derived was approved by the Makerere University School of Public Health Research and Ethics Committee (Protocol#: 749) and registered with the Uganda National Council for Science and Technology (Protocol#: SS411 ES). All participants provided written informed consent prior to participation in the study and all study procedures were performed in accordance with the ethical standards of the institutional and/or national research committees and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. In summary, we obtained written informed consent (or assent, as the case may be) from all the respondents. Adolescent girls aged 10–17 years who were still living with their parents or guardians were interviewed only after we obtained parental/guardian consent and the adolescent girls’ assent to the interview. However, those aged 10–17 years who were married, or living on their own, were interviewed after obtaining informed consent from them since these were considered as emancipated minors, as per the research guidelines from the Uganda National Council for Science and Technology.