According to World Health Organization expert Committee in 1971, family planning is defined as a way of thinking and living that is adopted voluntarily upon the basis of knowledge, attitudes and responsible decisions by individuals and couples in order to promote the health and welfare of the family group and thus contributes to the social development of the country  . It also refers to the conscious effort by couples to limit or space the number of children they want to have through the use of contraceptive methods  . Generally many developing countries like Nigeria are characterized by rapid population growth that is partly attributed to high fertility rate, high birth rates, accompanied by steady declines in death rates, low contraceptive use and high but declining mortality rate    . This rapid increase in population has an adverse effect on the national economy and also the increasing number of births has a deleterious effect on the health of the mother, which in turn hinders social and economic uplift of the family  . With natural growth rate of 2.4% and high fertility rate of 5.5 (rural, 6.2, urban 4.7), the population of Nigeria is still rapidly increasing with an estimated population of 177.5 million in 2014    . Going by this report, Nigeria is currently the 9th largest country in the world and the most populous black nation   . Worldwide, the 10 countries with the highest maternal mortality ratios (MMR) are in Africa of which Nigeria is one of them, and an estimated 14 percent of maternal deaths globally occur in Nigeria, despite the fact that Nigeria comprise only 2% of the world population   . Despite these associated problems, the contraceptive prevalence rate in Nigeria has remained consistently low, steadying at 12.6% from 2003 to 2008 but only increased marginally to 15% for use of all methods in 2013 National Survey    . This is of grave concern because contraceptives had been found to effectively control population explosion if properly used. Due to this high fertility rate and consequent problems, one of the cardinal objectives of Nigeria National Policy on Population is to reduce the high level of fertility in the Country  . The guiding principle in achieving this objective is to emphasize the voluntary acceptance of family planning method in accordance with fundamental human rights and making them available at little or no cost   . Several factors have been found to influence contraceptive use around the world and some of these factors have negative effects while others have positive effects on contraceptive use. Some of the factors found to influence use in some of the reviewed works were; age of women    -  , marital status      , religion        , level of education of women         -  , level of knowledge about family planning      , socio economic status of women (monthly income, occupation, ownership of household items and wealth index)        , fertility related issues, (parity, family size, number of males, age at marriage, and years of marriage)         , place of residence (rural or urban)/region of the country of respondent     , tribe of respondents   , family setting (monogamy or polygamy)  , and attitude towards family planning  . Issues concerning place of service like; quality of service rendered, proximity of service point, friendliness of care providers  and availability of family planning service  were also found to influence the use of family planning methods.
Others factors reported to have influenced contraceptive use were issues related to their male partners like; partners/spousal approval of use or support      , prior discussion with partner  , husbands occupation  , and level of education   .
Thus this study aimed to determine the factors influencing family planning method use among women of reproductive age in urban communities of Imo state, Nigeria.
2.1. Description of Study Area
Imo State is one of the 36 States of Nigeria in the South Eastern Region of the country. It has a total population of about 3.93 million people, comprising more males than females (2.03 million and 1.9 million people respectively), with population growth rate of 2.89 from 1991-1998 and 3.0 from 1999-2005. The majority of the people living in the State are Igbos  . The State has 27 Local Government Areas of which 5 are urban as designated by the National Population Commission (NPC)  . The major occupation of the people in the urban areas is trading, artisan and public service. The main religion of the people is Christianity. Owerri Municipal Local Government Area is an Urban Local Government Area and the state capital.
2.2. Study Design/Study Population/Inclusion Criteria
The study was a cross-sectional survey of the factors influencing family planning services use among women of reproductive age group (15 - 49 years) in urban Communities in Imo state. The study population consisted women of reproductive age group in the selected study areas of the state. All women of reproductive age (15 - 49 years) whether married or single were included in this survey. For an individual to be selected she must have been resident in the enumeration areas selected for the study for at least a period of one year prior to commencement of research.
