Contraceptive Practice of Clients Attending the Family Planning Clinic of the Olabisi Onabanjo University

Aim: To examine the socio-demographic characteristics, main source of information about family planning and contraceptive choices of women attending the family planning clinic Study Design: A retrospective descriptive analysis of the case records of all new clients. Methods: This study was carried out on new clients seeking contraceptive services within the study period. The age, marital status, parity, occupation, religion, ethnicity and educational level completed; source of information about family planning, interval between last confinement and first visit, and the intention of the clients were obtained. Results: A total of 733 new clients family planning clinic during the period of review. ranged between 17 and 48 years with a mean of 32.5±5.5 years. There was a low patronage of family planning clinic by the teenagers and unmarried women as they accounted for only 0.3% and 2.9% respectively of all clients seen during the period. The source of information about family planning services was mainly from health personnel 516, (70.5%). IUCD and injectables were the most frequently selected methods irrespective of the socio-demographic characteristics of the clients, their intention for family planning uptake; and interval between last confinement and commencement of family planning. Conclusion: This study showed that unmarried females and teenagers had a poor patronage of conventional family planning centers. Instead of the health personnel, the mass media should play a pivotal and leading role in information dissemination so that awareness on the use and utilization of contraception will be higher than what it is presently.


INTRODUCTION
Maternal mortality in many developing countries remains at unacceptably high levels despite efforts of international and development health agencies. Over half a million women, with nearly all of them in developing countries, die each from complications of pregnancy and childbirth according to World Health Organization (WHO) estimates [1]. Efforts to attain the Millennium Development Goal with respect to maternal health should include family planning as an important, effective and feasible step. Family planning lowers the level of maternal mortality through decrease in the number of unintended pregnancies and the total number of births and also the proportion of births that are high risk [2]. The low levels of maternal mortality in developed countries have been achieved only with both good obstetric care and low fertility. In developing countries today, modern obstetric care is often available in few teaching hospitals located in urban areas, but family planning programs are equally feasible in remote areas that comparatively share the larger burden of maternal ill-health. The contribution of family planning to lower maternal mortality and morbidity can therefore, not be underestimated.
Currently, Nigeria records one of the highest maternal mortality rates in the world as reports indicate that 1 in 13 women continue to die from pregnancy-related causes [3]. This can partly be attributable to the high total fertility rate (FTR) of 5.3 in spite of the staggering population of 170 million [4]. Unsafe abortion is also a major contributor to maternal mortality accounting for 20-40% of maternal deaths in Nigeria. Apart from preventing unplanned and unwanted pregnancies, family planning can help decrease the number of women who risk their lives seeking unsafe abortion [5,6].
Recently, a lot of progress has been made in the development of safer and more effective contraceptives and in the provision of affordable and accessible family planning services [7]. In spite of these developments, many couples mainly in developing countries do not use contraceptive either due to poor knowledge or poor accessibility despite their desire to space or limit their childbearing [8]. For instance, the rates of contraceptive use in Nigeria are very low and recent reports showed that the contraceptive prevalence is 11-13% with the highest value over the past 26 years at 15.3% in 1999 [8]. Various factors have been identified to be responsible for this low contraceptive prevalence including ignorance, low educational level, desire for large family size, religious and cultural beliefs etc. [9,10].
Knowledge of the contraceptive practice of a community will help in strategic planning of programs and activities targeted at increasing the contraceptive prevalence and thus reduce maternal mortality in the long run. Identification of the prevailing contraceptive choices as well as their determinants can help family planning service providers improve the quality of contraceptive services offered to their clients. It is against this background that this study was designed to examine the socio-demographic characteristics, main source of information about family planning and contraceptive choices of women attending the family planning clinic of a tertiary hospital in Southwest Nigeria. Information obtained from the case files included the socio-demographic profile of the clients such as age, marital status, parity, occupation, religion, ethnicity and educational level completed; source of information about family planning, interval between last confinement and first visit and the intention of the clients. The contraceptive use, pregnancy within one year of continued use of the method and reason(s) for discontinuation of initial method (where applicable) were also documented. The relationship between contraceptive method selected and the socio-demographic profile, reason for initiating contraception and the interval between last confinement and commencement of contraception were also explored.

MATERIALS AND METHODS
Data analysis was carried out with SPSS for Windows version 16.0. Results were presented in percentages, frequencies and summary statistics. Percentages and the chi-squared test were used for comparison where appropriate. Differences were considered as significant when P is less than 0.05.

