Determinants of Modern Contraceptive Uptake among Women in Peri-Urban Communities of Port Harcourt City, Nigeria.

Aim: The aim of the study was to investigate the determinants of contraceptive uptake among women of reproductive age in semi-urban communities of Rivers State, Nigeria. The information will be useful in reordering priorities and strategies for family planning interventions in the state. Study Design: The study was a cross sectional, household-based study, employing a cluster sampling technique proportionate to size, to recruit eligible participants. Study Location: The study was carried out in September 2013 in five contiguous communities located at the fringes of the Port Harcourt city. Methodology: Anonymous questionnaires were administered to 772 women of reproductive age normally resident in these five communities. Visitors were excluded. The data was analysed using Original Research Article Tobin-West et al.; BJMMR, 17(1): 1-10, 2016; Article no.BJMMR.27655 2 SPSS version 20 software package. The Chi-square test was performed to determine the association between contraceptive use and demographic and socioeconomic variables, while Logistic regression was used to identify determinants of contraceptive uptake. The level of statistical significance was set at p= .05. Results: A total of 772 women aged (15-49) years participated in the study and 731 (94.7%) knew about modern contraceptives and their benefits. Young age (15-34 years old), (χ 2 = 12.7, df = 3, p= .01) and being single, (χ 2 =16.270, df=3, p < .01) were significantly associated with contraceptive usage. Younger women had six times higher odds of contraceptive usage than older women; [O.R (95% C. I) = 5.97 (1.56-22.90) and 5.96 (1.63 -21.71)], and women with contraceptive knowledge had 19% higher odds of usage than contraceptive naïve women [O.R (95% C. I) = 0.19 (0.090.40)]. Conclusion: This study underscores the importance of young age and knowledge about contraceptives in promoting its acceptance among women. We therefore advocate for an early introduction of curriculum-based family planning education in schools, local media campaigns and peer education to create more awareness about contraceptives.


INTRODUCTION
Pregnancy and childbirth are major health risks for women in developing countries. About 56% of maternal deaths from pregnancy and childbirth occur in the African sub-region, with a woman having a 1 in 16 risk of dying in pregnancy or childbirth, compared to a 1 in 4,000 risk in developed countries [1]. Although a number of countries in sub-Saharan Africa have made tremendous progress by halving their levels of maternal mortality since 1990, with maternal mortality declining approximately at a rate of 2.6% per year, the decline is far from the projected annual rate of 5.5% required to achieve the fifth millennium development goal (MDG 5) by 2015 [2]. It is estimated that 560 maternal deaths per 100,000 live births occurred in Nigeria in 2013, representing a 53.3% decline from 1200 deaths per 100,000 live births in 1990 [1]. Most of the maternal deaths are said to have resulted from unplanned pregnancies, unsafe abortions and low use of contraception [3,4]. Furthermore, unsafe abortions account for up to 40% of these deaths in Nigeria, as a result of the abysmal use of modern contraceptives (the pills, injectables, implants, sterilization, the IUDs, the diaphragms, male or female condoms) [3,4]. According to the Nigerian National Demographic and Health Survey (NDHS) reports, the contraceptive prevalence rate (CPR) among sexually active women aged 15-49 years stood at 16% for all contraceptives, but 11% for modern contraceptives. The rates are considerably lower in rural areas compared to urban areas: 6% against 17% [5]. Contraceptives protect women from unwanted or mistimed pregnancies, thereby preventing high-risk pregnancies or unsafe abortions by unskilled providers or under unhygienic conditions. It is estimated that if all susceptible women could avoid high-risk pregnancies by using appropriate contraceptives, a quarter of maternal deaths could be averted, aside from other benefits such as prevention of cervical cancers and sexually transmitted infections, including HIV/AIDS [6,7].
In Nigeria, like in many other developing countries, the majority of the population (about 70%) lives in the rural communities [8]. These rural communities have higher fertility rates than the urban communities (6.2 versus 4.7 births per woman), while the national average is 5.5 births per woman [5]. The Total Fertility rate (TFR) refers to the average number of live births a woman would have if she were subjected to the current age-specific fertility rates throughout her reproductive years (15-49 years).
[5] The goal of the National Policy on Population for Sustainable Development of Nigeria is to achieve a reduction in the total fertility rate of at least 0.6 children every five years [5]. Ironically, it has been reported that many women in the rural and periurban areas seem reluctant to accept any artificial method of contraception. Rather, they appear to show more interest in the survival of their existing children because of the widely held view in Nigeria that children are as a source of economic support for their parents at old age [9,10].
Some studies, however, have suggested that ignorance and inadequate information about contraceptives were some of the likely significant factors militating against acceptance of contraceptives in Nigeria [11,12]. These findings underscore the key strategic thrust of the National Reproductive Health Policy of Nigeria, which focuses on the provision of appropriate family planning knowledge to women in order to significantly reduce maternal morbidity and mortality due to pregnancy and childbirth [13].
Unlimited access to contraception and family planning has a beneficial impact on sustainable livelihoods and job growth in resource-limited settings. It gives women greater liberty for employment and increased productivity, which ultimately result in increased earnings for the family [14]. Furthermore, with women's participation in wealth creation significant contributions are being made to household incomes, with several positive multiplier effects on the health and education of their children [15]. Unfortunately, despite the momentous benefits of modern contraceptives and several efforts of the health care system to promote its acceptability and sustainable usage among women of childbearing age in Nigeria, their usage has remained disappointingly low [16][17][18]. In order to provide better support for programme policies, it will be necessary to understand the determinants of acceptability of modern contraceptive among women of childbearing age in Rivers State, Nigeria, especially among those in rural and semi-urban communities. The information will be useful in reordering priorities and strategies for programme direction in family planning interventions in the state.

