Knowledge of the ovulatory cycle and its determinants among adolescent females in Ghana (2025)

Background

Good knowledge about the ovulatory cycle plays an important role in reducing unwanted pregnancies and unsafe abortions among adolescent females. However, in Ghana, knowledge of the ovulatory cycle among adolescent females is not well studied. Thus, this study sought to assess adolescent females’ knowledge regarding the ovulatory cycle and its determinants in Ghana.

Methods

This study used data from the 2022 Ghana Demographic and Health Survey. It comprised a sample of 2,835 adolescent females (Mean age = 16.9, standard deviation ± 1.42). Multilevel multivariable logistic regression was used to analyse the determinants of ovulatory cycle knowledge among Ghanaian adolescent females. Four models were fitted incorporating individual and community levels. All associations were considered statistically significant at 95% confidence level in the fixed effect results. The random effects were quantified in terms of Intra-Class Correlation (ICC) and Primary Sampling Units (PSUs) variance.

Results

The level of knowledge about the ovulatory cycle was 24.6% (95%CI=23.0-26.0%). Adolescent females with secondary/higher education (AOR = 2.36; 95% CI = 1.26–4.43), at least one child (AOR = 2.01; 95% CI = 1.40–2.89), used traditional contraceptives such as rhythm, withdrawal methods (AOR = 2.26; 95% CI = 1.52–3.67), menstruated in the last six weeks (AOR = 2.01; 95% CI = 1.08–3.57) and media exposure to family planning messages (AOR = 1.89; 95% CI = 1.52–2.35) had higher odds of having good knowledge about the ovulation cycle. At the community level, respondents who resided in communities with high literacy levels had higher odds of having good knowledge of the ovulatory cycle (AOR = 1.62; 95% CI = 1.14–2.31).

Conclusions

Knowledge of the ovulatory cycle among adolescent females in Ghana is low and this may be contributing to unwanted pregnancies. Public health interventions on the ovulatory cycle should target adolescent females who have lower levels of education and those who do not use contraceptives.

An adolescent refers to an individual between ages 10 and 19 [1]. Adolescents, particularly, females are likely to face varied health and social challenges including unwanted pregnancy and unsafe abortion [2]. Yearly, about 21million adolescent pregnancies are recorded in low and middle-income countries (LMICs). The prevalence of adolescent pregnancies is highest in South Asia and sub-Saharan Africa [3, 4]. Pregnancy among adolescent females is associated with varied complications including a high risk of maternal mortality, stillbirths, neonatal deaths, poor education, unemployment, and intergenerational cycles of poverty [4,5,6]. One of the strategies for preventing unintended pregnancy and related consequences including abortion is having good knowledge of the ovulatory cycle [5, 7, 8].

Ovulation is when the dominant follicle releases its egg from the ovary into the fallopian tube for potential fertilization and is regulated by a surge in the luteinizing hormone [9]. The ovulatory period is the fertile period during which a female can conceive [5]. Generally, ovulation occurs at about the midpoint of one’s menstrual cycle. Therefore, for a female with an average menstrual cycle of 28 days, ovulation will occur about 14 days after the onset of her menstruation. However, there can be variations in the day of ovulation depending on the length of one’s menstrual cycle [10, 11].

Factors including women’s age, education, place of residence, marital status, wealth index, employment status, knowledge of contraceptive methods, and access to media are reported to be associated with knowledge of the ovulatory cycle [7, 9, 10, 12]. Having good knowledge of reproductive physiology, particularly, the ovulatory cycle helps females who do not utilize modern contraceptive methods to successfully use natural contraceptive methods including the rhythm and standard day methods which are based on fertility awareness [13]. Also, those who intend to become pregnant have a higher chance of doing so by having unprotected sexual intercourse in the days leading to ovulation [10].

Although awareness of the ovulatory cycle might protect females from unintended pregnancies and related complications such as unsafe abortions, there is scant literature on knowledge among adolescent females in sub-Saharan Africa including Ghana. Available studies have predominantly focused on reproductive women [9, 10, 14, 15]. However, evidence from previous studies shows that adolescent females tend to have poor knowledge of the ovulatory cycle and have a higher likelihood of reporting unintended pregnancy than adult women [8, 16]. Therefore, the present study sought to assess adolescent females’ knowledge about the ovulatory cycle and its determinants in Ghana. Findings from this study could provide strategies to help increase adolescent female’s knowledge of the ovulatory cycle and consequently help reduce unintended pregnancies and related consequences.

