|Year : 2016 | Volume
| Issue : 2 | Page : 30-34
A quantitative survey on potential barriers to the use of modern contraception among married women of high parity attending an antenatal clinic in Kaduna, Northern Nigeria
Amina Mohammed-Durosinlorun1, Zainab Mohammed Idris2, Joel Adze1, Stephen Bature1, Caleb Mohammed1, Mathew Taingson1, Amina Abubakar1, Solomon Avidime3, Lydia Airede1, Polite Onwuafua3
1 Department of Obstetrics and Gynaecology, Faculty of Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Community Health, Kaduna State University, Kaduna, Nigeria
3 Department of Obstetrics and Gynaecology, Faculty of Medicine, Kaduna State University; Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
|Date of Web Publication||20-Apr-2017|
Department of Obstetrics and Gynaecology, Faculty of Medicine, Kaduna State University, Kaduna
Source of Support: None, Conflict of Interest: None
Background: Nigeria has high maternal mortality ratios, and women of high parity are at higher risk of obstetric complications. Understanding barriers to the uptake of contraception is thus important. Methodology: A cross-sectional quantitative survey was done at the antenatal and postnatal clinics of Barau Dikko Teaching Hospital between September and December 2015. Questionnaires were administered to 400 married consenting women of high parity (five or more deliveries). The questionnaire extracted general and demographic information, history of contraception, and possible barriers to contraceptive uptake. Data were analyzed using Statistical Package for Social Sciences (SPSS) software version 22. Descriptive analysis was done using frequencies, percentages, and cross-tabulation. Chi-square test was used as a test of association where relevant, and P< 0.05 was considered statistically significant. Results: About 353 questionnaires were retrieved; respondents were mainly aged between 30 and 39 years, educated up to secondary level, Hausa and Muslims, and homemakers or traders. Women had a mean parity of 7 deliveries and highest, 15. There was high level of awareness of contraception, adequate spousal communication, and approval but a perception of high risk and side effects with contraceptive use. Conclusion: Fear of side effects was a major barrier to contraceptive use. However, a window of opportunity exists because they would be willing to use contraception in future. Hence, specific and individualized contraceptive counseling and patient selection is needed, as well as further education of women.
Keywords: Barriers, contraception, high parity
|How to cite this article:|
Mohammed-Durosinlorun A, Idris ZM, Adze J, Bature S, Mohammed C, Taingson M, Abubakar A, Avidime S, Airede L, Onwuafua P. A quantitative survey on potential barriers to the use of modern contraception among married women of high parity attending an antenatal clinic in Kaduna, Northern Nigeria. Arch Med Surg 2016;1:30-4
|How to cite this URL:|
Mohammed-Durosinlorun A, Idris ZM, Adze J, Bature S, Mohammed C, Taingson M, Abubakar A, Avidime S, Airede L, Onwuafua P. A quantitative survey on potential barriers to the use of modern contraception among married women of high parity attending an antenatal clinic in Kaduna, Northern Nigeria. Arch Med Surg [serial online] 2016 [cited 2019 Jun 19];1:30-4. Available from: http://www.archms.org/text.asp?2016/1/2/30/204802
| Introduction|| |
Nigeria's maternal mortality ratio remains at an unacceptably high level and is considered to be one of the highest in the developing world., Nigeria represents approximately 2% of the world's population but contributes a disproportionate 10% of all global maternal deaths., In 2008, Nigeria's maternal mortality ratio was reported to be 545/100,000 live births, with wide regional disparity; the average maternal mortality ratio in Northern Nigeria was 2420 (range: 1060–4477) per 100,000 live births, while similar data in the southern parts of the country were considerably lower between 454 and 772/100,000 live births.,, Women with higher number of deliveries (parity) are exposed to even higher risks of obstetric complications such as hemorrhage, malpresentation, anemia, uterine rupture, and complications associated with chronic medical problems such as diabetes and hypertension, as well as neonatal morbidity and perinatal death., High parity may imply nonuse of contraception or an unmet need for contraception. The average total fertility rate (TFR) in Nigeria is 5.5, but fertility rates are however highest in northwestern Nigeria (6.7). Fifteen percent of currently married women in Nigeria use a method of contraception, but the usage is lowest in the North; 3% in the North East, 4% in the North West, and as high as 38% in the South-West Zone. Increasing contraceptive uptake and reducing the number of pregnancies and potential pregnancy complications are thus important strategies of reducing maternal mortality.
