|Year : 2016 | Volume
| Issue : 1 | Page : 3-10
Prevalence and determinants of contraceptive use in rural Northeastern Nigeria: Results of a mixed qualitative and quantitative assessment
Musa Abubakar Kana1, Yetunde O Tagurum2, Zuwaira I Hassan2, Tolulope O Afolanranmi2, Gabriel Ofikwu Ogbeyi3, Joshua Abubakar Difa4, Peter Amede5, Olubunmi O Chirdan2
1 Department of Community Medicine, Kaduna State University, Kaduna, Kaduna State, Nigeria; EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal
2 Department of Community Medicine, University of Jos, Jos, Plateau State, Nigeria
3 Department of Community Medicine, Benue State University, Makurdi, Benue State, Nigeria
4 Department of Community Medicine, Gombe State University, Gombe, Gombe State, Nigeria
5 Directorate of Health and Social Welfare, Nigeria Prisons Service, Bauchi, Bauchi State, Nigeria
|Date of Web Publication||6-Sep-2016|
Musa Abubakar Kana
Department of Community Medicine, Kaduna State University, Kaduna State University, Nigeria. EPI Unit, Institute of Public Health, University of Porto, Portugal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Family planning is an effective intervention for promoting maternal health, but its acceptability and utilization are impeded by many factors in Northern Nigeria. This study aims to assess the prevalence and identify determinants of contraceptive use in a rural setting.
Methods: A mixed method cross-sectional descriptive study was conducted in Gumau, a rural community of Bauchi State, Northeastern Nigeria. Quantitative data were collected using an interviewer-administered questionnaire while the qualitative data were collected using focus group discussions with selected women and their husbands, and key informant interviews with family planning service providers.
Results: Family planning commodities were regularly available in the community and the prevalence of current contraceptive use was 26%. The main determinants included age <35 years (odds ratio [OR] = 3.0; confidence interval [CI] = 1.0–8.9; P = 0.028), Christian religious affiliation (OR = 2.4; CI = 1.1–4.9; P= 0.025), and spousal support (OR = 55.1; CI = 16.0–189.8; P = 0.000). The qualitative data also reinforced the crucial role of sociocultural factors, especially men in decision-making and contraceptive uptake.
Conclusion: Sociodemographic factors, especially spousal support is a key determinant of contraceptive use that should be considered in the design of acceptable family planning intervention.
Keywords: Contraceptive use, determinants, mixed methods, Nigeria
|How to cite this article:|
Kana MA, Tagurum YO, Hassan ZI, Afolanranmi TO, Ogbeyi GO, Difa JA, Amede P, Chirdan OO. Prevalence and determinants of contraceptive use in rural Northeastern Nigeria: Results of a mixed qualitative and quantitative assessment. Ann Nigerian Med 2016;10:3-10
|How to cite this URL:|
Kana MA, Tagurum YO, Hassan ZI, Afolanranmi TO, Ogbeyi GO, Difa JA, Amede P, Chirdan OO. Prevalence and determinants of contraceptive use in rural Northeastern Nigeria: Results of a mixed qualitative and quantitative assessment. Ann Nigerian Med [serial online] 2016 [cited 2020 Sep 23];10:3-10. Available from: http://www.anmjournal.com/text.asp?2016/10/1/3/189801
| Introduction|| |
Nigeria accounts for 14% of global burden of maternal mortality with the extremely poor Northeastern region having an estimated maternal mortality ratio (MMR) of 1549 deaths per 100,000 live births, which is more than 5 times the global average., Family planning has been widely acknowledged to intensify maternal death reduction, which is recommended by the World Health Organization as one of the six essential health interventions needed to achieve safe motherhood. Accordingly, it has been demonstrated that by reducing high-parity births, family planning lowers a county's MMR by an estimated 450 points during the transition from low to high levels of contraceptive use.
Unfortunately, there are barriers to access and effective utilization of family planning services even where it exist in the community, and these determining factors include logistic, social, behavioral, and medical issues. Thus, the development of an effective and efficient family planning service requires intervention strategies to be designed in tandem with community-specific determinants of contraceptive usage.
