DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2018 No. 138

Sabawoon Ajmal

Anwar Idris

Behzad Ajmal

June 2018

This document was produced for review by the United States Agency for 

International Development.

Factors Affecting Contraceptive Use and Unmet Need 

among Currently Married Women in Afghanistan: 

Further Analysis of the 2015 Afghanistan 

Demographic and Health Survey

DHS Working Paper No. 138

Factors Affecting Contraceptive Use and Unmet Need 

among Currently Married Women in Afghanistan: 

Further Analysis of the 2015 Afghanistan Demographic 

and Health Survey

Sabawoon Ajmal1

Anwar Idris1

Behzad Ajmal1

ICF

Rockville, Maryland, USA

June 2018

1Kabul University of Medical Science, Faculty of Public Health, Kabul, Afghanistan

Corresponding author: Sabawoon Ajmal, Department of Epidemiology and Biostatistics, Faculty of 

Public Health, Kabul University of Medical Science, Kabul, Afghanistan; email: 

sabawoonajmal@gmail.com
Acknowledgments: The authors of this working paper are extremely thankful to USAID through ICF for 

providing the opportunity for two rounds of workshop and sharing lessons from different countries. We 

appreciate the support of facilitators Wenjuan Wang and Shireen Assaf, and co-facilitators Ehab Sakr and 

Henock Yebyo, who made it possible to write this paper in a systematic way. It is equally important to thank 

Kerry MacQuarrie, who also provided constructive comments on presenting data. Furthermore, we extend 

our gratitude to all 2018 DHS Fellows for their comments and discussion while presenting methods and 

results. Finally, we also wish to extend our thanks to the Kabul University of Medical Science, which

supported us to attend both workshops and played a stewardship role in capacity development for lecturers 

and students.

Editor: Bryant Robey

Document Production: Joan Wardell

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (#AID-OAA-C-13-00095). The views expressed are 

those of the authors and do not necessarily reflect the views of USAID or the United States Government.

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about The DHS Program 

contact: DHS Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: 301-

572-0950; fax: 301-572-0999; fax: 301-407-6501; email: reports@dhsprogram.com; internet: 

www.dhsprogram.com.

Recommended citation:

Sabawoon, Ajmal, Anwar Idris, and Behzad Ajmal. 2018. Factors Affecting Contraceptive Use and Unmet 

Need among Currently Married Women in Afghanistan: Further Analysis of the 2015 Afghanistan 

Demographic and Health Survey. DHS Working Paper 138. Rockville, Maryland, USA: ICF.
iii

CONTENTS

TABLES........................................................................................................................................................ v

FIGURES .................................................................................................................................................. viiii

ABSTRACT.................................................................................................................................................. ix

1 INTRODUCTION.............................................................................................................................. 1

1.1 Research Objective............................................................................................................. 3

1.2 Research Questions............................................................................................................ 3

1.3 Conceptual Framework ....................................................................................................... 3

2 DATA AND METHODS ................................................................................................................... 5

2.1 Data Source ........................................................................................................................ 5

2.2 Description of Variables ...................................................................................................... 6

2.3 Statistical Analysis .............................................................................................................. 7

3 RESULTS ........................................................................................................................................ 9

3.1 Brief description of outcome variables .............................................................................. 10

3.2 Bivariate analysis of sociodemographic characteristics by outcomes .............................. 11

3.3 Multinomial logistic regression analysis of contraceptive use .......................................... 14

3.4 Binary logistic regression analysis of unmet need for family planning ............................. 16

4 DISCUSSION................................................................................................................................. 19

5 CONCLUSION AND POLICY IMPLICATIONS............................................................................. 21

REFERENCES............................................................................................................................................ 23

v

TABLES

Table 1 Sociodemographic characteristics of currently married women age 15-49, 

Afghanistan 2015 DHS............................................................................................... 10

Table 2 Contraceptive use among currently married women age 15-49 by 

sociodemographic characteristics, Afghanistan, 2015 DHS ...................................... 13

Table 3 Unmet need for family planning among currently married women age 15-49 by 

sociodemographic characteristics, Afghanistan 2015 DHS ....................................... 14

Table 4 Adjusted relative risk ratio of contraceptive use among currently married women 

age 15-49, Afghanistan 2015 DHS............................................................................. 16

Table 5 Adjusted odds ratio of unmet need for family planning among currently married 

women age 15-49, Afghanistan 2015 DHS................................................................ 17

vii

FIGURES

Figure 1 Conceptual framework, demonstrating factors affecting contraceptive use 

and unmet need among currently married women age 15-49 in Afghanistan ............. 4

Figure 2 Derivation of sample for analysis ................................................................................. 6

Figure 3 Percentage of currently married women age 15-49 currently using a contraceptive 

method ....................................................................................................................... 11

Figure 4 Percent distribution of currently married women age 15-49 by need for family 

planning ...................................................................................................................... 11

ix

ABSTRACT

The objective of this study is to analyze sociodemographic factors affecting both contraceptive use and 

unmet need for family planning. Secondary analysis was conducted based on data from the 2015 

Afghanistan Demographic and Health Survey. The sample included 29,461 women age 15-49 interviewed

in the survey. A frequency distribution of independent variables for the study sample was carried out and 

then a Pearson’s chi-square test was conducted for association and strength of association measured by 

multinomial and binary logistic regression.

The study found that 29% of women were using a contraceptive method (25.5% a modern method and 3.5% 

a traditional method). Among the modern methods, pills were the most common, followed by injection and 

male condom. The study found that a woman’s number of living children was positively associated with 

contraceptive use; women with more than six children were the most likely to be using contraception. Uzbek 

and other minority ethnic groups seemed less likely to use contraceptive methods. Each level of women’s 

educational attainment increased the use of contraceptive methods. Moreover, women who were exposed 

to media were more likely to use modern contraceptive methods compared with women not exposed to 

media. Finally, women in the two top wealth quintiles (richer and richest) were more likely to use modern 

contraceptive methods compared with poorer women. The study findings show that every factor except 

rural residence that is positively associated with contraceptive use is also negatively associated with unmet 

need for family planning, and vice versa.

