Abstract
Objectives
To determine the knowledge and attitudes on modern contraceptive use of women living in an inner city area of Osogbo.
Materials and methods
Three hundred and fifty nine women of childbearing age were studied utilizing a community-based, descriptive, cross-sectional study design. A multistage random sampling technique was used in recruiting respondents to the study. A four-part questionnaire was applied dually, by interviewers and by respondents’ self administration, and the data was analyzed using the SPSS software version 17.0.
Results
The mean age of respondents was 28.6 ± 6.65 years. The majority (90.3%) of respondents were aware of modern methods of family planning (FP), 76.0% claimed awareness of where to obtain FP services, and 74.9% knew of at least five methods. However, only 30.6% had ever used contraceptives, while only 13.1% were current users. The most frequently used method was the male condom. The commonly perceived barriers accounting for low use of FP methods were fear of perceived side effects (44.0%), ignorance (32.6%), misinformation (25.1%), superstition (22.0%), and culture (20.3%). Some reasons were proffered for respondents’ nonuse of modern contraception. Predictors of use of modern contraceptives include the awareness of a place of FP service provision, respondents’ approval of the use of contraceptives, higher education status, and being married.
Conclusion
Most of the barriers reported appeared preventable and removable and may be responsible for the reported low point prevalence of use of contraceptives. It is recommended that community-based behavioral-change communication programs be instituted, aimed at improving the perceptions of women with respect to bridging knowledge gaps about contraceptive methods and to changing deep-seated negative beliefs related to contraceptive use in Nigeria.
Introduction
Increasing the level of contraceptive use among women of child bearing age is an important component of many national population and developmental programs in sub-Saharan Africa; however the prevalence use of these methods is still low despite the efforts of many governmental and nongovernmental agencies (NGOs).Citation1 Globally, unplanned pregnancies and sexually transmitted infections (STIs) persist as significant threats to women’s reproductive health.Citation2 Barriers to the use of modern contraceptives by women might inhibit uptake of novel woman-controlled methods for preventing unwanted pregnancies and STIs/human immunodeficiency virus (HIV). Illegal abortions arising from unwanted pregnancies constitute a major reproductive health problem in Nigeria. Data indicate that the proportion of women having unwanted pregnancies in this country is increasing: women and couples increasingly want fewer children, and although they are also beginning to bear fewer children, behavior is lagging behind preference.Citation3,Citation4 Thus women and couples are increasingly having more children than they want.
Since abortion is illegal under most conditions in Nigeria, an increase in the incidence of unwanted pregnancy is likely to result in a rise in the incidence of unsafe abortions. This in turn, is likely to raise the proportion of women with abortion-related morbidity and mortality. The increasing incidence of complications from unsafe abortions can have a substantial impact on the country’s fragile health system. The use of “modern” contraceptive methods (oral pills, condoms, intrauterine devices, sterilization, implants, and injectables) has traditionally been low in sub-Saharan Africa, but there is evidence of an increase during the past decade.Citation5 During the 1990s, the self-reported use of modern contraceptives among married women increased in East Africa by 1% each year, to 17% by 1999; in West Africa, it increased by 0.5% each year, to 8% by 1999.Citation6
Huge resources have been committed to family planning (FP) programs by the stakeholders in reproductive health, however, communities are not usually involved in the planning and pre-implementation phases of programs, which would have encouraged their full participation and help to unravel the barriers to uptake of services. In addition, evidence as to how community-level contextual factors influence variations in the use of contraceptive methods is limited; this information could be useful, most especially in inner cities, where there are peculiar social and reproductive health problems, urbanization, and population growth and explosion. To date, most efforts at contraception have been health facility-based, while community-based distribution of contraceptives is still in the conceptual stage in Nigeria.
Knowledge, perceptions, attitudes towards contraceptive use, and barriers to use were investigated in this paper, with the aim of providing evidence-based data for stakeholders, including national governments, agencies, and NGOs, working on fertility reduction programs through contraception; these data can inform policy decision making and also serve as an advocacy tool, for a more coordinated and community-based approach in the design of programs that would remove barriers to use of modern contraceptives. This study determined the knowledge of and attitude toward modern contraceptive use, in women of childbearing age living in an inner city area of Osogbo.
Materials and methods
Study area
Osogbo is the capital of Osun State in the southwestern part of Nigeria. The town has a population of about 2.6 million, as per the last national census.Citation7 In the inner city area of Osogbo metropolis, the majority of inhabitants are traders, artisans, and civil servants. There is a teaching hospital, a general hospital and numerous Primary Health Centers (PHCs), as well as mission and private hospitals providing care within the metropolis.