2.3. Minimum Sample Size Estimation
Using the Cochran sample size formula for calculating minimum sample size in populations greater than 10,000 and proportions of women in reproductive age group in South East Nigeria who are currently using any form of contraceptive method among urban dwellers from a previous study (15.2%)  .
n = Sample size to be estimated, p = Proportion of women within the reproductive age currently using any form of contraceptive method (15.2%)  , Z = Standard normal deviate corresponding to 95% significance level ≈ 1.96, d = level of precision desired for the study set at 0.05. The total sample size of 560 was used for this study.
2.4. Sampling Technique
The sampling technique used for this study was multistage sampling technique. The first stage involved the selection of the Local Government Area that was used for the study from the 27 Local Government Areas in the State. The Local Government Areas (LGA’s) were grouped into 2 categories. Category A, were made up of 5 urban Local Government Areas; and category B, consisting of 22 rural Local Government Areas. From category A, Owerri Municipal Local Government Area was selected by simple random sampling technique, using balloting. The second stage involved the selection of the primary sampling units from the LGA’s. The enumeration areas (EA’s) which are geographic clusters that have been clearly demarcated by the National Population Commission (NPC), served as the primary sampling units. Then using simple random sampling technique, ten EA’s were selected out of 750 EA’s in Owerri Municipal.
The third stage involved the selection of the respondents that were interviewed. From the LGA, 560 women in the reproductive age group (15 - 49 years) were recruited for the survey, thus a total of 57 respondents per EA were recruited. In each of the selected EA’s, a random starting point was determined in the field by the supervisor using a community landmark such as village square, church, or a mosque, market, school or streets and movement was in a clockwise direction. Eligible respondents were consecutively recruited and interviewed until the required sample size for the selected EA was achieved.
In any EA where the required sample size could not be obtained, simple random sampling was used to select another EA outside those previously selected and respondents studied until the required size for that EA is completed. Only one eligible respondent per household was interviewed during the survey. If a household had more than one eligible respondent, only one was randomly selected by simple balloting.
2.5. Data Collection Process, Techniques and Analysis
There was proper community entry, sensitization and mobilization. A semi-structured, pretested, interviewer administered questionnaire for women of reproductive age group was used. The questionnaire was pretested for comprehensibility, appropriateness of language, sensitivity of questions, and average duration for administration. The questionnaire was divided into 2 major sections, the first section was designed to obtain the socio-demographic characteristics of the respondents and the second section was designed to access the knowledge, awareness, practice and use of family planning services. This was to ensure validity and reliability of the study. Data collected was cleaned and validated manually, while a computer software package (EPI INFO version 3.3.2) was used for data entry and analysis. Frequencies and percentages of relevant variables were generated and bivariate analysis conducted using chi-square. For the purpose of this study; respondents who could not mention any family planning method were categorized as having poor knowledge, any correct mention of any two (2) or less was classified as fair knowledge and correct mention of any three (3) or more was classified as having good knowledge of family planning methods. A p-value < 0.05 was considered.
2.6. Ethical Consideration
Ethical clearance was obtained from the Ethics Committee of the Nnamdi Azikiwe University Teaching Hospital Nnewi (NAUTHEC) before the commencement of the study. In addition before the questionnaires were administered, the concept of the study was carefully explained to each participant and consent obtained from all the respondents. They were also assured of confidentiality and that participation was optional. All authors hereby declare that the study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
Table 1 shows that mean age of the respondents was 32.7 ± 7.7 years with majority of them, 365 (65.9%) being currently married, had secondary 295, (52.3%) or tertiary 244, (43.6%) education, were of catholic Christian denomination, 251 (44.8%), employed, 410 (73.2%), of Igbo extraction, 550 (98.2%) and were in monogamous unions, 390 (92.2%). Average family size and number of male children were 3.5 ± 0.8 and 1.5 ± 0.4 respectively with a median personal monthly income of 20,320 naira (68 USD). Most of the married women, 350 (82.7%) were currently staying together with their husbands’ and majority of their husbands, 413 (97.6%) were employed, had secondary 216 (51.1%) or tertiary education, 174 (41.1%).
Table 1. Socio-demographic characteristics of respondents.