The key determinants for contraceptive use and for unmet need for family planning are parity, level of 

education, ethnicity, media exposure, and wealth index. The findings of this research show that there is still 

space in Afghanistan to increase contraceptive use among women of reproductive age, which consequently 

could decrease the proportion of unmet need for family planning.

Key words: Afghanistan, contraceptive methods, ethnicity, level of education, married women, media 

exposure, unmet need, parity, wealth index.

1

1 INTRODUCTION

For nearly two decades the Afghan Health System has been taking steps toward improving health outcome 

indicators. As a developing country, Afghanistan still suffers from high maternal and child mortality. Access 

to primary health care service for the total population in Afghanistan increased from 9% in 2002 to 87% in 

2014, considering access to health services within a two-hour distance (M. of P. H. of Afghanistan 2016). 

During this period two main packages of health care services, namely the Basic Package of Health service 

(BPHS) for primary health care, and later the Essential Package of Health Service (EPHS) for hospital care, 

were developed in 2003 and 2005. BPHS focuses on provision of primary health care service, mainly 

maternal and newborn care, child health, and immunization, along with other basic services mentioned in 

the BPHS document, throughout primary health care centers (M. of P. H. of Afghanistan 2010). EPHS is 

mainly structured to standardize the hospital service provision in the country.

Afghanistan still suffers from high maternal and child mortality rates. While the national reproductive, 

maternal, newborn, child and adolescent health (RMNCAH) strategy 2017-2021 suggests a decline in the 

maternal mortality ratio (MMR) during the last 15 years, a slight increase in MMR has occurred since 2010. 

Despite a huge difference between the 2010 Afghanistan Mortality Survey (AMS), which showed an MMR 

of 327 maternal deaths per 100,000 live births (M. of P. H. and C. S. O. of Afghanistan 2010), and the 2015 

Afghanistan Demographic and Health Survey (AFDHS), which showed an MMR of 1,291 maternal deaths 

per 100,000 live births (M. of P. H. and C. S. O. of Afghanistan 2015), the Ministry of Public Health 

suggested an MMR of 661 women per 100,000 live births.

The RMNCAH strategy 2017–2021, through its monitoring and evaluation framework, sets 12 indicators 

to measures the progress of its stated objectives. By 2021 the Ministry of Public Health aims to increase 

the coverage of modern contraceptives by 30% and to reduce unmet need for family planning by 15%. The 

AFDHS showed that the prevalence of any method of contraceptive use in Afghanistan was low, at 23% in 

2015, compared with other countries in the region, such as Tajikistan (28%), Pakistan (35%), India (54%), 

Turkmenistan (62%), and Bangladesh (62%). In contrast, the unmet need for family planning in Afghanistan 

is 25%, relatively higher compared with regional countries such as Bangladesh (12%), India (13%), 

Pakistan (20%), Tajikistan (23%), and Turkmenistan (13%) (DHS 2018).

Family planning allows people to attain the number of children they desire and to have better management 

for spacing pregnancies, which can be achieved by use of various contraceptive methods (WHO 2018). 

Despite many debates about the pros and cons of contraceptive use in different societies in the world, it has 

been accepted that family planning has a crucial role to avoid unintended pregnancies, ensure physical and 

emotional health of women, and reduce maternal and newborn mortality. In Afghanistan, provision of 

contraceptive methods as one of the subcomponents of maternal health with the BPHS has been almost 

institutionalized in all types of health facilities for family planning (Ministry of Public Health of 

Afghanistan 2012). One of the challenges in Afghanistan is perception about desired family size, because 

married women, husbands, and mothers-in-law perceive that they will be happier and that more children 

will contribute to family economic wellbeing, taking care of parents, and compensating for possible loss 

due to war and illness (Shafiqullah et al. 2016). In addition, people have perceived modern contraceptive 

methods as dangerous, leading to numerous side effects such as pain, bleeding, weight change, mood 

change, and so forth (Shafiqullah et al. 2016).
2

Many studies have been done to analyze factors associated with contraceptive use and unmet need, but most 

have focused on countries in sub-Saharan Africa, and South and Southeast Asia. These studies discussed 

associations between demographic and socioeconomic factors and contraceptive use. Among the very few 

studies conducted in Afghanistan, a study found that factors such as age, place of residence, media exposure, 

parity, education, wealth index, and antenatal care (ANC) visits in last two years were significantly 

associated with contraceptive use (Osmani et al. 2015). A study in Pakistan concluded that, despite a 

growing family planning program over time, a gap remained in use of family planning by socioeconomic 

factors linked to the poor and illiterate groups (Aslam et al. 2016). A study in West Bengal, India, revealed 

a positive association between the level of media exposure and the use of modern contraceptive methods 

among all age cohorts (Haque and Patel 2015).

Furthermore, a study conducted in Benin Republic found that women’s education, discussion about family 

planning, number of living children, fertility preference, marital status, household wealth index, sex of 

household head, religious membership, and place of residence were significant covariates of modern 

contraceptive use (Dansou et al. 2017). Similarly, a study in Ethiopia found that respondents’ and parents’ 

education, ethnicity, urbanization, and women’s employment status were significant factors for family 

planning use (Gizachew Balew et al. 2015). In Uganda a study conducted to determine trends and patterns 

of modern contraceptive use from 1995-2011 indicated that women with post-primary education, women 

in urban areas, women in a higher wealth quintile, and women with more living children had higher odds 

of using contraception compared with the reference categories (Andi et al. 2014). Moreover, another study 

in Namibia found that young women with at least secondary education were more likely to use 

contraceptives than those with no schooling (Indongo and Naidoo 2010). With respect to economic status,

the study in Uganda (Andi et al. 2014) found that along with women’s education, the wealth index has been 

one of the highest predictors of modern contraceptive use.

