ABSTRACT

Background: While traditional contraception is widely used, in southern Nigerian modern contraception is a relatively recent phenomenon. Modern contraception is more wide spread among the educated and sexually active youth in Nigeria. Few studies have been done on contraception among educated women in Nigeria
Objectives: This study was carried out in December 2000 to determine factors that influence the choice of contraceptives among female undergraduates at the University of Benin and Edo State University Ekpoma.
Methods: Data was collected from a sample of 800 female undergraduates matched ethnic group, socio economic status, religion and rural urban residence. Subjects were selected by proportional representation and the instrument used was closed ended questionnaire.
Results: The responses obtained were analysed using Spearman Rank Correlation co-efficient and regression analysis. Findings revealed the highest correlation for availability (r = .96) vis a vis the use of various types of artificial contraceptive and cost (r =.96), next was safety (r = .95) and effectiveness (r = .95). Others were peer group influence (r = .80) and convenience (r = .77).
Conclusion: An important step in improving women’s reproductive health is the involvement of men. Health programmes should conduct campaigns to educate men about reproductive health and the role they can assume in family planning.

INTRODUCTION

There has been a proliferation of the use of various types of contraceptives particularly among category of young women.^1,2,3 The effectiveness safety, side effects, contraindications and availability of these methods, vis the pill, barrier methods, Intra-Uterine Contraceptive Device vary. Hence there is an opportunity to make a choice by individuals or couples. A perfect contraceptive would be 100% effective, totally safe, available to everyone, completely without side effects, instantly reversible and easy to use. It would not interfere with intercourse in any way and would require no advice or care from the clinician. There is no such method today and according to research experts, there are no likely prospects for any in the future. It is the responsibility of health professionals to ascertain that each person who obtains a family planning method has sufficient information on the proposed method and that this person is competent to make a choice.

Educated and working women are presumed to have closer conjugal ties with their husbands compared to non-educated and unemployed women.^5,32 The educated woman is therefore, expected to have similar reproductive attitudes as their husbands. On the other hand education and employment tend to give greater freedom and power within the household.⁴ It may then be argued that educated and non working wives are more likely to have reproductive preferences that are independent of their husbands. For instance5 found spousal agreement about contraceptive use to be positively related to education, while agreement about desired number of children was negatively associated with education.⁶

Empowerment literally means ‘to invest with power’. When used in context of women’s lives, it often refers to women’s increased control over decision-making, economic self-reliance, and legal rights to equal treatment, inheritance and protection against all forms of discrimination^7,8. In the context of family planning, the concept of women’s empowerment is generally associated with a variety of elements that range from delayed marriage, smaller families, access to accurate information, the ability of married females to discuss freely about their family planning needs with spouses and other members of the household and the community, and being able to make independent decisions on fertility regulation including going out of living boundaries to seek contraceptive supplies.

Subjects were selected by proportional representation from the university registry on the basis of ethnic group and religion. 32% were of Edo origin, 36% of Ibo and Yoruba origin and 22% of other minority ethnic groups like Ijaw, Itsekiri, Igala and Idoma, 66% of the respondents were christians and 31% were Moslems. The remaining 3% were of other religions such as Hindi, Bahai and Traditional African Religion.

The instrument consisted of a closed ended questionnaire in which responses were scaled using continuously discrete categories of the variables mentioned viz; safety/very safe, quite safe, moderate, little unsafe and very unsafe for all the variables mentioned. The data obtained from the scaled responses were subjected to statistical analysis using Spearman Rank Correlation Coefficient and Regression analysis. Previously a Pilot Study using twenty questionnaires was administered to ensure that response yielded desired information and a reliability test using Kuder Richardson Formula was carried out (r = .82).

Preliminary information on basic demographic data elicited at the beginning of the questionnaire.