Table 2 shows the level of awareness and knowledge about family planning amongst women. Almost all the women, 555 (99.1%), have had about family planning and the common methods mentioned were; pills, (63.2%) injections, (62.5%), condoms, (61.3% and natural family planning methods/rhythm, (49.5%). Majority of the women, 450 (81.1%) had a good knowledge about family planning methods.
Table 3 shows that contraceptive knowledge increases significantly with increase in educational attainment of respondents with those that had tertiary education having better contraceptive knowledge than others, (X2 = 25.30, p = 0.001) (Table 3).
Table 4 shows distribution of respondents’ views on issues concerning male involvement in family planning. Slightly above one third of women (28.4%) agreed that their partners did something to delay pregnancy though majority of
Table 2. Awareness and knowledge about family planning.
** = multiple response.
Table 3. Educational attainment and contraceptive knowledge.
* = significant.
Table 4. Distributions of Respondents views on issues concerning male involvement in family planning.
them, (92.7%) responded that their partner opinion was important in family planning use. Majority of the women (81.9%) said that they cannot decide to use family planning without their partners consent while a lower proportion of them, (41.3%) claimed to have ever discussed family planning issues with their spouses. Less than half of their partners, (44.6%) were in support of modern family planning methods.
Figure 1 shows that the prevalence of contraceptive ever used was 54.1% while current use was 35.2%.
Table 5 and Table 6 shows that contraceptives methods commonly ever used were; condoms (36.0%), NFP/rhythm (27.7%), pills (25.0%), and injections (22.3%) while the common methods currently used were; condoms (26.0%), NFP/Rhythm (24.5%), withdrawal methods, (19.9%) and IUCD (19.4%). Commonest reason for choice of contraception used was; it is convenient, (49.5%), followed by it was recommended by healthcare professionals, (39.8%) and it is effective (35.2%), while the common reason for not using any form of contraception were; I want more children (47.4%), I am pregnant (24.1%), and fear of health problems/side effect (25.5%) (Table 5 and Table 6).
Table 7 demonstrates that age of the women influenced contraceptive ever use significantly, (X2 = 40.530, p = 0.000), showing an increasing likelihood of ever used with increasing age of respondents, those 45 - 49 years of age had the highest likelihood to have ever used any form of contraception (OR = 18.64; 3.97 - 83.22) than women in the other age groups. Employed or working women were more likely to have ever used any form of contraception in their life time than their unemployed counterparts, (X2 = 10.801, P = 0.000, OR = 0.53; 0.36 - 0.78). Those with greater than four children, (X2 = 54.144, p = 0.000, OR: 22.55; 10.00 - 50.84) and 3 - 4 male children, (X2 = 49.910, p = 0.000, OR: 12.50; 6.36 - 24.60) were more likely to have used any form of contraception than their counterparts. Level of contraceptive knowledge influenced ever use of any form of
Figure 1. Prevalence of contraceptive use among respondents.
Table 5. Contraceptive methods ever used and currently being used among respondents.
Others = diaphragm, cervical caps, vaginal foams/gels/spermicides and traditional methods. ** = multiple response.
Table 6. Reasons for current contraceptive method use and non-use.
** = Multiple response.
Table 7. Factors influencing ever use of contraceptives among respondents.
* = statistically significant.
contraception significantly, (X2 = 48.250, p = 0.000) and those with high or good knowledge were the most likely to have used any form of contraception than their counterparts with low knowledge about contraceptive methods (OR: 21.01; 2.72 - 162.05). Generally, religion had no significant influence on ever use among the women (P > 0.05) but those of orthodox domination were more likely to have ever used any form of contraception than their counterparts in other dominations (OR: 1.68; 1.06 - 2.64). Marital and educational status of women had no significant effect on ever use of any form of contraception, (p > 0.05).