As with contraceptive use, many factors have been shown to affect unmet need for family planning. A study 

in Ethiopia that assessed factors that influence unmet need for family planning showed that unmet need for 

spacing is higher than for limiting births (Hailemariam and Haddis 2011). A study based on a review of 51 

surveys conducted from 2006 to 2013 in Asian, African, Latin American, and Caribbean countries cited two 

major reasons for unmet need—infrequent sex and concerns about side effects or health risks of 

contraceptive use (Sedgh et al. 2017). In addition, another analytical study from Kenya using DHS data 

among rural women found that factors such as marital status, level of education, number of living children, 

wealth index, employment status, and exposure to media were significantly related to unmet need (Nyauchi 

and Omedi 2014).

Afghanistan has a higher proportion of unmet need for family planning, while the prevalence of any method 

of contraceptive use is lower compared with neighboring and regional countries. Still, little is known about 

the factors that may be associated with both contraceptive use and unmet need for family planning in 

Afghanistan. This study examined sociodemographic factors already tested in other countries in order to 

provide evidence for further policy formulation related to contraceptive use and unmet need for family 

planning.
3

1.1 Research Objective

The current study aimed to estimate the socioeconomic factors associated with methods of contraceptive 

use and unmet need for family planning.

1.2 Research Questions

This study answers the following research questions:

1. What are the demographic and socioeconomic factors that are associated with contraceptive use 

among non-pregnant married women age 15-49 in Afghanistan?

2. Do the demographic and socioeconomic factors have any effect on unmet need for family 

planning among women age 15-49?

1.3 Conceptual Framework

Based on the wide range of studies from other countries, we drew a conceptual framework depicted in 

Figure 1 describing the different demographic and socioeconomic variables. These variables come from 

relevant research, mostly based on DHS surveys, on contraceptive use and unmet need for family planning. 

As presented in the framework, there are two sets of variables: general, e.g. parity, age at first marriage, 

number of households, and ethnicity; and socioeconomic, such as women’s education, household wealth 

quintile, and media exposure, as found in the literature review. For example, in Afghanistan, Osmani found 

that as the number of household members increased the proportion of women using contraception also 

increased (Osmani et al. 2015). This pattern was more significant in the age group 20-39 (Haque and Patel 

2015). However, there is no consensus on the link between age at first marriage and contraceptive use. For 

example, a study in Ethiopia found that early marriage is associated with longer first birth interval (Gurmu 

and Etana 2014), while evidence from three rounds of Bangladesh DHS surveys, in 1994, 2004, and 2014, 

consistently found that women who married at age 18 or above were less likely to use contraception

compared with those who married below age 18 (Haq, Sakib, and Talukder 2017). 

Moreover, ethnicity and place of residence are other important factors that could be associated with

contraceptive use. We assume that some ethnic groups may not access health facilities as frequently as 

others, or may have different socioeconomic characteristics. Similarly to ethnicity, place of residence is 

also a key covariate that could play a role in contraceptive use in different ways—for example, by having 

direct links to access to health facilities, education, employment, and media exposure. Findings from 

Afghanistan suggest that women who live in urban areas are more likely to use contraceptive methods than 

rural women (Osmani et al. 2015). Many other studies have been consistent with the same pattern.

In addition to the general independent factors, studies have suggested that some socioeconomic variables 

are predictors for contraceptive use, such as women’s education, household wealth, employment status, and 

media exposure. We assume that there are some underlying factors, e.g., that access to school and higher 

education may result in better understanding of contraceptive use. These may in turn depend on place of 

residence and ethnicity that could ultimately result in differences in contraceptive use due to being either 

hard-to-reach geographically, insecure, or linked to beliefs about family planning.
4

Figure 1 Conceptual framework, demonstrating factors affecting contraceptive use and unmet need 

among currently married women age 15-49 in Afghanistan

Determinates Outcome

We realize that there is a negative association suggested between contraceptive use and unmet need for 

family planning—as the coverage of one goes up, the coverage of the other may go down. We assume that 

the covariates for contraceptive use mentioned above may also be linked to unmet need for family planning 

in the reverse direction.

Parity

Age at first marriage

Number of household 

members

Ethnicity

Women’s education

Household wealth

Employment status

Media exposure

Raising awareness, 

health promotion

Access to 

health facilities

Contraceptive use

Unmet need for 

family planning

Place of residence
5

2 DATA AND METHODS

2.1 Data Source

The current study used data from the 2015 AFDHS. The sampling frame used for the 2015 AFDHS was 

provided by the Central Statistics Organization (CSO). The sampling frame had information on 25,974 

enumeration areas (EAs). The 2015 AFDHS followed a stratified two-stage sample design and was intended 

to allow estimates of key indicators at the national level, for urban and rural areas, and for each of the 34 

provinces of Afghanistan. Zabul province was excluded due to security reasons, and data were only 

collected from seven urban EAs.

In the first stage, 950 clusters were selected, 260 in urban areas and 690 in rural areas. Overall, the survey 

was successfully carried out in 956 clusters. The second stage involved systematic sampling of households. 

A household listing operation was undertaken in all of the selected clusters, and a fixed number of 27 

households per cluster was selected through an equal probability systematic selection process, for a total 

sample size of 25,650 households (M. of P. H. and C. S. O. of Afghanistan 2015).

Data for this study came from the individual recode file, which includes data on women age 15-49. In total,

29,461 women age 15-49 completed interviews. For this study, we have used data only on married women. 

Among all women who completed interviews, 790 were not married and therefore we assume that sexual 

activity is nearly nonexistent among them (to comply with norms and laws) and thus they have no need for 

contraception. Furthermore, if a woman is pregnant, there is no reason to use contraception, so in the second 

step, in the analysis of contraceptive use we also excluded 6,391 women who were pregnant at the time of 

the interview. As a result, 22,280 women who were currently married and not pregnant form the analytic 

sample for examining contraceptive use, while for analysis of unmet need for family planning a total of 

28,671 women who were married make up the sample.
6

Figure 2 Derivation of sample for analysis

2.2 Description of Variables

Outcome variables

Contraceptive methods: The DHS questionnaire asks about contraceptive use—“Are you currently doing 

something or using any method to delay or avoid getting pregnant?” Possible responses are categorized as

no use, traditional methods, or modern methods. Women who replied that they currently are using either 

male or female sterilization, injectables, intrauterine devices (IUDs), contraceptive pills, implants, male 

condoms, or the lactational amenorrhea method (LAM) are classified as modern method users. If they 

mentioned rhythm method, withdrawal, or another traditional method, they are categorized as traditional 

method users.