All the variables were examined in the questionnaire for each contraceptive as indicated below:

Socio Demographic Characteristics

Caldwell and Caldwell¹⁸ reported that in Ibadan City, Nigeria, initial use was to allow pregnancy-free premarital sex in 35 per cent of cases, to space births in 31 per cent, to replace terminal abstinence (when grandmothers) in 7 percent, and for stopping childbearing in 4 per cent. By the early 1990s, the situation with regard to all contraceptive demand in Ado-Ekiti, Nigeria, was not very different: 44 per cent for premarital sex, 27 per cent for spacing, and 6 per cent for stopping²². Later in the decade, in the four traditional settings of northern Ghana villages, it was 46 per cent for spacing and 23 per cent for limiting²³. In Nodola, Zambia, the demand for spacing is three times that for stopping²⁴. This is a pattern found nowhere else in the world and dictates the necessity for providing a range of temporary methods.

In Nigeria, pills have been mostly provided, but in urban clinics the IUD is now competing and female sterilization is acceptable²⁵. As early as 1990,²⁶ had pointed to the acceptability of female sterilization which then made up 41per cent of contraceptive use in Kenya, 19 per cent in Ghana and 14 per cent in Liberia, although only one per cent in Ondo State, Nigeria.

Nigeria is one of the countries with the highest fertility and population growth rates in Africa²⁷. The Nigerian Fertility Survey⁸ reported completed fertility of 5.84 children ever born for all women and 5.85 children for currently married women. An overwhelming majority of 87.3 per cent of the currently married women wanted to have more children. The report further showed that contraceptive knowledge and use levels were very low. As many as 66.3 per cent of respondents had never heard of any contraceptive methods. Use levels were correspondingly low, 84.9 per cent had never used any method, and 12.5 per cent had used at least one inefficient method, while only 2.4 per cent had used an efficient method.

The Nigerian Demographic Health Survey⁸ showed that the mean number of children born to women aged 40 - 49 years was 6.9 children, an increase from the figure of 5.41 children in the 1981/ 82 Nigerian Fertility Survey. Contraceptive knowledge and use levels had increased slightly, 45.7 per cent of women did not know any method, 6.0 percent were currently using a method while only 3.5 per cent were using a modern method. Follow up studies by the Federal Office of Statistics (FOS) showed that knowledge of family planning had increased considerably, from 33.6 per cent in 1981/ 82 to 83.1 per cent by 1992. Current use of a modern method was only 10.5 per cent by 1992. Thus Nigeria presents a setting of high fertility and low demand for contraception.

High fertility translates into high population, and the growth rate was estimated to be between 2.5 and 3.0 per cent per annum. Nigeria’s population currently estimated to be 115 million persons is expected to reach 190 million persons by the year 2005, and 338 million persons by the year 2050⁸. Such rapid population growth raises various problems for economic growth and development in Nigeria. Furthermore it is estimated that half of all births in many less developed countries, including Nigeria pose high risks to the health of both mother and child, as births occur to women who are too old or too young, or who have many previous births, or whose current births are too soon after the previous birth. Family planning can reduce high rates of sickness and death among women and children. Infant mortality rate is estimated to be 73.34 per 1,000 live births⁸.

Female education had a positive and significant association with approval of the family planning, number of methods heard of, number of sources of supply known (urban women only), ever use and current use of family planning as well as use of efficient methods. It had a negative and significant association with children ever born. The association was strong for urban women²⁸.

Responses on parents socio-economic status were also elicited in the questionnaire to determine the exact role of cost on choice of contraceptives.

Table 1

Table 3 displays results based on multiple regression analysis of the three demographic variables of interest. The type of artificial contraceptive used is categorized as being influenced by safety, cost, availability, convenience, effectiveness and peer group influence as co-variates. Table 3 present OLS regression co-efficients for type of contraceptive use. With a few exceptions, the same set of independent variables are examined in both regression models. Discussions based on the three outcome variables, in the two tables will be undertaken simultaneously.

The striking differences observed in the succeeding descriptive analysis between type of Contraceptive use and the variables mentioned persists in the multivariate models. Table 3 shows that more Christians than Moslems use artificial contraception, and the low incidence of usage among Muslim women could be highly attributable to the religion.