Study design
This was a community-based, descriptive cross-sectional study of barriers to the use of modern contraception among women of reproductive age in the inner city area of Osogbo metropolis.
Study population
The target populations were women of reproductive age, 15 to 49 years, living in the inner city area for at least 5 years. The women who responded to the research instruments constitute the study population.
Sample size estimation
Using the sample size calculation formula for the calculation of sample size greater than 10,000Citation8 and a prevalence rate of 30.1%Citation9 for contraceptive utilization rate, the calculated sample size was 316. This was increased to 332 after adjusting for a 5% nonresponse rate; however, 380 respondents were surveyed.
Sampling method
A multistage sampling method was adopted in sample selection. In stage 1, a list of designated areas in the inner city area of Osogbo was obtained from the town planning unit of the State Ministry of Lands and Physical Planning. Fifty percent (four out of the eight areas) were selected by simple random sampling, employing simple balloting. A list of communities in each designated area was drawn in stage 2, and two were selected using simple random sampling (simple balloting). This evolved a total of eight inner city communities. Questionnaires were equally allocated to each community.
In stage 3, a sampling frame of all enumeration areas in each community was drawn. The enumeration areas used were allocated by the National Population Commission for the 2006 National population census. One enumeration area was selected per community using simple random sampling (simple balloting). In stage 4, a sample frame or list of all streets in an enumeration area was prepared, and two streets were chosen per enumeration area by simple random sampling employing simple balloting. On a street, the existing primary health care household numbering was utilized to select houses. Every house with the last number being an even number was selected, and the consenting women of child-bearing age therein participated in the completion of the research instrument until the allocated questionnaires for that community was exhausted.
Data collection
All eligible consenting women met in the sampled houses were interviewed with precoded, pretested, interviewer-administered questionnaires conducted by trained research assistants who could also speak the local language. A vernacular version of the questionnaire was prepared for the uneducated respondents, to reduce interobserver variation in interpretation during the interview. The questionnaire was translated and back-translated between the English and the local Yoruba language. Whenever a house was found to be empty, such houses were omitted, and the next even numbered house to it was selected to replace it. Data collection was conducted within a convenient period of 1 month. The study variables included information on the socioeconomic characteristics of the respondents, knowledge, attitude, the utilization of modern contraceptives, and barriers to use.
Ethical consideration and limitation
Ethical approval to conduct this study was obtained from the Research Ethics Committee of Ladoke Akintola University of Technology (LAUTECH) Teaching Hospital Osogbo. Approvals were also obtained from the Local Government Departments of Health and Community Development and the heads of selected communities. Verbal informed consent was obtained from each respondent.
Data management
The SPSS Version 17.0 (SPSS Inc., Chicago, IL, USA) statistical package was used for data entry and analysis. The validity of the data collected was ensured by double entry and by random checks for errors. Relevant frequency distributions tables and summary measures were generated. The Chi-square test was used to demonstrate relationships between categorical variables, and the level of significance was set at P-values ≤ 0.05, at the confidence interval of 95%, for all inferential analysis.
Results
A total of 380 respondents were surveyed, but only 359 questionnaires were adequately completed, giving a 94.0% response rate. shows the sociodemographic characteristics of the respondents. The mean age of respondents was 28.6 ± 6.65 years. At the time of survey, 265 (73.8%) were “ever married,” 194 (54.0) were Christians, and 278 (77.4%) had at least a secondary level education.
Table 1 Sociodemographic characteristics of respondents
shows that 324 (90.3%) respondents were aware of modern methods of F P, and 273 (76.0%) of these claimed awareness of where to obtain FP services. Awareness of most modern contraceptives was very high among respondents. The most commonly mentioned contraceptive method known to the respondents was male condoms (328 [91.4%]), followed by injectables (295 [82.2%]) and oral pills (258 [71.9%]). Many of the respondents were able to identify the common benefits and side effects of modern contraception. Among the most commonly cited benefits were child spacing (63.5%) and prevention of unwanted pregnancies (59.9%). However, the perceived side effects of modern contraceptives mentioned included irregular menstruation (59.1%), abdominal pain (24.0%), headache (22.3%), and infertility (21.2%).