Over the years, many family planning intervention approaches have been implemented in Northern Nigeria, but contraceptive use has not considerably improved.,,,, Various studies have been conducted in this area of Nigeria to explore and understand the barriers to uptake, but few have comprehensively examined community-specific determinants of contraceptive use from the demand and supply perspective.,,, In this study, we aim to assess the prevalence and identify determinants of contraceptive use in a rural community of Northeastern Nigeria by employing mixed quantitative and qualitative methods.
| Methods|| |
Study design and context
A mixed method cross-sectional descriptive study was conducted between April and June 2008 in Gumau town, a rural settlement in Toro Local Government Area (LGA) of Bauchi state, Northeastern Nigeria. Despite its rural nature, it is linked with a good road network and modern telecommunication service. Arable and pastoral agriculture as well as trading are the main occupations of the population. Modern health services are available in two government-owned primary health care (PHC) facilities, three private clinics, and six patent medicine stores. Specifically, family planning could be accessed in five of these outlets.
Study population and sample size
The study population consisted of resident women of childbearing age (15–49 years) and their husbands. Others were the heads of health facilities (private and public) and patent medicine vendors/chemists providing family planning service in the study community. A minimum sample of 151 was obtained, but 200 women consented and were eventually included in the study. The sample size was calculated on the basis of contraceptive awareness prevalence from a previous study (89.0%), taking the sampling error to be 5.0% with a level of confidence of 95.0%.
Both quantitative and qualitative instruments of data collection were used in this study. These consisted of a semi-structured interviewer-administered questionnaire used to obtain information on sociodemographic characteristics, knowledge, and utilization of contraceptive. The qualitative data collection tools included a key informant interview (KII) guide for family planning/contraceptive service providers, and the focus group discussion (FGD) guides to derive information on utilization from women of childbearing age and their husbands. The KII guide probed for information on the availability and preferred contraceptives and factors that affected their use. The FGD explored the knowledge, source of knowledge, utilization, and source of contraceptive devices as well as factors in the community that affect access and utilization of contractive devices.
Ethical approval and permission to conduct the research were sought and obtained at the institutional (Jos University Teaching Hospital, Jos, Nigeria) and community levels. Four trained research assistants (public health specialty resident doctors) were responsible for data collection. The selection of households was carried out by systematic sampling technique after conducting a household census that provided a sampling frame. The final selection of study participants was done at the household level. In each selected household, an eligible woman that gave informed consent was selected. In the households with more than one eligible woman, only one participant was selected by balloting that was done in the presence of all of them.
At each selected household, permission was obtained from the household head, and written informed consent obtained from the index female before the commencement of the interview. Three FGDs for younger women of childbearing age (15–30 years), older women of childbearing age (31–49 years), and husbands of women of childbearing age, respectively were conducted. Before commencement of the FGDs, verbal consent was obtained, and the procedure explained to the participants, especially the use of the tape recorder. Three KIIs were conducted in the contraceptive service delivery points; PHC center, private clinic, and patent medicine vendor.
The data were processed and analyzed using the SPSS version 22.0 statistical software (IBM SPSS Statistics for Mac, Armonk, NY: IBM Corp.). Continuous data were summarized as mean ± standard deviation and categorical variables expressed in proportions. The contraceptive prevalence rate was calculated as the percentage of women who were using contraceptive. Bivariate analysis was conducted to identify determinants of contraceptive use. Odds ratio (OR) and 95% confidence interval (CI) were used to estimate the strength of association between independent (sociodemographic) variables and the dependent (current contraceptive use) variable. The qualitative data obtained from the KII and FGDs were transcribed and thematic analysis conducted.
