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ABSTRACT

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. 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. The objective of this study aims to determine the factors associated with utilization of family planning services among women in rural areas of Akwa Ibom state, Nigeria. It is a descriptive cross-sectional, conducted among 364 women of childbearing age (15 to 49 years), utilizing the multi-stage sampling technique.139 (37%) of the respondents were within the age group 15 to 24 years, all respondents were married (100%) and 135 (37%) had more than 5 children. About half of the respondents (48.7%) had no formal education. Few were currently using a contraceptive method, however, the majority whom were not using any method had main reasons being lack of appropriate knowledge on family planning, fear of side effects and availability .The most significant socio-demographic determinants of utilization of family planning services were religion (p-value 0.01), family setting (p-value <0.001),age (p-value 0.01) and male involvement (p-value <0.001) . The utilization of family planning services among the rural women was poor, with religion, fear of side effect and husbands’ disapproval among other reasons being the main reasons for non use.

 

CHAPTER ONE INTRODUCTION

1.1. Background to Study

 

Family  planning  is  a global phenomenon which is among  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, Family Planning contributes to achieving the Millennium Development Goals (MDGs) via provision of 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.⁴

Nevertheless, Demographic and Health Surveys (DHS) reveals that in many countries- including those 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.⁹

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.¹⁰ 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).¹¹ 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.¹² 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 2015.¹⁴ 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.¹⁴ 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.^17,18 This greatly contributes to the high rate of unintended pregnancies leading to induced abortion with its consequent complications.¹⁷ 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.^14,19,20 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.^14,20,21

 

1.2 Problem Statement

 

The duration and number of pregnancies in a woman’s reproductive period affects the maternal mortality risk; other factors include the presence of co morbidities, and obstetric care. The effect of these factors is quantifiable by four measures: the number of maternal deaths, the maternal mortality rate (MMRate), the maternal mortality ratio (MMRatio), and the lifetime risk of maternal death.

 

The MMRate is the yearly number of maternal deaths per 1000 women of childbearing age (15– 49 years). The MMRatio has the same numerator, but is expressed per 100,000 live births. Lifetime risk of maternal death is the cumulative probability of a woman dying of maternal causes during her reproductive life, and is a measure of pregnancy-related female death. Both the MMRate and lifetime risk of maternal death respond directly to fertility rates and thus quantify the risk of maternal death per woman, whereas the MMRatio is indicative of risk per pregnancy due to poor access to and quality of obstetric services. A fall in the number of pregnancies lowers the number of maternal deaths because, self-evidently, in the absence of pregnancy, the risk of maternal death is non-existent.

 

Although the MMRatio is linked directly to improvements in maternity care, it also responds to fertility rates, which can affect the proportion of births to women with greater-than-average obstetric risk—ie, those who are younger than 18 years or older than 34 years, those with only one child or more than three children, and those whose births are closely spaced.

Increased contraceptive use and subsequent fertility decline results in decreased obstetric risk, mainly by reducing unwanted pregnancies in women of high parity. The risks associated with high parity are seen in parity-specific MMRatios, most of which, in developing countries, are derived from hospital delivery records. MMRatios tend to be raised at parity 1, then become lowered at parities 2–3, then raised again at 4–5, and highest at parities greater than 6. Raised maternal mortality risks at high parities have been seen in Pakistan, Senegal, and west Africa.

 

In terms of birth spacing, an analysis of more than 450 000 births in Latin America and the Caribbean between 1985 and 1997 identified an adjusted odds ratio (OR) of 2·5 (95% CI 1·2– 5·4) for maternal death when the interpregnancy interval (the length of time between pregnancies) was less than 6 months. However, a systematic review of 22 studies, a third of which were done in developing countries, examined birth spacing and maternal outcomes and showed inconsistent effects from short interpregnancy intervals on maternal mortality. The investigators reported a strong relation between short birth intervals and poor pregnancy outcomes and maternal morbidity, but a weak relation with maternal mortality, a paradoxical pattern warranting further research.