INTRODUCTION       

Contraception is the use of the various methods to prevent a pregnancy other than abstinence from coitus.¹ A reversible contraception is a temporal prevention of fertility and it includes all currently available contraceptive methods except sterilization.²

Family planning is an important subject in the developing world especially sub-Saharan Africa. This is because Africa has one of the highest fertility rates in the world.^2,3 The fertility rate in Nigeria is 5.5%,^3,4 while fertility rate in the United Kingdom and the United States of America are 1.89% and 1.87% respectively as at 2016.^2,5   Nigeria has a population of about 170 million with a doubling time of 23 years.²

 With population explosion globally, there is much burden on the limited social infrastructure and amenities, limited economic development, unemployment prevalence, worsening food scarcity, vicious cycle of poverty; decrease efficiency and productivity of the work force and environmental degradation.⁶  In other to curb all of these negative impacts of population increase, contraceptive uptake have become imperative especially in developing countries.

In developing countries contraceptive uptake is low and it could result from non-availability of contraception, low level of knowledge of the contraceptive methods amongst other reasons.⁶ The knowledge of contraceptive methods is high in Nigeria as most women and men know at least one contraceptive method but their actual use or uptake amongst women in Nigeria is very low (about 10.5% from family planning worldwide sheet 2013).⁴ Thus a high knowledge of contraception does not translate to increase uptake of contraception.

Developing countries are characterized by rapid population growth which is usually due to high fertility, high birth rate and low contraceptive prevalence rate.⁷ In Africa, the rate of population growth is high compared to the rest of the world; consequently the number of people in need of health, education, basic infrastructure among other public benefits is enormous.⁷

This in turn requires large amount of resources and personnel; and it may be an impediment towards the realization of the sustainable development goals.⁷

Promotion of family planning and access to modern contraception in countries with high birth rate has the potential of decreasing poverty, hunger, decreasing unwanted pregnancy, slowing population growth, decreasing the cost of meeting sustainable development goals in terms of universal primary education which is influenced by the number of children in need of education; decreasing injuries, illness and death associated with child birth, abortion, sexually transmitted infection including HIV, averting maternal deaths and new born mortality, improving life expectancy, and reducing the dependency ratio with preservation of the environment.⁸  The use of modern contraceptives also affects educational prospects and human capital among adolescent girls by preventing teenage pregnancies.⁹

Unintended pregnancy poses a major health challenge to reproductive health. About 36% of pregnancies are unplanned leading in most cases to criminal abortion and maternal deaths.¹⁰

Although there is a wide spread awareness of contraception methods in Nigeria, there is no increase on the adoption of the contraception measures which is a pointer to the fact that there are other variables that determine the uptake of contraception in Nigeria.¹⁰   These variables may be age, education, religion, residence, ethnicity, media exposure to family planning, positive attitude to reproductive health issues. The implication of low contraceptive use varies from unintended pregnancies with its attendant illegal unsafe abortion to population expulsion.¹⁰

MATERIALS AND METHODS

The study was conducted at the Federal Medical Centre which is located in Yenagoa, the capital of Bayelsa state Nigeria; with the annex of the hospital at Otuoke. The hospital serves as a referral centre for primary and secondary (both private and government funded) hospitals in the Niger Delta region.

From the family planning and contraception register, kept at the family planning and contraceptive unit of the hospital, the registration number of 2,676 clients who attended the family planning unit of the hospital between the 1st of January 2014 and the 31st of December 2018 were obtained.

With the clients’ registration numbers, the family planning files were retrieved from the record office of the hospital; the following information was extracted: age, sex, educational status, marital status, religion, parity, the reversible contraceptive method adopted, the reason for adopting the reversible contraceptive method and the source of referral to the family planning and contraceptive unit of the hospital. The data was collected using a Proforma and it was entered into Microsoft Excel spread sheet. The data was analysed using Statistical Package for Social Sciences Software Version 20.0 or windows. The results were expressed in frequencies, percentages and presented in tabular form.

RESULTS

A total of 8,613 clients visited the gynaecological out-patient clinic between the 1st of January, 2014 and the 31st of December, 2018 while 2,676 clients presented at the family planning and contraceptive unit of the hospital within this period. A total of 2,663 clients chose a reversible contraceptive method.

 Most clients who adopted a reversible contraceptive method were aged between 30 years and 34 years (34.5%) followed by 35 to 39 years (23.4%), the least were the teenagers (0.19%) (Table 1).  The mean age of all clients, both the new users of a reversible contraceptive method and those who had return visits was 33.3 years.