| Results|| |
Sociodemographic characteristics of participants
Two hundred eligible women responded to the questionnaire survey. [Table 1] outlines the sociodemographic characteristics of the participants. Their mean age was 27.3 years; 4% of them were aged <15 years, and the modal age group was 25–34 years (52%). Almost half (47.5%) of the participants were Hausas, and 15.5% were Fulanis. Other ethnic groups represented included Sanga (8.5%), Gusawa (7.0%), and Jarawa (3.0%). Their religious affiliation was Islam (78.5%) and Christianity (21.5%). Ninety-four percent of them were married; 53.5% and 46.5% in polygamous and monogamous marriages, respectively. Most (72.0%) of the married participants had been married only once in their lifetime while 20.5%, 6.0%, and 1.0% were in their second, third, or fourth marriages, respectively. The mean age at first marriage of the participants was 16.59 years with a range of 12–29 years. The mean parity and number of living children were 4 and 3, respectively while the mean interval between pregnancies for 43.5% of participants was 2 years.
|Table 1: Sociodemographic and gynecological characteristics of participants|
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Utilization of contraceptives
The prevalence and pattern of contraceptive utilization are detailed in [Table 1]. It shows that 42% of the participants had ever used contraceptives in the past, and the proportion of current users was 26%. Among the current users, only 35.5% of husbands were aware of their spouse's contraceptive usage. The injectable contraceptive was used by 64.6% while oral pills and implant were used by 14.6% and 20.8%, respectively. The reason for contraceptive use was based on multiple responses for 67.7% of those that had ever used it. The main reasons stated were child spacing (77.4%), medical reasons (19.4%), and completion of family size (3.2%). Twenty-eight women had previously discontinued contraceptive usage and half (14) of them were due to multiple factors. The specific reasons mentioned included experiencing of side effects (8; 28.6%), contraceptive failure (1; 3.6%), irregular use (1; 3.6%), and uncomfortable with contraceptive method (4; 14.2%).
Determinants of contraceptives utilization
The determinants of contraceptive utilization were assessed by quantitative [Table 2] and qualitative [Table 3],[Table 4],[Table 5] methods. Quantitatively, the main factors influencing contraceptive use were husband's support (OR = 55.1; CI = 16.00–189.76; P = 0.000), women aged <35 years (OR = 3.00; CI = 1.01–8.95; 0.028), Christian religious affiliation (OR = 2.37; CI = 1.12–4.99; P = 0.025), previous contraceptive use (OR = 120.6; CI = 16.09–904.14; P = 0.000), and awareness of contraceptive side effects (OR = 3.88; CI = 1.83–8.24; P = 0.000).
|Table 2: Factors influencing contraceptives utilization: results of bivariate analysis|
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|Table 3: Summary of focus group discussion with women of reproductive age|
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|Table 4: Summary of focus group discussion with husbands of women of reproductive age|
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|Table 5: Summary of key informant interview with heads of government owned and private family planning providers|
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The qualitative perspective on determinants of contraceptive use was extracted from FGDs with eligible women and their spouses. Both female and male participants expressed high awareness of contraceptives. The major sources of information comprised of radio, friends, and women who were educated at the maternity clinic. The women recognized that shyness and societal demand for female reserve contribute to nondisclosure of utilization. However, a lone respondent believed, “it has no benefit, which is why she doesn't use it.” Even though societal censorship constitutes a barrier to contraceptive use, many of the female discussants admitted ever using contraceptive. “The women commonly access family planning service from private sources (patent medicine stores/chemists) and only a few obtained it from the government maternity clinic.” “The preference for private providers was due to privacy when seeking family planning service.” Important reasons specified for contraceptive use by the female discussants included child spacing and maternal rest, which they believed would help maintenance of health and beauty. In addition, the women mentioned that people needed to restrict their family size as a result of the harsh economic condition. Nevertheless, “daily ingestion of oral contraceptives and lack of husband's support were major reasons for discontinuation of contraceptives use in the past.”
The male discussants proffered that family planning is beneficial for child spacing, limiting number of children, and maternal rest. In practice, they acquiesced that “its utilization was mostly by persons who were aware and reinforced by the “harsh” economic conditions necessitating restriction of family size. However, “the men generally admitted hindering contraceptive utilization by their spouses.” The men mostly base their decision on high cost of contraceptives, even though most of the participants were not aware of its actual cost. Some potential users do not want to be seen in public seeking the commodity because of the stigma attached to its utilization in the community. Importantly, “the men referred to religious injunctions that encourage procreation and thus abhorring contraceptive use.”