Table 2 Respondents’ awareness and knowledge about modern contraception
shows the reproductive history, fertility desires, contraceptive use, and perceived barriers to contraceptive use among the respondents. One hundred and forty-nine respondents (41.5%) had at least two living children, while 14.5% had “ever lost” children. Most, 209 (58.1%), of respondents wanted at least four or more children in their lifetimes, and 216 (60.2%) reported desire for more children. The major reasons for wanting more children related to pressure from husband/relatives and the belief that child survival in Nigeria was not reliable. Only 110 (30.6%) had ever used modern contraceptives, while only 47 (13.1%) were current users. The most commonly stated reasons for not using contraception were the desire for more children (39.8%), fear of side effects/complications (38.6%), ignorance of contraceptive methods (26.5%), and perception of low risk of getting pregnant (because they did not have sex regularly or were sexually inactive) (15.3%), while nine (3.6%) respondents claimed that their husband did not support contraceptive use. The most commonly perceived barriers of respondents accounting for low use of FP methods in the community were fear of perceived side effects (44.0%), ignorance of contraceptive methods (32.6%), misinformation (25.1%), superstition (22.0%), and culture (20.3%).
Table 3 Fertility desires, contraceptive use, and barriers to use among respondents
The results showed that 284 (79.1%) of respondents declared their support/approval for the use of modern contraception. The most frequently used method was the male condom.
shows the attitudes of respondents towards modern contraceptive use. Although 277 (77.2%) of the respondents agreed that FP is good for the mother, as many as between one-quarter and one-third of these respondents opined that religion “is against” contraceptive use, that FP encourages infidelity/promiscuity, that it has many harmful side effects, that only the women should use contraceptives, and that the husband should be the one to take FP decisions.
Table 4 Respondents’ attitude to use of modern contraceptive methods (n = 359)
Analysis of the association between the respondents’ demographic/reproductive characteristics and uptake of contraception showed that “ever lost a child” (P < 0.01), awareness of place of FP service provision (P < 0.0001), approval of usage of contraception (P < 0.002), marital status (P = 0.001), and number of living children (P < 0.00000001) were all statistically significantly associated with “ever use” of contraception ().
Table 5 Association between respondents’ demographic/reproductive characteristics and uptake of contraception
shows the results of the multivariate logistic regression analysis of “ever used contraceptives” and some selected variables. Women who were aware of a place of FP service provision were five times more likely to have ever used contraception than were those women who were not (odds ratio [OR] 5.81; 95% CI 2.7–12.5; P = 0.001). Women who approved of the use of contraceptives were about three times more likely to have ever used contraception than were those who did not approve of it (OR 2.8; 95% CI 1.4–5.4; P = 0.001). Women with tertiary level education were about one-and-a-half times more likely to have ever used contraception than were those with secondary level education. (OR 0.66; 95% CI 0.36–1.22; P = 0.092). Women who were married were also three times more likely to have ever used contraception than were women who were single, (OR 0.34; 95% CI 0.18–0.64; P = 0.001), while women with more than two children were also three times more likely to have ever used contraception than were women with less than two children (OR 0.30; 95% CI 0.17–0.49; P = 0.001).
Table 6 Multivariate logistic regression analysis of “ever used contraceptives” and some selected variables
Discussion
Two-thirds of respondents in this study signified their desire for more children, with an average of three to four children desired per woman. This supports a studyCitation10 in which the mean number of children desired was four. Desire for more children is an indication of a desire for future fertility among women. This may be due to the relaxation of some fertility reduction campaign efforts made during the military era of the 90’s and to the fact that maternal services are free of charge in most states in Nigeria, even at both primary and secondary levels of health care. With a current population of over 150 million and a growth rate of approximately 2.4% per annum, Nigeria is the most populous country in Africa.Citation11 Population explosion causes a reduction in the “carrying capacity” of the ecosystem, bringing overexploitation, depletion, and pressure on natural resources, thus threatening public health.Citation12 Committing a vast amount of resources into organized and well-targeted FP programs could help curtail this public health problem. The population of inner cities, which is likely to be high, would only surge as a result of the reported pattern of fertility desires. This also has the potential of maintaining the expansive pattern of population pyramids of Nigeria and other developing countries, in which a significant proportion of the population are in the dependent younger age group.