Data

This is a quantitative study that used the 2022 Ghana Demographic and Health Survey (GDHS). The GDHS is a nationally representative sample survey that is conducted every five years by the Ghana Statistical Service. The 2022 GDHS is the seventh round in the series and it followed a two-stage sample design to select participants. The first stage involved selecting 618 clusters from the sampling frame using a probability proportional to size strategy for urban and rural areas in each of the 16 regions in Ghana. Afterward, the number of targeted clusters was selected with equal probability systematic random sampling of the clusters selected in the first stage for urban and rural areas. In the second stage, a household listing and map updating operation were carried out in the selected clusters to develop a list of households for each cluster. This list served as a sampling frame for the selection of the household sample. The 2022 GDHS sampling procedure and methodology have been described elsewhere [13]. In the 2022 GDHS, 15,317 women aged 15–49 were eligible to participate in the study. However, a sample of 15,014 women were interviewed which translated to a98% response rate [13]. The present study focused on women aged 15 to 19; thus, 12,179 women were excluded because they were over 19. The analysis of the current study was based on a weighted sample of 2,835 adolescent females aged 15–19 years who responded to all the questions used (See Fig.1).

Study variables

Outcome variable

The outcome variable of the current study was knowledge of the ovulatory cycle. In the 2022 GDHS, respondents were asked, “From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant? Possible answers to the question were: ‘just before her period’ begins, ‘during her period’, ‘right after her period has ended’, ‘halfway between two periods’, ‘other’, and ‘Don’t know’. From the responses, a two-category variable measuring knowledge of the ovulatory cycle was created: Good knowledge of the ovulatory cycle and poor knowledge of the ovulatory cycle. All respondents who stated halfway between periods were classified as having good knowledge while all other responses were classified as having poor knowledge of the ovulatory cycle.

Independent variables

Independent variables that were considered include individual level factors such as educational attainment (no education, primary, secondary, or higher), marital status (never married, married), employment status (employed, unemployed), and wealth status (poor, middle, rich). Wealth status was computed from household assets, including television, bicycle, or car, as well as dwelling characteristics, such as a source of drinking water, sanitation facilities, and type of flooring material. Principal components analysis was used to generate factor scores for every household asset. A standardised score was used to divide the household wealth score into lowest, second, middle, fourth, and highest. The lowest and second were reclassified as poor, the middle category was categorised as middle while the fourth and highest were reclassified as rich. Detailed information about the computation of household wealth can be found at Ghana Statistical Service et al., 2024. Other variables such as children ever born (no children, 1 to 3 children), menstruated in the last six weeks (yes, no), use of contraceptives (use modern contraceptives, use traditional contraceptives, do not use any contraceptive method) and media exposure to family planning messages were used in the present study. Media exposure to family planning messages was computed from the following questions: have you heard about family planning on the radio? (yes, no), heard about family planning on television? (yes, no), heard about family planning in newspapers/magazines? (yes, no), heard about family planning from text messages on mobile phones? (yes, no), heard about family planning from community meetings? (yes, no), seen about family planning on social media (yes, no), seen about family planning on posters/brochures? (yes, no), seen about family planning on outdoor signs/billboards? (yes, no). A ‘yes’ response to any of the above questions was coded ‘1’, indicating media exposure to family planning messages. A ‘no’ response was coded ‘0’ and classified as no media exposure to family planning messages. Community level variables that were examined included residency (rural and urban), community literacy level (low, high, medium). and community socio-economic status (low, high).

Data analysis

The data were analysed with STATA version 17. The data were weighted to make it representative and to provide a better statistical estimate. The characteristics of the respondents were described using descriptive statistics such as frequencies and percentages. Pearson chi-square test was used to determine the association between knowledge of the ovulatory cycle and the independent variables. The Variance Inflation Factor (VIF) command was used to test multicollinearity between the independent variables. The results indicated no evidence of multicollinearity (Mean VIF = 1.42, maximum VIF = 1.82, minimum VIF = 1.06) (See S1 Appendix).

Multilevel multivariable logistic regression analyses were conducted to assess the association between individual level factors, community level factors, and knowledge of the ovulatory cycle. Four models were built, Model I (null model) was run without any explanatory variables. This was to account for variability in knowledge of the ovulatory cycle which can be attributed to the clustering of the primary sampling units (PSUs) or clusters without the effect of individual and community level factors. Only the individual level variables were fitted in Model II, while Model III considered only community level variables. Model IV included both individual and community level variables. All associations were considered statistically significant at 95% confidence level in the fixed effect results. Since the models were nested, the Akaike information criterion (AIC) was used to measure their fitness. The random effects, which are measures of variations of knowledge of the ovulatory cycle across clusters were expressed in terms of intra-class correlation (ICC) and PSUs variance. The computation of the ICC and PSUs variance help to quantify the degree of variation of ovulatory cycle knowledge across clusters and the proportion of variance explained by successive models.