Table 8 shows factors influencing current use of contraceptives among women in urban communities of Imo State, Nigeria. Age of women was found to significantly influence current use of any form of contraception (X2 = 21.740, p = 0.001) with women 40 - 44 years, (OR: 4.83; 1.05 - 35.27) being more likely to use than their younger counterparts. Religious denominations attended by the women played a significant role (X2 = 5.72, p = 0.017) with women in orthodox denomination (OR: 1.86; 1.18 - 2.93) being the most likely to be using any form of contraception than their other counterparts in other denominations. Family size, (X2 = 35.710, p = 0.000) and number of males a woman had, (X2 = 39.90. p = 0.000) had significant influence on current use of contraception with those of the family sizes greater than four, (OR: 34 86; 8.14 - 149.26) and males greater
Table 8. Factors influencing current use of contraceptives among respondents.
* = statistically significant, Na = not applicable.
than four (OR: 16.39; 5.07 - 52.99) being more likely to be using any form of contraception than their counterparts. Monthly income of the respondents significantly influenced current use of contraception, (X2 = 14.360, p = 0.000) with those earning 40,000 Naira (110 USD) and above being more likely to be using any contraception than the other counterparts with lower income, (OR: 4.26; 2.07 - 8.77). Women with good or high knowledge about contraceptive methods are more likely to be using any form of contraception than their counterparts with lower contraceptive knowledge (X2 = 35.440, p = 0.000, OR: 3.74; 2.05 - 6.80). Those who had used any form of contraception previously were more likely to currently use, (X2 = 241.741, p = 0, OR: 226.93; 55.35 - 930.41). Marital status, educational level of women, employment status, and family type did not play any significant role in influencing contraceptive use among the women, (p > 0.05).
Table 9 shows the influence of male associated factors on current use of any form of contraception among the women. Women who have ever discussed family planning with their partners, (X2 148.230, p = 0.0000, OR: 10.90; 7.24 - 16.43), those whose partners were in favour of modern family planning methods, (X2 = 73.180, p = 0.000, OR: 4.94; 3.41 - 7.24) and women who could access and
Table 9. Influence of male associated factors on current use of contraceptives among respondents.
* = statistically significant.
pay for family planning services without their husbands support, (X2 = 7.96, p = 0.004, OR: 1.69; 1.19 - 2.40) were more likely to be using any form of contraception than their counterparts. Husbands’ level of education, occupation, and current stay with husband did not play any significant role in current use of any form of family planning method, (P > 0.05).
The contraceptive awareness reported in this study was high (99.1%) and the common contraception methods known were; pills, injections and condoms while the least known method was traditional method. Also the level of knowledge among the respondents about contraceptive method was high (81.1%). This was higher than the national average of 85.2% for all women of reproductive age in Nigeria but consistent with 99.7% reported from the state  . It was also higher than the figure reported from a Country wide survey  . This high awareness might likely be due to increased contraceptive information spread through the mass media and other sources. The contraceptive prevalence was 35.2%, it higher than figures reported from the 2013 National survey (15.0%), and a figure reported from urban localities of the country (27.0%)    . It was consistent with the figure reported from the state (34.1%)  . The high awareness noticed in this survey did not translate to high contraceptive use and this could have accounted for poor health indices recorded in the state and country at large. This brings to question the quality of information gotten and the source of contraceptive information. The commonly used contraceptives were condoms, Natural methods, pills and injections. This was still the pattern in some of the reviewed works     even though the prevalence of tubal ligation in this study was higher than what was reported in these studies. The primary reason why condom was the commonest used was its dual purpose of prevention of unwanted pregnancy and protection from the transmission of sexually transmitted diseases which is on the rise globally.
Age of the respondents was found to influence contraceptive use significantly, both ever and current use increased with increasing age of women. Older women above 40 years of age were more likely to use than those in the younger age group. This pattern has been reported in several studies    -  . This pattern possibly reflects the desire for more children among young women than the older women who would have completed their families and would want to use family planning to limit family size rather than for spacing births which is commoner among women in the young age group. However an older study from Burkina Faso and New Delhi India showed that current use of contraceptive method was higher among the younger age groups, 20 - 29 years and 15 - 29 years of age respectively   .
Religion influenced family planning method use with those in orthodox denominations being more likely to use family planning than others. This pattern has been reported from several studies around the world        . This supports the widely speculated belief that some religions bodies tend to have a higher disapproval rate for contraceptive method use than others. This is not a good report in a country like Nigeria with deep religious beliefs, high population growth rate and high infant and maternal mortalities. A good starting point may be advocacy to Clerics and church leaders for them to help convince their adherents that family planning is beneficial and to explore possible areas of common ground among those with dogmatic disapproval to contraception.
