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CHAPTER ONE

INTRODUCTION

1.1 Background to Study

Family planning is one of the most ―health-promoting‖ and cost-effective activities in public health promotion and has the potential to avert approximately 30% of maternal and 10% of child deaths.1 Thus, FP contributes to achieving the Millennium Development Goals (MDGs) through healthier birth spacing and by reducing mortality and morbidity associated with pregnancy.2 Decades of research and investment in family planning programmes have resulted in dramatically improved programme coverage and biomedical technologies as well as significant (although uneven) increases in contraceptive uptake throughout most of the developing world.3 Contraceptive options—not all of which are available in many developing countries—include a variety of hormonal regimens and modes of delivery for women (e.g., pills, injectables, implants, patches, vaginal rings, medicated intrauterine devices) as well as improved male and female condoms, spermicides, cervical caps and other vaginal barriers, post-coital (emergency) contraception, improved fertility awareness-based methods, and simpler and more effective surgical techniques for tubal ligations and vasectomies.
Nevertheless, Demographic and Health Surveys (DHS) reveal that in many countries- including some with quite high rates of contraceptive prevalence -40% or more of women who recently gave birth reported that the pregnancy was wanted later or not at all.5 Proportions of married women with an unmet need for contraception also range up to 30 to 40% or more in a number of countries.6 Both of these situations reflect, to variable degrees, programme- and method-related inadequacies, including contraceptive failures due to a variety of reasons, as well as personal and situational factors such as partner’s opposition or women’s experiences or fears of side-effects that need to be addressed.7 Contraceptive information, needs and motivations evolve through the life course as male and female adolescents become sexually active before marriage or cohabitation (perhaps with several partners) or at the time of their marriage, and as couples decide if and when to begin childbearing (if they have not already accidentally done so); accumulate experiences with contraception (or its absence) and with pregnancy and childbearing; think about spacing and stopping; and are potentially faced with 10 or 20 more reproductive years at risk. Some women and men will divorce, remarry and decide to have another child; others will bear children (wanted or unwanted) outside of marriage or be motivated to avoid it. The environmental and contextual scenarios are many; the individual trajectories even more diverse. The challenge for educational and health sectors is to meet these changing needs with comprehensive information about pregnancy risks, acceptable contraceptive options, and correct and consistent use. Interventions include countering beliefs in ineffective methods and overcoming unrealistic fears about contraceptive side-effects that adolescents may already have acquired.
A sustained service package adapted to the specific and changing needs of individuals and couples and linked with other sexual and reproductive health inputs must be offered.8 The evidence base is by now quite extensive on how to create more user-friendly family planning environments, enhance client-provider interactions and other aspects of quality of care, and involve men as well as women in the discussion of contraceptive choices with respect to ease of use and need for partner cooperation, possible effects on sexual expression (e.g., coitus-dependent or independent methods), safety, efficacy, side-effects, acceptability, accessibility and cost.
Guidelines have been established for counseling clients such as unmarried adolescents who need dual protection; couples wanting to use a natural method; couples wishing to postpone their first pregnancy or space subsequent pregnancies; women or men who want to use a method without their partners’ knowledge; postpartum and breastfeeding women; women receiving post-abortion care; women who have had unprotected intercourse (including rape victims); individuals or couples looking for long-acting reversible or permanent methods; and women approaching menopause. The evidence base has also expanded greatly with respect to the medical aspects of contraception for male and female users. Method-specific medical eligibility criteria have been established for women of all reproductive ages who have particular health problems, such as heavy smokers and those with chronic diseases receiving long-term drug treatments (e.g. antihypertensive agents, antiretroviral drugs). Ongoing investigations are assessing the protective and risk factors of particular methods with respect to certain diseases (e.g., breast, cervical or testicular cancers, cardiovascular disease, endometriosis).
Family planning is an important preventive measure against maternal and child morbidity and mortality. It is an essential component of primary health care and reproductive health. It plays a major role in reducing maternal and neonatal morbidity and mortality. It confers important health and development benefits to individuals, families and communities and the nation at large. It helps women to prevent unwanted pregnancies and limit the number of children, thereby enhance reproductive health. By this, it contributes towards achievement of Millenium Development Goals (MDGs) and the Target of the Health for all Policy.13 The MDGs call for 75% reduction in maternal mortality and two-thirds reduction in child mortality between 1990 and 2015. As such effective utilization of family planning services is critical for the attainment of these goals thus improving health and accelerating development across the regions.15Access to family planning also has the potential to control population growth and in the long run reduce green gas house emission with it associated risk.13 Similarly it has been estimated that preventing unwanted pregnancies by the use of family planning would avert a total of 4.6million Disability Adjusted Life Years.16 Despite the importance and benefits of family planning, it has been estimated that about 17% of all married women globally would prefer to avoid pregnancy but are not willing to use any form of family planning.17 As a result, 25% of all pregnancies are unintended particularly in developing region of the world. This results to an estimated 18million abortion taking place each year, thereby contributing to high maternal morbidity and injuries.14,17 Sub-Saharan Africa which is home to only 10% of the world’s women, contributes annually, 12million unwanted or unplanned pregnancies and 40% of all pregnancy related deaths worldwide. The contraceptive prevalence in sub-Saharan Africa is low, estimated at 13%, in spite of the evidence of the pivotal role of family planning, while in Nigeria the estimation is 8.0% with 17% unmet need for family planning. This greatly contributes to the high rate of unintended pregnancies leading to induced abortion with its consequent complications. Despite the fact that Nigeria constitutes only 2% of the world’s population, it has being shown to account for 10% of the world’s maternal deaths. There is relatively high fertility rate in suburban and rural Nigeria despite the efforts of government and other non-governmental family planning services providers. Even though the fertility rate is high, acceptance and utilization of modern family planning methods has been low due to various reasons. In Africa, provision of family planning services is hindered by poverty, poor co-ordination of the programme and dwindling donor funding. Additionally, traditional beliefs favouring high fertility, religious barriers, fear of side effect and lack of male involvement have contributed significantly in weakening family planning interventions among women.