Characteristics of the respondents

Table1 shows the characteristics of the respondents. The mean age of the respondents was 16.9 years (standard deviation ± 1.42). The majority (81.3%) had attained secondary or higher education and a few (3.7%) had no education. Also, the majority (92.1%) of the respondents were never married, and more than half (59.2%) were employed. Comparatively, the highest proportion (37.7%) of respondents belonged to the rich category of wealth and the lowest (23.8%) were in the middle category. About one-tenth (10.9%) of the respondents had at least a child and the majority (83.7%) of them were non-users of contraceptives. More than half (58.4%) of the respondents had media exposure to family planning messages. Additionally, more than half (54.4%) of them resided in urban areas.

The results further revealed that respondents with secondary/higher education constituted the highest proportion (28.7%) of those with good knowledge about the ovulatory cycle. The lowest proportion (11.4%) was observed among those who had no education (P < 0.001). The highest proportion (29.7%) of the respondents who had good knowledge about the ovulatory cycle belonged to the rich category of wealth while the lowest proportion (22.2%) were in the poor category (p < 0.001). Comparatively, a higher proportion (32.4%) of respondents who had at least one child had good knowledge about the ovulatory cycle than their nulliparous counterparts (32.3%; p < 0.05). Respondents who were using traditional contraceptives including rhythm and withdrawal constituted the highest proportion of those who had good knowledge about the ovulatory cycle (39.4%). The lowest proportion was recorded among those who were not using any contraceptive (25.2%; p < 0.001). A higher proportion of urban residents (28.4%) had good ovulatory cycle knowledge compared to rural residents (24.3%; p < 0.05). Additional characteristics of the respondents are presented in Table1.

Level of knowledge about the ovulatory cycle

Concerning knowledge of the ovulatory cycle, about one-fourth (24.6%; 95% CI = 23 − 26%) of adolescent females in Ghana had good knowledge (Table1).

Predictors of knowledge of the ovulatory cycle among adolescent females

The fourth model (Model IV) in Table2 depicts the fixed effects results of individual and community level factors of knowledge of the ovulatory cycle among adolescent females in Ghana. The findings indicate that education level, children ever born, contraceptive use, menstruation in the last six weeks before the survey and media exposure to family planning messages were significantly associated with knowledge of the ovulatory cycle at the individual level. Also, community literacy level was significantly associated with knowledge of the ovulatory cycle at the community level. Specifically, adolescent females with secondary or higher education had 2.36 times the odds of having good ovulatory cycle knowledge as those without education (CI = 1.26–4.43). Also, respondents with at least one child had 2.01 times the odds of having good ovulatory cycle knowledge as those without children (CI = 1.40–2.89). The results further indicated that adolescent females who were using traditional contraceptives including the rhythm and withdrawal methods had 2.26 times the odds of having good ovulatory cycle knowledge as those who used no contraceptives (CI = 1.52–3.67). Respondents who indicated that they menstruated in the last six weeks before the survey had 2.01 times the odds of having good ovulatory cycle knowledge as those who did not menstruate (CI = 1.08–3.57). Regarding media exposure to family planning messages, adolescent females who had media exposure to family planning messages had 1.89 times the odds of having good ovulatory knowledge as those who never had media exposure to family planning messages (CI = 1.52–2.35). Finally, respondents who resided in communities with high literacy level had 1.62 times the odds of having good ovulatory cycle knowledge as those in communities with low literacy level (CI = 1.14–2.31).

Random effect and model fitness

The random effect results shown in Table2 indicate variation in knowledge of the ovulatory cycle (Cluster variance = 1.07; CI = 0.77–1.49]. As shown in Model I, the intra-class correlation (ICC) is 0.25. This indicates that about 25% of the variation in knowledge of the ovulatory cycle among adolescent females is attributable to cluster differences, and the remaining 75% is attributable to variations of individual factors. The ICC values were relatively stable across the Models (Model II = 0.22; Model III = 0.24, Model IV = 0.22). The model fit test revealed that the value of the estimated coefficient of the null model was lower (-1525.20), however, there was an improvement in the subsequent models, particularly in Model IV (log likelihood = − 1458.23). Also, the null model was found less desirable (AIC = 3054.40). However, the successive models showed improvement, with Model IV emerging as the most suitable model for this study (AIC = 2950.47).