Sim ilar findings w ere observed by²⁹ in Bangladesh and Iran. Other explanatory variables that affected the probability of using contraception were wife’s age, spousal age difference, the wife’s education religion, and having a girl aged 8 - 16^25,8. Other variables that influenced the choice were fertility preferences, wealth level and geographical location.

Myryar and Tabibian³⁰ attributed the fertility decline in Iran to important changes in the socio-economic composition of the population. These changes include a rise in the urbanization and literacy ratio, rise in age at first marriage and improvement in the levels of education, health and welfare of the population. Mirzaie³¹ also noted other factors including the reduction in the infant mortality rate, rise in the relative cost of children, increase in literacy.

For Nigeria, the same is through for urbanization, public awareness about population problems, and Government Family Planning Programme32. The OLS regression analysis in Table 4 also confirms the above finding with respect to the use of Intra Uterine Contraceptive Device. It should be noted that Christian women tended to visit family planning clinics more than Muslim women, significant at P<.02. This impression of a significant difference between Christians and Moslems may be spurious one since the insertion of Intra Uterine Contraceptive device takes place in Family Planning Clinics by providers of such services. The low acceptability of other methods of contraceptive device could be attributable to religious barriers. Hence, we found the same pattern of association when ethnicity was entered into the equation. Edo, Yoruba and Ibo having a higher incidence of Artificial Contraceptive usage than the other minority tribes of the middle belt.

EMPOWERMENT AND CONTRACEPTION: BIVARIATE

ANALYSIS

Knowledge of Contraceptive Methods Knowledge of contraceptive methods was assessed by asking women to name the contraceptive methos that they knew about. A girl was considered to have some knowledge about a method if she could name a method without prompting. It was found in the study that knowledge about pill was almost universal in the study area irrespective of empowerment status; however, women’s knowledge about other contraceptive methods rises with increase in both freedom of movement score and decision-making score. Only 19 per cent of women in the lowest empowerment category (for both indices mentioned condom, whereas 42 per cent of girls in the highest freedom of movement category, and 35 per cent in the highest decision making category mentioned condom without being prompted (Table 4). The difference in knowledge was found to be widest for IUD between the highest and the lowest categories of both the indices. Only 44 per cent of the girls in the freedom of movement category knew about IUD, while about 69 per cent women with freedom of movement score 3-4, and 71 percent of girls with freedom of movement score 5-6 had knowledge about the IUD. Similar result was observed between different categories of decision -making index. Knowledge of tubectomy and vasectomy was also highest among more empowered women even though knowledge about vasectomy as a method of contraceptive was generally found to be the lowest. Table 4 also shows that women with more empowerment reported higher number of methods of contraception.

DISCUSSION

Safety

The Spearman Rank Correlation co-efficient of the final measures of the Independent variables respectively for the entire sample (N = 800) are presented in Table 2. The results show a significant relationship (.95) between the Pill and effectiveness and safety. Further information from the social background of the respondents showed that more students from affluent homes and whose parents are educated tended to use the pill than those from less priviledged homes. The Moslem respondents tended to prefer other methods of contraception such as Intra Uterine Device to the Pill. Similar findings were found in Iran³³. There was no significant relationship between ethnic group and pill usage.

Effectiveness

There was a high correlation (r =.95) between use of the pill and effectiveness and between use of the Intra-Uterine Device and effectiveness. Other responses obtained revealed that more students who used Intra Uterine Device had previous unwanted pregnancies than did those who used other methods of Contraception. Respondents who preferred the use of condom and other barrier methods did so for other reasons other than convenience such as safety, availability and peer group influence.

Convenience

There is a high correlation between Intra Uterine Device Usage (r =.77) and convenience. Most of these respondents (7%) who used barrier methods did so for convenience. The low incidence of usage of these barrier methods could be attributable to the fact that they tended to reduce libido.

Cost

There was a high correlation (r =.96) between the cost of a contraceptive and its use. More of the students who used the expensive contraceptives such as Jellies, Foams, Diaphragms were from affluent homes (see Table 3). Most of the respondents who preferred the Intra Uterine device did so because the services were quite cheap. Most of the students who claimed to use the pill did so because they had registered with a family planning clinic. A cross-price effect was found for the IUD, since clients were more likely to use the IUD than the pill if the cash price of the pill increased.