RESULTS
A total of 733 new clients attended the family planning clinic during the period of review. There were 4145 new gynaecological consultations during the period and the contraceptive prevalence represented 17.6% of the total gynaecological consultations. Table  1 shows the socio-demographic characteristics of the study population. All the clients were women. The age of the clients ranged between 17 and 48 years with a mean of 32.5±5.5 years. A significant proportion of the women (60.3%) belonged to the 30-39 years age group. There was a low patronage of family planning clinic by the teenagers and unmarried women as they accounted for only 0.3% and 2.9% respectively of all clients seen during the period. Nineteen (2.6%) of the clients were nulliparae and 128 (17.5%) of them were grandmultiparae. Only 21 (2.9%) of the women were childless while the rest 712 (97.1%) had at least a living child. The median number of children alive was 4. was no record of the duration of contraceptive use as they were lost to follow-up during the period. Two (13.3%) of the 15 clients with evidence of discontinuation before one year got pregnant while on the contraceptive method and others stopped due to the side-effects which included menorrhagia, chronic backache and disturbance of sexual activity by IUCD tag. These two clients were on oral contraceptive pills.
The logistic regression analysis showing the relationship between some selected sociodemographic characteristics and contraceptive choice of the clients is shown in Table 3. Factors significantly related to the likelihood of choosing IUCD and injectables were marital status, parity and level of education. Married women, parous women and women who had secondary or higher education were twice more likely to choose IUCD and injectables than single women, nulliparous women and women who had less than secondary education respectively.  Table 4 shows the relationship between intention of the clients and their choice of contraceptive. It showed that the intention of clients for seeking family planning services did not influence their contraceptive choice as IUCD and injectables remained the most frequently chosen methods irrespective of the client's intention. Only 17 (7.5%) out of 226 clients that did not desire further childbirth opted for bilateral tubal ligation while the rest selected temporary contraceptive methods.
The interval between the last confinement and commencement of contraception choice of clients is shown in Table 5. More than half (54.2%) of the clients opted for a contraceptive method within one year of last confinement while the remaining (45.8%) commenced after one year. The contraceptive choice of the clients was not influenced by the interval between their last confinement and commencement of contraceptives as IUCD and injectables were the two most frequently chosen methods regardless of the period between childbirth and initiation of contraception.

DISCUSSION
This study showed that there was low patronage of family planning services by teenagers, unmarried single ladies and nulliparae. The most frequently chosen contraceptive methods by clients were the IUCD and injectables. The contraceptive choice of the clients was not found to be influenced by their socio-demographic characteristics, intention for family planning and interval between last confinement and commencement of contraceptive method. The study also indicates that the mass media was the least frequent source of information about family planning services.
The finding in this study of a low patronage of family planning services by teenagers, unmarried single ladies and nullipara is similar to observation from other studies in Nigeria and Africa [11,12]. This poor patronage of conventional family planning clinics by teenagers may be attributed to the cultural and religious restriction on premarital sex and the general conception that associate adolescent contraception with sexual promiscuity as well as the judgmental attitude of the family planning service providers. In addition, the location of most family planning clinics within maternal and child health unit shows that they are geared towards mature females in a stable relationship, thus discouraging teenagers from accessing these services. This poor patronage does not equate to non-use of contraceptive but only shows that the source of contraceptive supply of this group of women may not be from public sector like ours but rather from private sources like chemist/patent medicine shops and the likes [4][5][6][7][8][9][10][11][12][13]. The teenager therefore, becomes a candidate for unwanted pregnancies and ultimately unsafe abortion with its attendant complications since she has not been adequately counselled and guided by the chemist and patent medicine store on the choice and proper use of contraception [14]. Therefore, efforts must be made to discourage this cultural barrier and also encourage the establishment of adolescentfriendly clinics where young people can go for counselling and obtain contraceptive of their choice including emergency contraceptive pills.
In similar vein, the unmarried women may be wary of coming forth for contraception at conventional family planning centers as this might indicate that they have an active sexual life in a culture which is probably still conservative, where premarital sex is not accepted. Parous women are more likely to access family planning services than nullipara who for fear of future infertility may not access family planning services and are therefore exposed to the risk of unsafe abortion [9].
Most of the clients in this review obtained their information about contraception from health personnel, which is not surprising as most of them had their evaluation in this hospital where counselling is often given about family planning. The under-utilization of the mass media in the propagation of family planning in this study with a figure of 9.4% is similar to findings from other studies [12,15,16]. This is further supported by the report of the 2003 Nigeria Demographic and Health Survey (NDHS) where more than half of women (56%) and 41% of men were not exposed to family planning messages from a mass media source [4]. This indicates that the role of the mass media in health information dissemination is under-utilized, considering the fact that the majorities of the potential users are poor health facility seekers and would rely on health information from other means such as the mass media. The exorbitant cost of advertisement, the lack of political will for promoting family planning as well as cultural and religious barrier to propagation of family planning services may account for the low participation of the mass media.
The choice of IUCD and injectable as the contraceptive mostly used by clients in this study is similar to reports from other centers [15][16][17][18][19]. This is a reflection of the advantages of the two methods in this environment, which include safety, effectiveness and reversibility, availability, convenience of use and their cost effectiveness. In addition, majority of the women in this study were in the age group 30-39 years, multiparous who desired an effective, long-term birth spacing method which IUCD and injectable provides. The low usage frequency of Implant is due to the fact that it is scarce and requires trained personnel for insertion and removal. The low condom use from this study compared to other parts of the world where the usage is 5-33% may be because most of our clients were married women and most users of condoms are single men and women who need it for protection from HIV as well as for contraception [20].
Voluntary sterilization is usually recommended for grandmultiparous clients who want a permanent method of contraception. However, this study showed that only 7.5% of the clients who desired no more children chose the permanent method (BTL). This is an indication of the aversion for sterilization in our environment [18]. The importance placed on childbearing and the high infant mortality coupled with some cultural myth concerning reincarnation and the invasive nature of the procedure are some of the reasons for the low acceptance rate of sterilization in this environment [21].

CONCLUSION
This study shows that unmarried females and teenagers had a poor patronage of conventional family planning centers as against the good patronage exhibited by the married female population.
There is need to encourage the establishment of adolescent-friendly clinic to cater for the unmet contraceptive need of the young people.
The mass media should play a pivotal and leading role in information dissemination so that awareness on the use of contraception and also the utilization will be higher than what it is such that the incidence of unwanted pregnancies, unsafe abortion and ultimately maternal death will be reduced to the minimum.

CONSENT
Consent is not applicable because it is a retrospective study.