This study used data from the 2022 GDHS to assess knowledge about the ovulatory cycle and its determinants among adolescent females in Ghana. The findings indicate that about one-fourth (24.6%) of adolescent females in Ghana have good knowledge of the ovulatory cycle. This finding is quite higher than what has been reported among reproductive women in Ethiopia (23.6%)and Haiti (24.1%) [7, 12, 17] respectively. However, previous studies in Nigeria [17] Turkey [18] and the United States of America [19] reported high levels (25%,47.6% and 32.8%, respectively) of good ovulatory cycle knowledge. The difference in the prevalence of ovulatory cycle knowledge might be due to differences in the study population, and educational level. While the present study was conducted among adolescent females, Wolde et al.’s [7] study in Ethiopia and Simon et al.’s [12] study in Haiti were conducted among reproductive women. Adolescents and reproductive women may have diverse characteristics and experiences that may influence their ovulatory knowledge levels differently. Also, Ozsoy et al.’s [18] study was conducted among university students in Turkey. This group of persons has higher literacy rates and thus might be better informed on reproductive health issues.

Consistent with previous studies [7, 9, 10, 20] the present findings demonstrate that secondary or highly educated adolescent females have good knowledge of the ovulation cycle. Similarly, adolescents in communities with high literacy levels had good ovulatory cycle knowledge. Education plays an important role in knowledge transmission [21, 22] and it is documented to have a positive effect on health and related behaviours including reproductive health [9, 23]. As found in this study, media exposure to family planning messages increases the likelihood of having good knowledge about the ovulatory cycle. Thus, educated adolescent females and communities with high literacy rates may have been exposed to the media including newspapers, radio, television, or websites where issues on reproductive health are discussed and therefore are better informed on reproductive health issues compared to those with no formal education. The finding underscores the crucial role education plays in health and related behaviours and this has pragmatic implications regarding reproductive health education strategies. Therefore, health policy makers, and relevant stakeholders should target adolescent females with little or no education as well as communities with low literacy rates in the design of reproductive health policies.

Also, it was evident in the present study that adolescent females with one or more children had higher odds of having good knowledge of the ovulatory cycle than those with no children. This finding is similar to a study by Ameyaw et al. [10] in Sierra Leone which reported lower levels of ovulatory cycle knowledge among women who had no previous births than those with previous births. The authors explained that women who have previously conceived or given birth tend to engage more with skilled health personnel on reproductive health information during anti-natal or postnatal services. This calls for periodic engagement between health professionals and adolescent females on reproductive health issues, particularly, within communities to help increase ovulatory cycle knowledge.

Further, adolescent females who were using traditional contraceptives had higher odds of having good knowledge of the ovulatory cycle than those who were not using any contraceptive method. This finding aligns with a study in India where women who were using traditional contraception methods had higher odds of having good ovulatory knowledge compared to those who used no method [20]. Also, in Haiti women who used no contraceptive method had lower odds of having good knowledge of the ovulatory cycle [12]. A plausible explanation is that effective use of traditional contraceptive methods (e.g. rhythm method) mainly requires having good knowledge of the ovulatory cycle [13]. Therefore adolescent females who adopted traditional methods may have acquired knowledge about the ovulatory cycle.

Moreover, the findings demonstrate that respondents who menstruated in the last six weeks prior to the survey had good knowledge about the ovulatory cycle. This is in line with other studies in low income African Countries [9] and Ethiopia [14]. The reason may be that they are likely to recall their recent menstruation period and thus can predict when their ovulation period will be [14].

The finding that adolescent females exposed to media family planning messages had higher odds of having good ovulatory cycle knowledge is supported by previous studies in sub-Saharan Africa [7, 9] and Haiti [12]. Mass media is one of the most effective ways to educate the masses [24]. It promotes public health by spreading health messages, raising awareness, and influencing health behaviour and attitude [12, 25]. Therefore, adolescent females exposed to media family planning messages may be better informed on the ovulatory cycle than those not exposed. Health organisations should continue to enhance the usage of the media as a viable means of reaching out to adolescent females for issues on reproductive health.

Limitations

The findings of this study should be considered within the following limitations. First, knowledge of the ovulatory cycle was self-reported and thus there is a possibility of information bias. Second, many of the socioeconomic variables explored may have bidirectional relationships with knowledge. Third, the Ghana Demographic and Health Survey data is cross-sectional and so, one cannot establish causality. Despite these limitations, this study is one of the few in sub-Saharan Africa which used nationally representative data to analyse knowledge of the ovulatory cycle among adolescent females. Therefore, it contributes to reproductive health literature in sub-Saharan Africa.

Authors and Affiliations

1. Department of Environment and Public Health, University of Environment and Sustainable Development, Somanya, Ghana

   Grace Frempong Afrifa-Anane

Contributions

G F A-A wrote the main manuscript text, analysed the data and reviewed the manuscript.

Corresponding author

Correspondence to Grace Frempong Afrifa-Anane.

Ethical approval and consent to participate

The protocol for the 2022 GDHS received approval from both the Ethical Review Committee (ERC) of the Ghana Health and ICF Institutional Review Board (IRB). Respondents gave informed consent to participate in the study before being interviewed.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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