Unmet need for family planning: Based on the standard definition, women who are not postpartum 

amenorrheic, are considered to be fecund and want to postpone their next birth for at least two years, or 

want to stop childbearing but are not using any method of contraception, are considered to have an unmet 

need for family planning (Bradley et al. 2012).

Independent variables

Parity: Parity is defined among women who have live children; therefore, women who do not have a living

child are considered as no parity. Among women with children there are three categories: women who have 

one to three children; women who have four to six children; and women who have more than six children.

Age at first marriage: Age at first marriage is divided into four categories: women who married before age 

15; women who married at age 15-19; women who married at age 20-24; and women who married at age 

25 or older.

Analytical sample for 

contraceptive use

(22, 280)

All women (29,461)

Married women

(28,671)

Not married (790)

Married non-pregnant 

women (22, 280)

Married women

(28,671)

Pregnant (6,391)

Analytical sample for 

unmet need for family 

planning (28,671)
7

Ethnicity: Afghanistan, like other countries, has multiple ethnic groups. We categorized the ethnic groups

into five categories: Pashtun, Tajik, Hazara, Uzbek, and other ethnic groups.

Number of household members: This refers to the total number of individuals who are living in the same 

house and share meals. We divided this into four categories: households with 7 individuals or fewer; 

households with 8 to 10 individuals; households with 11 to 15 individuals; and households with more than 

15 individuals.

Education attainment: Education is divided into four categories: women who have no formal or informal 

education and are not able to read and write; women who have completed primary level education; women 

who have a secondary level education; and women with higher education.

Household wealth quintile: The five wealth quintiles are defined as: poorest, poorer, middle, richer, and 

richest.

Women’s employment status: The employment status of women is considered in two categories, yes, or 

no. Women who did not have a current job or a job in the last year are classified in the “no” category, while 

women who were currently working and who have a job but were on leave in the last seven days are 

classified in the “yes” category.

Exposure to media: Women who responded that they have heard about family planning in the last few 

months from radio, television, or newspapers or magazines are categorized as having exposure to media; if 

they have not heard about family planning from any media source, they categorized as having no media 

exposure.

2.3 Statistical Analysis

Since the study aims to identify the associations of demographic and socioeconomic factors with 

contraceptive use and unmet need for family planning, a separate statistical analysis was executed for each 

outcome. The analysis was adjusted for the effect of complex design by applying svy commands.

Our analytical approach was stepwise. In the first step we ran frequency distribution for all sociodemographic variables accompanied by their relative percentage. In the next step we used descriptive 

statistics by cross-tabulating contraceptive use and unmet need for family planning with all independent 

variables to assess the bivariate associations between the two outcomes and each of the independent 

variables using Pearson’s chi-square test. In the third step we applied logistic regression for contraceptive 

use and unmet need for the independent variables that have a significant bivariate association with the 

outcome variable.

To identify the magnitude of association between contraceptive use and the independent variables, a 

multinomial logistic regression was used. Relative risk ratio (RRR) with 95% confidence interval (CI) and

P-value were considered to describe the relation between contraceptive method use and its explanatory 

factors. For unmet need, a binary logistic regression was used to assess its association with the independent 

variables. Odds ratio (OR) and 95% CI considering P-value were reported.

All statistical analysis was conducted with STATA version 15.
8
9

3 RESULTS

Overall, women in both analytic samples have several children, first married before age 19, are either 

Pashtun (about 4 in every 10) or Tajik (about one-third), live in rural areas, have no education, are not 

employed, and lack any exposure to media messages on family planning. They are most likely to live in 

households with 1-7 members (about 4 in every 10) or with 8-10 members (about one-third). Women are 

relatively evenly distributed across wealth quintiles.

There are few differences between the two analytic samples, and the differences that do appear are small. 

For example, compared with the study sample for unmet need for family planning, there are slightly higher 

percentages of women in the sample group for contraceptive use in the richest wealth quintile (21% versus

19%), in urban areas (26% versus 23%), and of Tajik ethnicity (34% versus 32%). The percentage of 

Pashtun women in the contraceptive use sample is slightly smaller compared with the unmet need sample

(38% versus 40%). A smaller percentage of women in the contraceptive use sample have no children 

compared with the unmet need sample (8% versus 10%), while a larger percentage have more than six

children (20% versus 17%).
10

Table 1 Sociodemographic characteristics of currently married women age 15-49, Afghanistan 2015 DHS