Interviewing government and private family planning service providers provided understanding of the supply factors of contraceptive use in the community. The available modern contraceptive methods included oral (Lo-Femenal), injectable (Noristerat) and Depo-provera. The contraceptive commodity supply is based on requisition to the PHC Department of the LGA (Government providers) and procurement from whole sellers in nearby urban settlement (private providers). Family planning commodities were always available and never experienced stock out. All categories of women demand for it but “men never come or escort their spouses to access family planning.” The most common method dispensed is injectable, especially Noristerat, which has good compliance due to its three monthly dose. Condom is not acceptable, and supplies normally get expired. “Clients' decision is affected by husband's lack of support and shy women do not like to come to the government maternity clinic, which has reinforced preference for chemist as a source because of the perceived privacy.”
| Discussion|| |
Findings of this study indicated that almost a quarter of women were currently using contraceptive, which is comparatively higher than the Nigeria demographic and health survey (NDHS) contraceptive prevalence rate of 4% reported for contemporary period of the study or later NDHS findings in Northeastern Nigeria., This observation has to be contextualized with the fact that our study was sited in only one community among many that constitute the sampling frame for the NDHS in this part of the country. Furthermore, the information we obtained from quantitative and qualitative assessment provided complementary evidence of discreet contraceptive use by women, which is undisclosed mainly due to lack of spousal support and societal censorship.
Sociodemographic factors influencing contraceptive utilization were examined in this study. Generally, we observed that the decision and demand for the uptake or discontinuation of contraceptive use were founded on multiple factors. This study showed that even with availability and accessibility of affordable contraceptives in a community with high knowledge of contraceptive among women. Spousal support featured as a significant decider of its actual utilization, which is an expression of underlining economic privation and patriarchal culture evident in parts of Northern Nigeria, where men play dominant role in decision-making for reproductive and family health., This finding is braced by results from other parts of the world, which showed that men were dominant decision makers in the reproductive health needs of families.,,,, In addition, intervention studies have validated that the rate of effective contraceptive usage among women improves, especially where family planning service targets both sexes.,,
Even though, a paradigm shift is advocated for targeting men in family planning programs. In Nigeria, male involvement has been observed to be minimal partly because the past family planning programs have been mainly directed toward women. Moreover, it has been documented that in many societies the reason for much resistance to family planning measures has a social-cultural basis: People do not easily accept rapid change in their customs. Fundamentally, respect for tradition and religious taboos are mixed with the fear that a family with only a few offspring might die out entirely, a compelling consideration for an environment where early childhood mortality rates remain high.,,
Certainly, the provision of an acceptable and effective contraceptive methods can only happen at a local level, taking into greater account of the social conditions, and without offending individual consciences. Essentially, birth control programs and services should be designed to meet the needs of individual communities by recognizing and taking into account of cultural idiosyncrasies to achieve set goals. The accumulated evidence robustly favors the enhancement of the integration of men into family planning program design and implementation.
Strength and limitation of study
This study is limited by its sample size and design of its quantitative component that precludes generalization and causal attribution. However, its major strength was the mixed methods employed to explore the determinants of contraceptive use. The triangulation of quantitative and qualitative data sources ensured that collected information was complementary and consistent. Although, qualitative findings reveal that societal censorship may potentially inhibit disclosure of the current or past contraceptive usage. The challenges to validity of the measurement of contraceptive use included social response and recall bias, for example, some of the respondents might have indicated past usage even when asked about current use. We hope that future studies with bigger sample sizes and covering wider geographical area would investigate this phenomenon by concurrent application of quantitative and qualitative methods.
| Conclusion|| |
The findings of this study showed that family planning services are available in the study community via government and private sources. The utilization of contraceptive in this community was principally determined by the woman's age, religious affiliation, spousal support, and knowledge of contraceptive (benefits and side effects). Therefore, we recommend culturally sensitive and acceptable strategies directed at relevant determinants as vital tools of improving the acceptance and utilization of contraceptives in this setting.
We appreciate the guidance and support of the PHC Department, Toro Local Government, Bauchi State of Nigeria. We are also thankful to Dr. Musa Umar who assisted with data collection, the Gumau Community, and participants of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]