The majority of respondents in this study were aware of at least five modern methods of F P, however only about one-tenth (13.1%) of respondents were currently using a modern method of F P. This high level of awareness and poor utilization pattern corroborates several other studies,Citation13–Citation16 in which awareness of contraception was high among majority of respondents, but only a minority used a method. Women in inner cities may be more exposed, have better access to media facilities, and may have visited nearby health facilities to obtain information on modern contraception and other reproductive health services. However, evidence has shown these are not sufficient to engender uptake of contraception. Low use of contraceptives could lead to unwanted pregnancies and its consequences, including psychological and physical health problems and unsafe abortions. This identified low utilization of contraception among this at-risk group of women calls for urgent intervention from both governmental agencies and NGOs. It should also inform policy makers and program planners on the need to target this very important sector of the society.
The most frequently used method among our respondents was the male condom. This had been reported by another similar study.Citation17 Condoms are accessible, affordable, and easy to apply or use, and its side effects are minimal. The presence of numerous retail shops that characterized inner cities could also explain this trend. The cultural acceptability of use of condoms for HIV prevention has increased over the yearsCitation18–Citation20 and may be responsible for this high utilization rate of condoms.
Several reasons were given by respondents for nonuse of contraception. Ignorance and misinformation were leading barriers to contraceptive use. This corroborates several other studies.Citation21,Citation22 Higher awareness would stimulate community members to look for more accurate information on desired methods from health care providers and consequently, promote correct and consistent use of the method. Alternately, gaps in women’s knowledge of modern contraceptive methods and misperceptions about contraception could prevent higher uptake of effective contraceptives, including methods that would prevent both pregnancy and STIs.
The safety of contraceptives and fear of side effects were prominent perceived barriers to contraceptive use in this study, and this agreed with findings from some other studies.Citation22,Citation23 In another related study, one-third feared safety, and about two-thirds reported at least one side effect, while one-half considered FP ineffectiveness of method as barriers to use.Citation24 In a similar study, the ability to tolerate the product’s properties, including the look, feel, smell, color, and taste was a determinant of and barrier to use of contraceptives.Citation25
Husband’s opposition was also significant among the barriers to contraceptive use in this study, and this corroborates other studies.Citation22,Citation23 Research on the reasons for FP nonuse in Nigeria generally points to women’s perceived lack of need for contraception (as was reported in our study), fear of side effects, and opposition to contraception on personal or religious grounds.Citation17,Citation26 As a result of the difficulties with modern contraceptive methods discussed above, young women were more likely to rely on traditional methods, such as periodic abstinence, withdrawal, or charms and herbal mixtures from traditional healers,Citation27–Citation29 and this is also supported by the findings from the current study. This finding provides evidence for the need of greater involvement of men in contraception and other reproductive health and rights issues affecting their spouse and family.
Inner-city people are more likely to be educated, have access to FP services, and lay little emphasis on traditional and cultural values, due to westernization. However, contrary to the National Demographic Health Survey, Nigeria (NDHS) 2008,Citation8 in which only one-quarter of respondents signified that they desired a greater number of children, the relatively higher proportion of desiring more children in this study, suggests that fertility issues have not been resolved adequately in Nigeria, probably due to the various barriers. The persistently high fertility in Nigeria despite FP programs suggests that there are yet undetermined barriers to contraceptive use and factors associated with contraception that has been rendering the current strategy less effective.
The associations found between some of the variables and the results of the regression analysis done in this study suggest awareness of a place of FP service provision, respondent’s approval of the use of contraceptives, higher education status, and being married as possible predictors of use of modern contraceptives. If a woman knows of health facilities where she can purchase contraceptives, most especially at an affordable price, it is likely that she would see out contraception. Better educated women are also more likely to seek information about reproductive health and are possibly more likely to have been empowered to convince their husbands of the need for contraception, even in instances where men were reported to initially constitute obstacles to contraception.
In addition, married women are more likely to be current users since they are formally married and are traditionally expected to be sexually active, refecting the cultural influences on sexuality and contraception. For reasons of health concern, the thinking that they have successfully completed their desired family size, and/or for economic reasons, women of reproductive age may also decide to use contraceptives. All these factors should be considered when planning fertility reduction programs in Nigeria.
Conclusion
Several socioeconomic and health facility-related barriers have been reported in this study. These might have been responsible for the low prevalence of modern contraceptive use among women living in the inner city area of an urban location in Nigeria, despite high awareness and favorable indicators for increased levels of use. Because many of these barriers are removable/modifiable, it is recommended that a community-based behavioral-change communication program be instituted, aimed at improving the awareness and perceptions of women with respect to desire for more children, at bridging the knowledge gaps about contraceptive methods, and at changing the deep-seated negative beliefs related to contraceptive use in Nigeria.
Disclosure
The authors report no conflicts of interest in this work.
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