Previous studies suggest that possible barriers to contraceptive use may include lack of awareness, especially where there are low levels of education, lack of access, cultural factors, religion, opposition to use by partners or family members, and fear of health risks and concomitant medical disorders.,,
This study aims to provide baseline data and to understand barriers, if any, to the use of modern contraception among married women of high parity in Northern Nigeria using Barau Dikko Teaching Hospital (BDTH) antenatal/postnatal clinic setting as a case study and to make recommendations based on results on how policies and programs can change to increase contraceptive uptake, especially in North Nigeria.
| Methodology|| |
Ethical approval was obtained from the Kaduna State Ministry of Health and verbal consent from participants to indicate their interest to participate in the study. The study setting was Kaduna. Kaduna state is located in the northwestern zone of Nigeria. It has a population of about 6.63 million based on the 2006 census projections.
The BDTH is the state-owned teaching hospital with a 240-bed capacity and offers secondary/tertiary care. It is located in Kaduna town and caters for the metropolis and its environs. The study design was a cross-sectional quantitative survey. Sample size was determined using the formula by Lemeshow et al.;n = z2pq/d2. For the purpose of the study, a prevalence rate of 15% is used, the national contraceptive prevalence rate obtained from the 2013 Nigerian Demographic and Health Survey. An additional 10% of calculated size was then added for attrition giving a minimum sample size of 216. Only married consenting women of high parity (five or more deliveries) were recruited. Women were recruited conveniently from the antenatal and postnatal clinics of BDTH from September to December 2015. The instrument of data collection was a semi-structured pretested questionnaire administered by three trained research assistants (two nurses and one health worker). The questionnaire extracted general and demographic information, history of contraception, and possible barriers to contraceptive uptake. After data entry and cleaning, data were analyzed using Statistical Package for Social Sciences (SPSS) software version 22 (Armonk, NY: IBM Corp). Descriptive analysis was done using frequencies, percentages, and cross-tabulation. Chi-square test was used as a test of association where relevant, anda P value of < 0.05 was considered statistically significant.
| Results|| |
Four hundred questionnaires were distributed and 353 were retrieved (88.3% retrieval). [Table 1] shows the demographic characteristics, parity, and number of living children of respondents. Most of the respondents were aged between 30 and 39 years (65.5%), with a minimum age of 20 years and a maximum age of 46 years and a mean age of 33.1 years. Majority of women were educated up to secondary level (45%), Hausa (74.2%), and Muslims (95.7%). Most of the women were homemakers or traders. About 36% of women were in polygamous marriages. Women had a mean parity of seven deliveries, and the highest parity was 15.
|Table 1: Demographic characteristics, parity, and number of living children of respondents|
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Not all women responded to all questions. When asked if they had attained their desired family size, 168 women responded and only 10 (16.8%) of them had attained their desired family size. One hundred and thirty-four women out of 340 (39.4%) admitted that they had unplanned pregnancies in the past. One hundred and eighty-five out of 335 (55.2%) had never used contraception. Among previous contraceptive users, 66 (44%) had experienced problems, mainly irregular bleeding.
Based on literature review, potential barriers for using contraception were classified as personal, partner, method, or service facility barriers as shown in [Table 2]. More women were aware of contraception and its benefits, and would be willing to use contraception. Only very few women had religious objections to the use of contraception such as: that it was improper to die and be buried with a foreign body like an intra-uterine contraceptive device and contraceptive implant, some felt it was religiously prohibited, especially if it was not medically indicated, there were other religious ways of avoiding a pregnancy. Most women communicate with their spouses about contraception and most husbands would approve the use of contraception. Most women had their preferred methods of contraception available but were worried about the side effects of contraception, mainly irregular menses. Other side effects they were worried about include weight gain, future infertility, predisposes to hypertension, cancer, and difficult deliveries in subsequent pregnancies. Contraception was generally accessible and affordable to women. Providers had previously denied choice of contraception in ten women but this was because the provider felt that the method was not suitable for the client.
|Table 2: Responses of clients to questions relating to potential barriers to contraception|
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On cross-tabulation, education, religion, ethnicity, occupation, and type of marriage were significantly associated with awareness and use of contraception (P < 0.05), while age, parity, and number of living children were not (P > 0.05) as shown in [Table 3].
|Table 3: Cross-tabulation of demographic factors and the awareness, previous and future use of contraception among women of high parity|
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| Discussion|| |
There were more Muslims (95.7%) and Hausas (74.2%) in this study as compared to other religious and ethnic groups. Although they are prevalent in the study setting, it could also be that they are more likely to be of high parity. The mean parity in this study was seven deliveries. This is higher than the current average Nigerian TFR of 5.5, though this varies by residence and region. Fertility is highest in the North-West zone where women have an average of 6.7 children and is consistent with our study. Fertility is lowest in the South-South zone, where women have an average of 4.3 children.