In the study, 19 (0.7%) of the clients were men, the rest were women (Table 1).

As shown in Table 1, 80.2% of the clients had either some form of secondary education or had completed secondary education, while 15.3 % of clients had some form of primary education or had completed primary education (Table 1).  Those clients with tertiary education and no form of formal education were 2.6% and 1.9% respectively (Table 1).

All the clients were all married (Table 1).

Table 1 show that 1.6% of the reversible contraceptive users were Muslims while the majorities (98%) were Christians. 

The multiparous clients (61.1%) formed the majority of clients who adopted a reversible contraceptive method followed by the grand-multiparous clients (31.3%) and the primiparous clients (6.5%) while the minorities were the nulliparous clients (1%) (Table 1).

The major source of referral to family planning and contraceptive unit of the hospital were from the clinic personnel (63.6%) then by friends and relatives (11.7%) while the print media (2.7%) and the radio (1.6%) were among the least as shown in (Table 2).

The reason for choosing a contraceptive method was for child spacing (58.8%) and for completed family size (41.2%) (Table 3).

The most commonly chosen reversible contraceptive type amongst the reversible contraceptive users was Depo-Provera (45.6%), followed by Noristerat (29.7%) and Implanon (8.1%). The female condom was the least chosen form of reversible contraceptive method (0.6%) (Table 4). 

In the study period there was a decline in percentage of clients who chose a reversible contraceptive method each year; from 27% in 2014 to 14.5% in 2018. Thus, the percentage decline in reversible contraceptive uptake was 46.3% (Table 5).

Table 1:  Socio-demographic factors of the clients

Table 2:  Sources of referral for the clients

Table 3:  Reasons for adopting a reversible contraceptive method

Table 4:  Reversible contraceptive chosen by the clients

Table 5: Number of clients choosing a reversible contraceptive per year

DISCUSSION

A total of 8,613 clients visited the gynaecological out-patient clinic, while 2,676 clients presented at the family planning and contraceptive unit of the hospital within the same period. A total of 2,663 clients chose a reversible contraceptive method, giving a contraceptive prevalence rate of 30.9%

In this study, clients aged 30 to 34 years used reversible contraceptives than any other age group.  This is consistent with an Ethiopian study ¹¹ and in a study done by Adeyemi et al in Osogbo, South-Western Nigeria.¹² The mean age of first child birth for women in urban areas in Nigeria is 22 years; this reflects a need for contraception during the peak period of the reproductive life.¹³ Simply put this age bracket represents the peak reproductive period with more women deferring child bearing to their 30s in pursuit of education and career.

In this study, adolescents clients were few as also was noticed in a study by Gizat et al in Northern Ethiopia.¹¹ Low uptake of reversible contraceptive methods among teenagers/adolescents may stem from the fear of future infertility from the perceived side effects of modern contraceptives and the perception that abortion is an immediate solution to an unplanned pregnancy.¹⁴

From this study 0.7% of the clients were men, which is lesser than their female counterpart. The awareness of family planning among Nigerian men is high but this does not translate to the actual use or patronage of family planning services.^15-17  

The barriers to male involvement in family planning and the use of reversible contraceptive methods include the perception that family planning is a woman’s activity, poor cultural acceptability of family planning methods, long waiting time at family planning clinics, negative attitude of health care contraceptive providers to clients and cost.¹⁵

In this study, there were a high number of clients with completed secondary or higher level of education as was the trend in a North Western Nigeria study conducted in 2017.¹⁰ Completing or having some level of secondary education is an important predictor of modern contraceptive uptake in developing countries.¹⁰

In this study, clients with secondary and tertiary education were more likely to use a contraceptive than those with primary education or no formal education.  This is in keeping with similar studies in Ethiopia, Tanzania and Ghana.^{18, 19, 20} This may be associated with the role of female education in empowering women through enhancing their autonomy and participating in decision making, positively modifying health seeking behaviour and building social capital through expansion of social networks.²¹

All the clients were married. A possible reason for this may be that unmarried individuals may have perceived ‘stigmatization’ from contraceptive service providers, family and friends in engaging in a ‘premarital sexual relationship’. Thus, single persons are less likely to source for contraception openly because of cultural and religious prohibition of premarital sex in this part of the world.

In this study, 1.6% and 98.4% were Muslims and Christians, in a similar study conducted by Taingson et al, 51.2% and 36.3% were Muslims and Christians.¹⁰ The predominance of Christians in this study is a reflection of the religious affiliations of the inhabitants of Yenagoa, where the hospital is located.