Analytical Sample for 

Contraceptive Use

Analytical Sample for Unmet 

Need

Characteristics % Number % Number

Parity

0 7.9 1,767 10.0 2,875

1 to 3 36.2 8,067 38.0 10,906

4 to 6 35.9 8,002 34.6 9,931

>6 19.9 4,444 17.3 4,959

Age at first marriage

<15 14.4 3,217 14.1 4,036

15 to 19 57.8 12,881 58.4 16,741

20 to 24 22.8 5,076 22.6 6,479

≥25 5.0 1,106 4.9 1,415

Ethnicity

Pashtun 38.2 8,517 39.6 11,364

Tajik 33.5 7,459 32.4 9,304

Hazara 10.4 2,318 9.8 2,811

Uzbek 10.9 2,422 11.0 3,153

Others 7.0 1,563 7.1 2,038

Number of household members

1 to 7 38.5 8,577 38.8 11,113

8 to 10 32.5 7,252 32.2 9,246

11 to 15 19.8 4,413 19.8 5,680

≥16 9.1 2,037 9.2 2,632

Place of residence

Urban 25.5 5,690 23.3 6,673

Rural 74.5 16,590 76.7 21,998

Educational level

No education 82.8 18,446 83.4 23,921

Primary 8.1 1,813 7.9 2,257

Secondary 7.0 1,560 6.8 1,951

Higher 2.1 461 1.9 542

Wealth index

Poorest 19.5 4,350 20.1 5,757

Poorer 19.1 4,262 20.3 5,823

Middle 19.6 4,362 20.0 5,736

Richer 20.8 4,631 20.4 5,846

Richest 21.0 4,674 19.2 5,509

Employment status

No 88.8 19,779 88.6 25,402

Yes 11.2 2,501 11.4 3,269

Media exposure

No 59.7 13,291 60.6 17,377

Yes 40.3 8989 39.4 11293

Total 100.0 22,280 100.0 28,671

3.1 Brief description of outcome variables

The study found that 29% of married non-pregnant women age 15-49 currently use a contraceptive method 

(25.5% modern method and 3.5% traditional). Among the modern methods, pills are most commonly used, 

at 9%, followed by injection (6%), and male condom (Figure 3).
11

Figure 3 Percentage of currently married women age 15-49 currently using a contraceptive method

The study also found that among the sample population overall, 25% of current married women had an 

unmet need for family planning—18% for spacing and 7% for limiting births (Figure 4).

Figure 4 Percent distribution of currently married women age 15-49 by need for family planning

3.2 Bivariate analysis of sociodemographic characteristics by outcomes

Table 2 presents the bivariate analysis for contraceptive use. As shown above in Figure 3, 29% of women 

are current contraceptive users, and most of them use modern methods. Contraceptive use is significantly 

associated with nearly all covariates we examined. Contraceptive use is associated with a higher parity. 

While 1% of women without children use a modern contraceptive method, 30% of those with 4-6 children 

and 32% with more than 6 children use a modern method. A similar pattern was observed for traditional 

28.9

25.5

3.5

8.8

6.3

4.3

2.4

1.8

1.6

0.3

0 5 10 15 20 25 30 35

Any methods

Modern methods

Traditional methods

Pill

Injections

Male condom

Female sterilization

IUD

Lactational amenorrhea (LAM)

Any other modern method

11.0

11.0

53.0

18.0

7.0

Met need for spacing

Met need for limiting

No need for family

planning

Unmet need for spacing

Unmet need for limiting
12

method use. The study found an association of age at first marriage with use of contraceptive methods. 

Women who married before age 20 are relatively more likely to use modern methods compared with women

who married at age 25 or older (26% versus 18%).

Ethnicity is another factor found to be associated with use of contraceptive methods. While Tajik and 

Pashtun women share 31% and 27% of modern contraceptive use respectively, 22% of Hazara women, 16% 

of Uzbek women, and 14% of other ethnic women use modern contraceptive methods, indicating the 

variation between ethnic groups in contraceptive use. We found an association between number of 

household members and use of both traditional and modern methods. Place of residence is another factor 

that has an association with use of modern and traditional contraceptive methods. While 34% of urban 

dwellers use modern contraceptives, 23% of women in rural area use them. We found that 7% of women in 

urban areas use traditional methods compared with only 2% of women in rural areas. Our study also 

suggests that women’s level of education has an association with contraceptive use. Both traditional and 

modern method use exhibits a similar pattern—that increasing level of education is also associated with 

increasing use of both modern and traditional contraceptive methods (Table 2). Wealth index is found to be 

associated with contraceptive use. Among the richest and richer quintiles, 36% and 28% of women, 

respectively, used modern methods, while among women in the poorer and poorest quintiles, 22% and 20% 

used modern methods. A similar pattern was observed for the traditional methods. Finally, the study 

indicates that media exposure is associated with contraceptive use. Among women exposed to family 

planning messages in the media, 34% use modern contraceptives and 5% use traditional methods, while 

among women with no exposure to media, 20% use modern contraceptives and only 3% use traditional 

methods. There was no difference found in contraceptive use by women’s employment status.
13

Table 2 Contraceptive use among currently married women age 15-49 by sociodemographic 

characteristics, Afghanistan, 2015 DHS

Contraceptive Use

Traditional Modern Chi square 

Characteristic % CI % CI P-value

Parity

0 0.4 [0.2,1.0] 1.0 [0.5,1.9]

< 0.001

1 to 3 3.2 [2.6,4.0] 23.0 [21.0,25.2]

4 to 6 4.1 [3.4,5.1] 29.5 [27.0,32.1]

>6 3.8 [3.0,5.0] 32.4 [29.7,35.2]

Age at first marriage 

Under 15 3.3 [2.4,4.4] 26.6 [23.7,29.6]

0.004

15-19 3.4 [2.9,4.1] 26.3 [24.4,28.3]

20-24 3.9 [3.0,5.1] 24.1 [21.9,26.5]

≥25 2.1 [1.2,3.6] 18.4 [14.6,22.9]

Ethnicity

Pashtun 3.9 [3.2,4.6] 26.5 [23.5,29.6]

< 0.001

Tajik 4.6 [3.7,5.7] 30.9 [28.0,34.0]

Hazara 2.1 [1.2,3.5] 21.8 [18.1,26.0]

Uzbek 1.1 [0.5,2.0] 16.1 [11.2,22.4]

Others 1.6 [1.0,2.6] 14.0 [11.0,17.6]

Number of household members

1 to 7 3.4 [2.5,4.6] 24.5 [22.3,26.8]

0.021

8 to 10 3.9 [3.1,4.8] 27.9 [25.8,30.2]

11 to 15 2.6 [2.0,3.3] 24.6 [21.9,27.6]

≥16 4.1 [2.9,5.7] 22.4 [18.7,26.6]

Place of residence

Urban 6.9 [5.5,8.7] 34.0 [29.8,38.4]

Rural 2.3 [1.9,2.8] 22.5 [20.9,24.2] < 0.001

Education level

No education 2.7 [2.3,3.1] 24.5 [22.8,26.2]