Availability

The high correlation (r = .96) between availability and the use of the pill was attributable to the fact that the pill is easier to purchase than the condom because of the stigma associated with the latter. Purchasing a condom in an over the counter store might give the impression to the seller that the consumer is wayward since the general Nigerian society frowns at its usage among youths. Most of the students (78%) who used the condom used it because it was easily available.

Peer Group Influence

There is a high correlation between peer group influence (r = .80) and use of the pill and barrier methods such as the condom. Peer Group, films and sexual partners tended to have a strong influence on the user. This also depended on the degree of exposure of the user, her religious conviction as well as partner’s socio-economic status. There is an inverse relationship between Peer group influence and religious conviction particularly among the Moslem students.

The attitudes of elites, public servants, university teachers and students, journalists has changed, at least in the Anglophone countries, faster than might have been anticipated. Part of the explanation is the globalization of society, but most of it springs from the lack of confidence induced by a decade and half of grim economic news and the experience at family level of meeting new schooling and medical treatment costs. Most educated white collar workers now regard unrestricted population growth as threatening national and individual prosperity¹⁹.

The rapid spread of the AIDS epidemic in subsaharan African raises other issues concerning women’s ability to protect themselves against sexually transmitted disease (STDs) and the AIDS virus. Data form Ghana reveal that the incidence of infection is much higher among female than males, and although the female proportion of reported AIDS cases declined between 1986 and 1992, seventy sevel percent of all reported AIDS cases in 1992 were female³⁹. Female surplus of HIV/AIDS cases have been associated with the migration of women to work in the commercial sex industry in nearby countries, a factor that has been related to economic hardship, buttressed by underlying gender inequalities in employment opportunities¹. Social expectations of multiple partners for men and social acceptance of male extramarital sexual activity-partly related to wives postpartum sexual abstinence^{18, 22} - are indicative of the vulnerability to STDs and HIV is also associated with polygyny, mandatory widow inheritance, and men’s dislike of the condom - the only available preventive method against sexual exposure to the AIDS virus aside form abstinence). Furthermore, the association of condom or contraceptive use with infidelity or promiscuity may prevent many women from initiating discussions with their husbands about sex and condom use^{26, 40}.

The other threat is the AIDS epidemic for a range of reasons. An obvious solution would seem to be a focus on using condoms for both fertility and AIDS control. The condom is not the preferred method of fertility control anywhere in Sub Saharan Africa^18,41. To protect from AIDS it would have to be used consistently and this would frustrate even planned fertility. Condoms are least likely to be used in sexual relations between spouses or long term partners, just the relationships in which planned fertility is most likely to be required.

Finally, contraceptive use can increase if family planning providers emphasis¹ contraception as a means to improve a woman’s and child’s health² contraception as a way of spacing births²¹ contraception as a way of empowering women and¹⁹ contraception as a major component of human development and social justice⁴².

ACKNOWLEDGEMENTS

My special thanks goes to Ford foundation for funding this Research. My profound gratitude goes to Ms Coudou Bop, Yassine Fall and Mrs Juliet Djungu of the Association of African women for Research and Development (AAWORD) Dakar, Senegal for providing emotional supports throughout the trying period of this Research.