1.2 Statement of Problem
According to NDHS 2013, only 15 percent of currently married women in Nigeria are using a contraceptive method, indicating only a two percentage point increase from the 2003 NDHS. The majority of contraceptive users rely on a modern method (10 percent of currently married women), and 5 percent use traditional methods. Among the modern methods, injectables (3 percent), male condoms (2 percent), and the pill (2 percent) are the most common methods being used. The practice of all other modern methods is far less (under 1 percent). Interestingly, 3 percent use withdrawal as a method of contraception.
The use of contraceptives varies by women’s background characteristics. The proportion of currently married women who are currently using any method of contraception rises with age from only 2 percent among women age 15-19 to 22 percent among age 40-44. The use of contraception then decreases among women who are age 45 and older. Among modern methods, use of condoms is more popular among women under age 35, while injectables are more popular among women age 35-44. Currently married women in urban areas are considerably more likely to use any method of contraception (27 percent) than women in rural areas (9 percent). Use is higher in urban than in rural areas for each of these methods. Contraceptive use among currently married women aged between 15 to 49 years in North West Nigeria is 4.3% while that of North East and North Central are 3.2% and 15.6% respectively. Use is higher in Southern Nigeria with South East (29.3%), South South (28.1%) and South West (38.0%). Gross disparities occur among the six (6) geopolitical zones as well as among states. Kano State has contraceptive use of 0.6% (lowest in the North) with only 0.5% using any modern method (pill- 0.2%, IUD- 0.2%, injectables- 0.1% while 0.0% use implants, male condom, LAM, standard days methods and female sterilization).
There is a direct relationship between the outcome of pregnancy and family planning. The demographic transition theory states that only when fetal, infant, and child mortality rates are reduced it is likely that a family will accept family planning.29 Thus, improvement of maternal and child health services is a prerequisite for family planning. As a result, child spacing is a critical factor which influences the outcome of pregnancy. When women adhere to the World Health Organization recommended minimum inter-birth interval of 33 months between two consecutive live births, the incidence of prematurity reduces. Thus, prevention of rapid series of many pregnancies provides a greater possibility of reducing maternal, fetal, infant, and childhood mortality.30 In general, child spacing provides greater opportunities for nurturing the individual child thereby providing the possibility of preventing complications such as gastrointestinal infections and malnutrition during infancy and early childhood.30 Family planning may also improve the quality of life and raise the standard of living by decreasing the number of dependents requiring intensive personal care, education, food, shelter, and clothing, among others. Nevertheless, where family planning services may be available, its use may be limited due to a number of factors such as low literacy levels, socio-cultural beliefs favoring large families, and unavailability of services due to dysfunctional health services.31 Along with these dynamics in maternal care and contraceptive use patterns, there has been less progress in improving infant and child survival and primary care utilization. As of 2008, the North West and North East regions were the regions with the highest proportions of children 12-23 months who had never been vaccinated, 48.7% and 33.9%, respectively, and fewer than 15.0% had a vaccination card. Vaccination coverage rates in the four northern states of Zamfara, Katsina, Jigawa, and Yobe were all 5.4% and below.27 When their young children became sick with pneumonia, malaria or diarrhea, under half of all sick children were taken to a health facility for treatment. Infant mortality rate was 139 deaths per 1,000 births in the North West region and 126 deaths per 1,000 live births in the North East region, while under five mortality rate was 217 and 222 deaths per 1,000 live births, respectively. Hence, this study on factors mitigating against family planning amongst women in rural communities a case study of Obibe Ezena community, Owerri North, Imo state.