< 0.001

Primary 6.4 [4.3,9.5] 27.2 [23.3,31.5]

Secondary 6.8 [4.4,10.6] 32.5 [27.2,38.3]

Higher 11.6 [6.0,21.3] 35.0 [25.8,45.4]

Wealth index

Poorest 0.9 [0.6,1.5] 19.9 [17.2,22.9]

< 0.001

Poorer 1.8 [1.4,2.4] 22.0 [19.5,24.7]

Middle 2.4 [1.8,3.1] 20.7 [17.8,23.9]

Richer 4.6 [3.5,6.1] 27.7 [24.7,31.0]

Richest 7.2 [5.6,9.2] 36.0 [31.1,41.2]

Employment status

No 3.5 [3.0,4.1] 25.7 [24.2,27.3]

Yes 2.9 [1.9,4.3] 23.5 [19.9,27.5] 0.241

Media exposure

No 2.5 [2.0,3.0] 19.5 [17.7,21.5]

< 0.001

Yes 4.9 [4.1,5.9] 34.2 [31.7,36.8]

Total 3.5 [3.0,4.0] 25.5 [23.9,27.1]

Table 3 below presents the cross-tabulation of different sociodemographic characteristics of respondents by 

their unmet need for family planning. The overall unmet need for family planning is estimated to be 25%.

Unmet need for family planning is significantly associated with six of the nine covariates we examined. 

The study indicates that parity is a factor that could be associated with unmet need for family planning. 

Among women who have more than six children, 27% have unmet need for family planning, while only 

10% of women who have no children have unmet need for family planning. Our study indicates a 

relationship between age at first marriage and unmet need for family planning. While 23% and 24% of 

Pashtun and Tajik women, respectively, have unmet need for family planning, the levels are somewhat 

higher among Hazara, Uzbek, and other ethnic group women, at 27%, 28%, and 29%, respectively. Analysis 

of the number of household member variables shows that 22% of women who have up to seven household 

members and 27% of women who have more than 16 individuals in their household have unmet need for 
14

family planning, suggesting a variation between the number of household members and unmet need for 

family planning. Furthermore, the wealth index indicator suggests a variation between different quintiles. 

Among women in the poorest wealth index quintile, 27% have unmet need for family planning compared 

with 21% for the richest quintile. Among women exposed to the media, 23% have unmet need for family 

planning compared with 25% among women with no media exposure to family planning messages. The 

findings suggest that there is no association between women’s place of residence, level of education, or 

employment status and unmet need for family planning.

Table 3 Unmet need for family planning among currently married women age 15-49 by 

sociodemographic characteristics, Afghanistan 2015 DHS

Unmet need for family planning

Characteristic % CI

Chi square 

P-value

Parity

0 10.2 [8.6,12.0]

< 0.001

1-3 26.6 [25.0,28.2]

4-6 24.8 [23.1,26.6]

>6 27.4 [25.7,29.2]

Age at first marriage

<15 27.6 [25.5,29.8]

0.038

15-19 24.1 [22.9,25.3]

20-24 24.1 [22.2,26.0]

≥25 21.5 [17.0,26.9]

Ethnicity

Pashtun 22.6 [21.2,24.1]

0.002

Tajik 23.9 [22.1,25.9]

Hazara 26.5 [23.1,30.3]

Uzbek 28.2 [24.9,31.7]

Others 28.7 [25.5,32.0]

Number of household members

1 to 7 22.4 [20.9,24.0]

< 0.001

8 to 10 24.6 [23.1,26.1]

11 to 15 27.0 [25.1,29.1]

≥16 27.1 [24.2,30.2]

Place of residence

Urban 24.2 [21.5,27.2]

Rural 24.5 [23.5,25.6] 0.848

Education level

No education 24.8 [23.6,26.0]

0.063

Primary 23.5 [20.4,27.0]

Secondary 23.6 [20.3,27.4]

Higher 16.0 [11.5,21.8]

Wealth index

Poorest 26.8 [24.9,28.8]

0.040

Poorer 24.8 [22.9,26.8]

Middle 24.5 [22.8,26.2]

Richer 24.8 [22.5,27.2]

Richest 21.3 [18.3,24.7]

Employment status

No 24.6 [23.6,25.7]

Yes 23.4 [19.2,28.1] 0.604

Media exposure

No 25.4 [24.1,26.7]

0.022

Yes 23.1 [21.5,24.7]

Total 24.5 [23.4,25.5]

3.3 Multinomial logistic regression analysis of contraceptive use

Table 4 summarizes the results of multinomial logistic regression of factors associated with use of 

contraceptive methods. After controlling other factors, users of modern and traditional methods of 
15

contraception are compared with nonusers by different sociodemographic characteristics, and weighted 

relative risk ratios and confidence intervals are presented.

Among all factors significantly associated with both traditional and modern methods in bivariate analysis,

four of them—parity, ethnicity, level of education, and wealth index—show an association with use of both 

traditional and modern methods. Media exposure was found to be associated with use of modern methods 

only, while place of residence was found to be associated only with traditional method use. Finally, this 

model did not provide evidence to support an association of age at first marriage and women’s employment 

status with use of contraception.

As parity had significant statistical differences for the both methods of contraception, the logistic regression 

found the relative risk ratio of 0.05 and 0.02 for using traditional and modern contraceptive methods 

respectively for women who had no children compared with those with more than six children. The relative 

risk ratio for using traditional methods was found to be lower for Hazara (0.4), Uzbek (0.22), and other 

ethnic groups (0.43) relative to Pashtun ethnic group, while the relative risk for using modern methods was 

lower only for Uzbek (0.52) and other ethnic groups (0.48) compared with Pashtun ethnic group. No relative 

risk difference was observed for either traditional or modern contraceptive methods between Tajik and 

Pashtun ethnic groups. The relative risk for using any contraception was higher by any level of women’s 

education relative to women with no education (RRR=2.4 for primary education, 2.66 for secondary, and 

4.95 for higher education), but the relative risk for use of modern contraceptive methods was 52% higher 

compared with women with no education. The relative risks for using traditional methods were higher for 

women in the poorer, middle, richer, and richest quintiles compared with the poorest quintile, while for 

modern contraceptive use the relative risk for the richer quintile was 42% higher, and for the richest quintile 

it was 77% higher compared with women in the poorest wealth quintile.