REFERENCES

1. Pereira CA, Pagnette GE, Wood PB and Grant S. Clinical and Laboratory Screening of Chlamydia Trachomitis in Women attending a University Health Service. Journal of Adolescent Health Care. 1987; 36: 39 -42.
2. Azenabor, AA and Eghafona NO Optimal growth conditions of a location strain of chlamydia trachomitis and its sero-epidemidogical study in gynaecological disorders, J M. L. S 1993; 3:57-61.
3. Senayake P and Kramer DG. Contraception and aetiology of Pelvic Inflammatory disease. New Perspectives. American Journal of Obstetric and Gynaecology 1980; 138: 852 - 860.
4. Dyson Tim and Mick M. “On kinship structure, female autonomy, and demographic behaviour in India” P.D. R. 9 March 1983: 35-60.
5. Coombs IC and Chang Ming-Chen: “Consistency of fertility attitudes between marital partners and its role in subsequent fertility. “Taiwan Population Studies,” 1979 Working Paper No.
6. Coombs LC and Fernandez D. Husband-wife agreement about fertility goal Demography 1978; 15 (1): 57 - 73.
7. Germaine A and Kyte R. ‘The Cairo consensus: The right agenda for the right time’. International Health Coalition.1995
8. World Population Department for economic and social information and Policy Analysis, Population division. New York 1996.
9. Mason KO. “Female autonomy and fertility in five Asian countries” paper presented at the Annual meeting of the Population Association of America, New York. March 1999.
10. Kishor S. “Women’s empowerment and contraceptive use in Egypt Paper presented at the annual meeting of the Population Association of America, 1999; New York.
11. Williams J, Menken J, Khan N. “Education, Health and Empowerment of Women in Rural Bangladesh”. Paper presented at the Annual Meeting of the Population of America, New York. March 1999.
12. Rohman M and Sutradhar SC. “ Women’s status and fertility behaviour in rural Bangladesh” in A. Kanter, Al-Sabir and N. Chakrabrarty (eds.) Bangladesh Demographic and Health Survey 1993-94: Extended Analysis, 1996; National Institute of Population Research and Training, Dhaka pp. 195 - 212.
13. Schuler SR and Hashemi SM.: Credit Programs, Women’s empowerment and contraceptive use in Bangladesh. Studies in Family Planning 1994; 25, 65 - 76.
14. Steele F, Amin S and Naveed R.T. “The Impact of integrated micro-credit programme on women’s empowerment and fertility behaviour in rural Bangladesh”. Working paper No. 115, Population Council, New York.1998.
15. Kritz MM and P Makinwa-Adebusoye “Wife and Husband’s Family Planning Approval in Nigeria: How influenced by male characteristics, wives authority, and ethnicity?” Paper presented in IUSSP committee on fertility and family planning in collaboration with the African population policy and health research centre seminar on reproductive change in Sub-Saharan Africa held on 1998; 2 - 4th November in Nairobi.
16. Fakeye O. Intra-Uterine device: Its effectiveness and acceptability at Ilorin. Nigerian Medical Practice 1986: 12: 7 - 10.
17. Fakeye O. Reasons for non-use of Family Planning Methods at Ilorin, Nigeria: Male Opposition and Fear of Methods. Tropical Doctor 1989: 19: 114 - 117.
18. Caldwell JC. Theory of fertility decline. London: Academic Press.1982
19. Caldwell JC and Caldwell P. “Cultural forces tending to sustain high fertility. “In Population Growth and Reproduction in Sub - Saharan Africa: A World Bank Symposium. Ed. George T.F. Ascadi, Gwendolyn Johnson-Ascadi, and Rodolfo A. Bulatao. Washington, D.C. The World Bank 1990: pp. 199- 214.
20. Caldwell J C and Caldwell,: “sub-saharan african family planning programmes in the 20^th and 21^st Centuries”. IUSSP committee on fertility and family planning in Dhaka, Bangladesh, 2000 17 - 20 January.
21. Bailey J. ‘An Evaluative look at F. P. R. C in Latin America’. Studies in Family Planning,1973; 4(10): 275-78.
22. Caldwell JC., Orubuloye, IO and Caldwell P “ The destabilization of the traditional Yoruba Sexual System”. Population and Development Review 1991 17(2): 229 - 262.