The high parity of respondents did not necessarily translate to a corresponding number of children currently alive. A sizeable number of women had lost at least one child or more (40.2%). Apart from high maternal mortality in the North, perinatal and child mortality is also high. This might be a contributory factor motivating women to have more children (hence stopping contraception) and replace children they lost, perhaps leading to a vicious circle as there is no guarantee the children from the current pregnancy will also survive. Hence, improving child care and survival may perhaps contribute to increasing overall contraceptive uptake in this setting.
Despite high parity, only 16.8% of women had attained their desired family size. Nationally, Nigerian women want, on average, 6.5 children while men want 8 children. Women's ideal family size is highest in the North-West zone at 8.4 (higher than 7 found in our study) and lowest in the South-West zone at 4.5. Low parity has been shown in other studies to correlate with increase in the likelihood of using reproductive health services.,
Fertility also varies with mother's education and economic status. Women who have more than secondary education have an average of 3.1 children, while women with no education have 6.9 children. Most of the women in this study were not very educated with only about 11% having tertiary education. According to the national demographic and health survey, contraceptive use among women increased with higher levels of education; contraceptive use was 37% in married women with more than secondary education, compared to 3% in married women with no education. This finding is consistent with finding from other studies , and reasons may include higher levels of awareness and information on contraception and better understanding of its benefits.
Knowledge of family planning methods is high in Nigeria; 85% of women and 95% of men aged 15–49 years know at least one method of family planning. In our study, only 67.5% of women were aware of contraception, lower than the national average. Since women were of high parity, they should have received information and contraceptive counseling during hospital attendance and care in their previous deliveries and their levels of awareness would have been expected to be much higher. We have already stated that the study population had low levels of education which might account for this. In addition, perhaps, they did not receive previous hospital care. A lot of antenatal clinics in our public hospitals are very full, and perhaps not all women are able to hear, or discern the health talks given. However, even among those aware of contraception, this does not necessarily translate into correct knowledge about contraception. Perhaps, more needs to be done to ensure knowledge is not tainted with myths and misinformation.
Surprisingly, an important negative finding in our study is that the usual barriers to contraception seen in others studies ,,,,, such as lack of awareness, inaccessibility, religious barriers, poor spousal communication, and lack of approval did not feature prominently among the study population. The main barriers to contraception noticed in this study were the perception that risks of contraception may outweigh benefits and the risk of side effects.
Injectable contraception, which is a hormonal method, is the most commonly used contraceptive in Nigeria and this population , and can cause irregular bleeding pattern. Irregular bleeding was the most common side effect experienced among previous contraceptive users in the study population. Irregular bleeding with injectables has been documented to lead to contraceptive discontinuation or method switching., In our experience in this setting of mainly Hausas and Muslims, common side effects of contraception such as irregular menstruation common with hormonal contraception can be very worrisome. This may probably be due to the fact that irregular menses disrupts religious obligations such as performance of prayers and even coital patterns and may have been overlooked by the service provider. This may probably account for why side effects of contraception constitute a significant barrier to contraception in this setting. There may also be ambivalence and overreliance on lactational amenorrhea method which is not reliable after 6 months postpartum. Fortunately, most women indicated that they would be willing to use contraception in the future (72.4%), meaning there is still an opportunity for the gap of unmet needs for contraception to be breached by intensifying information dissemination and provision of contraception.
| Conclusion|| |
Despite high levels of awareness of contraception, adequate spousal communication and approval, women of high parity in this setting do not use contraception due to perception of risk and side effects. However, a window of opportunity exists because they would be willing to use contraception in future. Hence, specific and individualized counseling will be needed to further educate them on the benefits on contraception. Research into newer contraceptives and proper selection of patients using standardized guidelines to select a suitable contraceptive method will help to minimize side effects and dispel myths. Counseling will especially be useful in the postpartum period before another pregnancy ensues. Girl child education needs to be encouraged and extended to postsecondary levels of education. Qualitative studies will also be useful to further explore the perceptions and fears about contraception.
Limitations of the study
The study was hospital based, so findings may not necessarily reflect why women of high parity in the community do not use contraception.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]