While bivariate analysis found significant statistical associations of place of residence and media exposure

with contraceptive use, the multinomial regression found 38% lower relative risks for using a traditional 

method for women in rural areas compared with women in urban settings. The study found no risk 

difference with respect to modern contraceptive use. In contrast, the study found no risk difference of 

traditional methods between women who were exposed to the media and those who were not exposed, while 

for women who used modern contraceptive methods, the study found 71% higher relative risk for women 

who were exposed to the media compared with those who were not exposed. No risk difference for either 

traditional or modern contraceptive method use was observed for age at first marriage and number of 

household members.
16

Table 4 Adjusted relative risk ratio of contraceptive use among currently married women age 15-49, 

Afghanistan 2015 DHS

Currently contraceptive use vs. non-use

Traditional Modern

Predictors RRR 95% CI RRR 95% CI

Parity

>6 1.0 1.0

0 0.1*** 0.0 - 0.1 0.0*** 0.0 - 0.0

1-3 0.6*** 0.4 - 0.7 0.6*** 0.5 - 0.7

4-6 0.9 0.7 - 1.3 0.9* 0.7 - 1.0

Age at first marriage

less than 15 1.0 1.0

15-19 1.3 0.9 - 1.8 1.1 1.0 - 1.4

20-24 1.4 0.9 - 2.0 1.0 0.8 - 1.3

≥25 0.7 0.3 - 1.3 0.8 0.6 - 1.0

Ethnicity

Pashtun 1.0 1.0

Tajik 1.0 0.7 - 1.4 1.1 0.9 - 1.4

Hazara 0.4* 0.2 - 0.9 0.7 0.5 - 1.0

Uzbek 0.2*** 0.1 - 0.5 0.5** 0.3 - 0.8

Others 0.4** 0.3 - 0.8 0.5*** 0.4 - 0.7

Number of household members

1 to 7 1.0 1.0

8 to 10 1.3 0.9 - 1.8 1.1 1.0 - 1.4

11 to 15 0.8 0.6 - 1.2 1.0 0.8 - 1.2

≥16 1.1 0.7 - 1.8 0.8 0.6 - 1.0

Place of residence

Urban 1.0 1.0

Rural 0.6* 0.4 - 1.0 1.0. 0.7 - 1.3

Education level

No education 1.0 1.0

Primary 2.4*** 1.7 - 3.5 1.2 1.0 - 1.4

Secondary 2.7** 1.5 - 4.8 1.5*** 1.2 - 2.0

Higher 5.0*** 1.9 - 12.8 1.7 1.0 - 3.0

Wealth index

Poorest 1.0 1.0

Poorer 2.0* 1.1 - 3.5 1.1 0.9 - 1.4

Middle 2.3** 1.3 - 4.2 1.0 0.8 - 1.3

Richer 4.3*** 2.4 - 8.0 1.4* 1.1 - 1.9

Richest 4.3*** 2.1 - 8.7 1.8** 1.2 - 2.6

Employment status

No 1.0 1.0

Yes 0.8 0.5 - 1.3 1.1 0.8 - 1.3

Media exposure

No 1.0 1.0

Yes 1.3 1.0 - 1.7 1.7*** 1.4 - 2.0

*** p<0.001, ** p<0.01, * p<0.05

3.4 Binary logistic regression analysis of unmet need for family planning

Table 5 summarizes results of the adjusted binary logistic regression of unmet need for family planning on 

different sociodemographic characteristics.

The odds ratio of having unmet need for family planning is higher among women who have at least one 

child compared with those who do not have any children. In contrast with lower relative risks for traditional 

methods for Hazara, Uzbek and other ethnic groups, this study found a higher odds ratio for same ethnic 

groups compared with Pashtuns. Compared with women who married before age 15, women who married 

at age 15-19 had lower odds of unmet need for family planning. The difference was not significant for the 

other two age groups. There were higher odds for unmet need among women who had at least eight 

household members compared with women who had fewer than seven members. On average, the odds for 
17

unmet need are 30% lower among rural women compared with urban women (OR=0.7). While the odds 

ratio for unmet need for family planning is 40% lower among the richest wealth quintile compared with the 

poorest quintile of women, the other three wealth quintiles do not have a significant association with unmet 

need for family planning. No significant difference for unmet need was found for women’s education, 

employment status, and media exposure.

Table 5 Adjusted odds ratio of unmet need for family planning among currently married women age 

15-49, Afghanistan 2015 DHS

Predictors OR 95% CI

Parity

0 1.0

1-3 3.1*** 2.5 - 3.9

4-6 2.8*** 2.3 - 3.5

>6 3.0*** 2.5 - 3.8

Age at first marriage

less than 15 1.0

15-19 0.9* 0.8 - 1.0

20-24 0.9 0.8 - 1.0

≥25 0.8 0.6 - 1.1

Ethnicity

Pashtun 1.0

Tajik 1.1 1.0 - 1.3

Hazara 1.3* 1.1 - 1.6

Uzbek 1.4*** 1.2 - 1.7

Others 1.4*** 1.2 - 1.7

Number of household members

1 to 7 1.0

8 to 10 1.2** 1.0 - 1.3

11 to 15 1.3*** 1.2 - 1.5

≥16 1.4*** 1.2 - 1.6

Place of residence

Urban 1.0

Rural 0.7*** 0.6 - 0.9

Education level

No education 1.0

Primary 1.0 0.8 - 1.1

Secondary 1.0 0.8 - 1.3

Higher 0.7 0.5 - 1.2

Wealth index

Poorest 1.0

Poorer 1.0 0.8 - 1.1

Middle 1.0 0.8 - 1.1

Richer 0.9 0.8 - 1.1

Richest 0.6*** 0.5 - 0.8

Employment status

No 1.0

Yes 0.9 0.7 - 1.1

Media exposure

No 1.0

Yes 0.9 0.8 - 1.1

*** p<0.001, ** p<0.01, * p<0.05

19

4 DISCUSSION

This study explored the demographic and socioeconomic factors that are associated with contraceptive use 

and unmet need for family planning among currently married women of reproductive age. Caution should 

be taken in extrapolating results because the study was based on data from a cross-sectional survey, and 

thus is not suitable for establishing cause and effect.