23. Debpurr C Nazzar A, Phillips, J.P. Ngom, P. and Binka, F. ‘The navrongo health and family planning project: Preliminary impact of projected activities on reproductive behavoiur’. Paper presented to IUSSP Seminar on reproductive change in sub-saharan Africa 1998, Nairobi.
24. Biddlecom AE and Fapohunda BM. ‘Covert contraceptive use: prevalence, Motivation and Consequences;Studies in family Planning 1998: 20, 360-72..
25. Konje JC, Oladini F, Otolorin EO and Ladipo OO. ‘Factors determining the choice of contraceptive methods at the Family Planning Clinic, University College Hospital, Ibadan, Nigeria’. British Journal of Family planning, 1998; 24, 107-10.
26. Van de Walle E and Foster AD ‘Fertility decline in Africa: assessment and prospects’. World Bank Technical Paper 1990; No. 125, World Bank, Washington DC.
27. Faruqee R, and Gulhati R.. Rapid population growth in sub Saharan Africa: Issues and Policies. World Bank Working 1983; Paper, No. 559, February.
28. Islam A Ahmed S Haider Z. “Women’s Empowerment and Contraceptive Use in Rural Bangladesh”. Paper presented at the IUSSP Seminar on Family Planning Programmes in the 21st Century, Dhaka, Bangladesh, 2000 January 17 - 20.
29. Mehryar AH And Tabibian M and Gholipour R. “Correlates and determinants of fertility decline in Iran, 1986 - 1996: a district level analysis.” Working paper, Tehran: Institute for Research on Planning and Development 1998.
30. Mirzaie. “Swings in fertility limitations in Iran”. Working paper in Demography, Canberra: Australian National University. 1998.
31. Okojie CEE.“Sustainability of Family Planning Programmes in an Environment of High Fertility, Low Demand Settings and Dwindling Resources: A Case Study of Edo and Delta States”. IUSSP Committee on Fertility and Family Planning in Dhaka, Bangladesh, 2000 January 17 - 20.
32. Levin A, Caldwell BK and Barkat-e-Khuda “Demand for Family Planning Services in Rural Bangladesh: Effects of Cash Prices and Access.” Paper presented at IUSSP Seminar on Family Planning Programmes in the 21st Century, Dhaka, Bangladesh, 2000; January 17 - 20.
33. Foreit, KGMPP de Castro, and EF Duarte Franco ‘The Impact of mass media advertising on a voluntary sterilization program in Brazil’. Studies in Family Planning, 1989; 20, 2: 107 - 116.
34. Omu AE, Weir SS, Janowitz B, Covington DL, Laptey PR and Burton NN. “The effect of counselling on sterilization acceptance by high-parity women in Nigeria’. International Family Planning Perspectives, 1989; 15, 2: 66 - 71.
35. Leon FR and A Cuesta “The need for quasi-experimental methodology to evaluate pricing effects”. Studies in Family Planning,1993; 24, 6: 375-381.
36. Fisher AA and V De Silva Satisfied IUD acceptors as family planning motivators in Sri Lanka’. Studies in Family Planning, 1986 17, 5: 35 - 42.
37. Aziken M et al: Knowledge and Perception of Emergency Contraception Among female Nigerian Undergraduates: International Family Planning Perspectives 2003; 29 (2): 84-87.
38. Adomako AA Women and aids in Ghana ‘I control my body’(or do I?).” paper presented at the IUSSP Seminar on Women and Demographic Change in Sub-Sahara Africa, Dakar, Senegal, March 1993; 3 – 6.
39. Van de Walle Etienne and Francise Van de Walle.“Women’s autonomy and fertility”. Paper presented at the conference on Women’s position and Demographic Impact in the course of Development, Asker, Oslo,15 -18 June. 1988.
40. Varga CA (eds), ‘South African young people’s sexual dynamics: implications for behavioural responses to HIV/ AIDS’, in J.C. Caldwell, P. Caldwell, J.Anarfi, K.Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J.Marck, W. Cosford,R. Colombo and E. Hollings Resistances to Behavioural Change to Reduce HIV/AIDS Infection in Predominantly Heterosexual Epidemics in Third World Countries. Australian National University, Canberra, 1999; PP. 13-34.
41. Letamo G. ‘Factors Influencing modern Contraceptive Use in Botswana’. Department of Demography Working 1996a; Papers No. 96-2 University of Botswana.

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