From this study, multiparous and grand-multiparous clients were 61.1% and 31.3% respectively which is similar to a study done by Taingson et al in 2017 were 62.1% and 36.3% for multiparous and grand-multiparous reversible contraceptive users respectively.¹⁰ Reversible contraceptive method uptake increased with parity in the study and subsequently fell with grandmultiparity.  This may reflect the reproductive needs of multiparous clients, who are at the peak of their reproductive career while the grand-multipara are more likely to be peri-menopausal.

Many of the clients got their information about reversible contraceptive from the health care personnel as seen in a study done in North west Nigeria¹⁰ and a study done by Decker et al²² and Chigbu et al.²³ The main sources of information on family planning and contraceptive methods in Nigeria are from friends, siblings, formal education and health care worker.²⁴ The lack of or inadequate information dissemination of reversible contraceptives on radio or the print media in Nigeria may account for their low contribution as a veritable referral tool for the clients.

Child spacing is the most common indication for reversible contraceptive usage by most clients requesting for a reversible contraceptive method followed by the need for limiting family size as seen in a study done in North-west Nigeria. ¹⁰    This may be so, as most of the clients in this study were at their peak of reproductive career.

Injectable contraceptive was the most common method used in a study in North-Western Nigeria ¹⁰ which is same with this study, as well as in similar studies done in Aba, Port Harcourt and Ilorin.^25,26 This may be a trend as corroborated by the National Demographic Health Survey.²⁷ A decrease in side effect of the injectable contraceptives may be the reason they are more appealing to clients.²⁸

Depot medroxyprogesterone acetate was the most popular choice accounting for 45.6% of the clients, followed by Noristerat (29.7%), then Implanon (8.1%) and male condoms (3.8%).  The less popular were intrauterine contraceptive device (2.7%) and female condom (0.6%). This may probably reflect the relative availability of each method and the cost variation. The invasive nature of intrauterine contraceptive device may contribute to making it less acceptable compared to the other methods available.

The number of clients who visited the family planning clinic of the hospital, for a reversible contraceptive declined each year during the study period. This was similar to a study by Wright K et al.²⁹ The low patronage rate or uptake of reversible contraceptive at the family planning and contraceptive unit of the hospital may be due to the fact that family planning is still a contentious issue in our environment because of traditional beliefs, cultural beliefs and incessant health care workers strikes in government owned hospital.^14,28 Less economic opportunities available for women that reduces the incentives for fertility decline through family planning services.²⁹ One may posit that due to the economic recession, potential clients refrain from visiting the family planning clinic instead they devote more time to looking for employment or working for longer hours.²⁹

CONCLUSION

From the study, the peak period of the reproductive career of the clients was the peak time for the uptake of reversible contraceptive methods. Reversible contraceptive method uptake by teenagers and men was low. Reversible contraceptive method uptake was increased with attainment of secondary level of education. Uptake of reversible contraceptive increased with increasing parity. Clinic personnel formed the bulk of reversible contraceptive method information dissemination tool. Child spacing was of more importance to the clients than completed family size.  Depot medroxyprogesterone acetate appealed more to the clients.

RECOMMENDATION            

Pidgin and the local language should be used and encouraged during counselling of clients with primary level of education or those without formal education. The misconceptions about other non-hormonal injectable contraceptives should be dispelled by way of adequate counselling on their benefits. The cost of other non-hormonal injectable contraceptives should be subsidized and they should be made available so that clients can have varied options.

Effort should be made to improve utilization of family planning and contraceptive services through public enlightenment by the use of the mass media, community sensitization programmes; engagement of the community opinion leaders on the benefits of contraceptives; eradication of stigmatization on teenagers/adolescents, men and unmarried individual seeking reversible contraceptives and positive attitudinal change among family planning and contraceptive services providers as they attend to clients. Enacting of laws or liberalization of existing restrictive laws to allow teenagers/ adolescents assess reversible contraceptives. Improve accessibility of teenagers to reversible contraceptives.

ACKNOWLEDGEMENT

The authors acknowledge the assistance rendered by the Nurses at the Family Planning and Contraceptive Clinic and Hospital Record officers of the Federal Medical Centre, Yenagoa during the process of data collection for this study.

SOURCE OF FUNDING

The research was funded by the authors.

CONFLICT OF INTEREST

The authors declare that there are no conflicts of interest.