The study found that every factor except rural residence that is positively associated with contraceptive use 

is also negatively associated with unmet need, and vice versa. Because increased contraceptive use reduces 

unmet need, it is not surprising that those factors that are associated with more contraceptive use are also 

associated with less unmet need. If we could invest more in improving the level of contraceptive use, then 

the level of unmet for family planning would decrease.

To be more specific, evidence from this study suggests that parity, ethnicity, and wealth index are key 

predictors that have an effect on use of contraceptive methods and also on unmet need for family planning. 

As the number of women’s living children increases, Uzbek and other minority ethnic groups are less likely 

used either modern or traditional methods of contraception. In contrast, these groups have higher levels of

unmet need for family planning. Ethnic diversity may be linked to other factors e.g., religious and 

perception about contraceptive methods. As Shafiqullah et al. found, some religious leaders have argued 

that contraception is a sinful act in Islam (Shafiqullah et al. 2016). A study in India found that Muslim 

women were 56% less likely to use contraception methods compared with other religious group (Ranjana 

2012). Furthermore, low levels of contraceptive use among Uzbek and other minority groups might be 

associated with some religious tenet, or it could be other factors. Again, evidence from a study in 

Afghanistan indicates that women who have a fear of various side effects and have doubts about a method’s

effectiveness due to irregular supply found it to be a challenge to use contraceptive methods (Shafiqullah 

et al. 2016). A study in Ethiopia reported, “people’s attitudes concerning family planning can be rooted in

individual experiences; however several societal factors have a strong impact in shaping one’s decision to

use modern contraceptive methods” (Hailemariam and Haddis 2011). Therefore, it would be worth 

investing in affecting individual attitudes toward modern contraceptive use.

Evidence from global studies suggests that economic status is a key determinant of contraceptive use. Our 

finding also suggests that an increasing level of household wealth is positively associated with use of both 

traditional and contraceptive methods, and is negatively associated with unmet need for family planning. 

While a study found higher levels of unmet need for family planning in a few selected Asian countries 

among poor women (Majumder and Ram 2015), the current study indicates no significant difference across 

the different wealth quintiles, except for the richest quintile. It is worth considering the complexity of 

measurement based on the wealth index in order to assess the comparability of data.

Interestingly, we did not find an association for employment status and either outcome—contraceptive use 

or unmet need for family planning—while most studies have found a potential relationship. For example,

Gizachew Balew et al. found employment status to be a significant factor for contraceptive use (Gizachew 

Balew et al. 2015); Solanke found that the odds ratio for unmet need for family planning was 24% lower 

among women who had a job compared with those who did not have a job (Solanke 2016). Considering 

reasons for not using contraception, Sedgh found infrequent sexual activity and concerns regarding side 
20

effects and health risks associated with contraceptive methods to be the most common reasons for nonuse. 

We believe further investigation may provide details on the potential relationship of employment status and 

contraceptive use and unmet need for family planning. 

Media exposure played a crucial role in improving health indicators. The level of media exposure has been 

found to have a positive association with modern contraceptive use (Haque and Patel 2015; Osmani et al. 

2015). The current study found that women who were exposed to media were more likely to use modern 

contraceptive methods, while no association was found for traditional contraceptive use and unmet need 

for family planning. It is worth mentioning that around 60% of Afghan women still do not have any 

exposure to media messages on family planning. If we could improve exposure to the media, it could 

increase the proportion of women using modern contraceptive methods.

There was no association between women’s place of residence and either contraceptive use or unmet need 

for family planning, while the logistic regression analysis found that women who are rural residents are less 

likely to use traditional methods and less likely to have unmet need for family planning. As every survey 

has its limitations, caution should be used in interpreting this result. One important point to be considered 

is the cross-sectional design, which can be used for association but not for causality. However, findings in 

other countries have shown that unmet need among women in rural areas can be lower compared with 

women in urban areas (Solanke 2016).
21

5 CONCLUSION AND POLICY IMPLICATIONS

Our findings show that key determinants for contraceptive use and unmet need for family planning in 

Afghanistan are parity, women’s level of education, ethnicity, and media exposure. The findings of this 

research show that there is still space to increase contraceptive use among women of reproductive age that 

consequently could decrease the proportion of unmet need for family planning.

The policy impact of this study could be to once again redirect the focus on changing women’s behavior 

toward family planning and use of contraception to control birth spacing and to limit childbearing, as the 

study finds that women, particularly in rural areas, have less unmet need. By proper media campaigns and 

counseling on the benefits of longer birth intervals using modern contraceptive methods, we may achieve 

the goal of increasing the proportion of women using contraception. An assessment of ethnic diversity may 

be helpful to formulate policy focusing on the areas with minority ethnic groups in order to provide family 

planning, which could help them access services and decrease unmet need. Meanwhile, considering the role 

of other factors, a multisectoral effort is still required to improve women’s education, economic situation,

and behavioral changes.

In Afghanistan, the Ministry of Public Health can consider the result of this study in shaping policies to 

address those factors that have significant association with contraceptive use and unmet need. Meanwhile, 

the successful lessons learned over the last one and a half decades, along with other countries’ success 

strategies, will be helpful to change family planning behavior, particularly with regard to the 

institutionalization of family planning measures and interventions. We hope the result of this study can help 

the program managers of the reproductive health directorate to conduct further analysis and to review their 

policy and strategy accordingly to ensure improvement and future success.

23

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