Fertility related issues i.e. family size and number males in the family was found to influence family planning method use in this study with those with large family size and number of males being more likely to use than those with smaller family sizes. This report was consistent with findings from other studies         , though a few reported no influence   . This further strengthens the fact that most women use family planning to limit family size rather than space pregnancies. Our culture still shows preference for males, forcing women with no males to continue having children, irrespective of the inherent damages thereby limiting their use of contraceptives as typified in our study.
Those who earn high incomes were more likely to use than those with low income. Also those who can access and pay for family planning services without their husband’s support were more likely to use than those who cannot pay without their husband financial support. Ever use was more among working women than those not working. Significant effect of socioeconomic status of women (monthly income, occupation, ownership of household items and wealth index) on contraceptive use has been reported from several studies around the world         , though a few other studies showed no significant relationship   . This shows that financial issues play a vital role in whether a woman will use family planning or not. This portrays a great danger in our country which is a male dominant society where the females seem to be less empowered financially and have to depend on their husbands for support. This calls for urgency in the empowerment of women and political will to provide free family planning services that is culturally acceptable to the people.
Though educational status of the respondents was not found to influence contraceptive use in this study, a pattern which has also been reported in some other studies    , yet contraceptive knowledge has high influence on contraceptive use with those having good knowledge about contraceptive methods being more likely to use than others. This pattern of influence of contraceptive knowledge on contraceptive use was consistent with findings from other studies within and outside the Country        . Despite the fact that education did not influence use, it was found that increase in educational level of respondents significant increased the level of contraceptive knowledge among the women. This has been reported in a study in Nigeria  . Thus whatever affects knowledge will likely influence contraceptive use, hence the right information when given properly improves knowledge and could lead to an increase in contraceptive use.
Other factors found to have positive impact on family planning in this study were issues related to male involvement or roles in family planning use. Those women who had ever discussed family planning with their partners or spouses were about 10 times more likely to use than those who have not discussed it with their spouses. This finding was similar to reports from studies elsewhere    . Also the study revealed significant association between partners support in favor of modern family planning and current contraceptive use with those whose partners were in support being about 5 times more likely to use than those whose partners were not. Similar studies done in different parts of the Country and beyond showed results consistent with the above findings         . This finding corroborates the fact that most of the Nigerian society is patrilineal with strong male influence on many household decisions making including those involving reproductive health matters. This is of a serious public health concern that needs urgent attention even as majority of the women (92.7%) reported that their husband’s opinion is important in family planning matters. Despite this perceived importance of males in family planning use in this study, some studies reported unfavorable attitude of spouses towards the use of family planning    .
Limitation to study: The study was a cross-sectional study and the findings were based on the responses of the study participants which may be subject to some level of response bias. Thus care should be taken in generalizing the findings of this study. Also it will be difficult to establish cause effect relationship.
Despite a high awareness found in this study, the use of family planning method was low. The factors influencing contraceptive use as found in this study were: age of women, religion, family size, number of males, monthly income, contraceptive knowledge, ability to access and pay for family planning services without partner financial support, prior discussion of family planning with partner and partner being in support of modern family planning methods. Most of these factors are modifiable and serious interventions focused on proper health education, provision of free and accessible family planning services, provision of incentives, inclusion of men in family planning and implementing of the existing family planning policies in the country will go a long way in improving the utilization of family planning services. These interventions among others have shown significant improvement in family planning services utilizations in countries where they have been implemented.
We want to thank these women who participated in this study including the Community Leaders who gave us access to their communities. This work is part of a postgraduate thesis submitted for the award of Fellowship of the West African College of Physicians (FWACP).
CBD carried out the research from conception to the write up of the final draft of the article. OE had supervised and critically commented at each stage of the research. All the other authors read and approved the final manuscript.
The authors hereby declare no competing interests.
Source of finding
There was no external source of funding.
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