Study Area and Population
The study was carried out in Obio/Akpor Local government Area (LGA) of Rivers State. The LGA is one of the two that make up Port Harcourt city, the capital city of Rivers state, Nigeria. The LGA is made up of 46 communities and has a total population of 462,350 people made of 238,951 males and 223,399 females. The sampled communities were Rumuekini, Rumuosi, Rumuokparali, Rumualogu and Ozuoba all of which are contiguous and are periurban; located at the fringes of Port Harcourt city. The communities were initially traditional and homogeneous communities with their unique cultures and traditions, but over the last three decades, they have become rapidly urbanized with the influx of people from other parts of Nigeria seeking job opportunities in the inner city. They have, however, maintained their traditional ways of life to a very large extent. The people are of the Ikwerre ethnic nationality of the Niger Delta region and are essentially subsistence farmers and petty traders. There are a number of poorly maintained physical infrastructures like roads, electricity and water supply in the area. There are also a number of educational and health care institutions like primary and secondary schools, primary health care centres, pharmacy and patent medicine shops. The University of Port Harcourt Teaching Hospital, a tertiary care hospital is located a few kilometres away from these communities. Overall, the literacy level in Rivers State and the LGA are among the highest in Nigeria, with at least 77.5% of the women 15-49 years having completed secondary school or higher [5]. Nevertheless, the contraceptive prevalence rate in the LGA is only 6.1% among all women aged 15-49 years, married or not [19].

Conceptual Framework
A number of demographic and socio-cultural variables may influence the respondent's decision to use or not to use contraceptives. Age, marital status, education, parity and others, all play a role in contraceptive acceptance and use [20]. Younger women are likely to be better educated about the benefits of contraceptives, unmarried and thus could be more disposed to the use of contraceptives Similarly, with increasing economic hardships, many more families now see the need to embrace birth control. Nevertheless, strong cultural factors such as the desire for large family size and several myths about side effects of contraceptives and male dominance have continued to limit contraceptive uptake. In all these, mediating factors such as availability and cost of health services, media and peer influences contribute to the uptake of contraceptives [20].

Study Design and Sampling
The study was a descriptive, cross-sectional household survey carried out among women of reproductive age (15-49 years) resident in the study communities. The study included normally resident individuals (residents for at least one year) who were sexually exposed, but excluded visitors and sexually unexposed. A minimum sample size of 687 participants was determined to be adequate for the study, by applying the formula for descriptive studies [21]; n=Z 2 pq/d 2 , n=minimum sample size, Z= normal standard deviate 1.96 at 95% confidence level, p= contraceptive prevalence in Nigeria (15.4%) [22], q=1-p, d=error margin of 5%, with adjustments made for a Design Effect (DEFT) =2 and non-response rate of 10%. Participants were selected by a cluster sampling method proportionate to the size of the communities.
The estimated populations of the communities were: Rumuekini, 3,506; Rumuosi, 3,405; Rumuokparali, 2,746; Rumualogu, 2,689 and Ozuoba, 3,367. The populations of women aged 15-49 years (22%) [15]  The first participant in each community was determined with the interviewers assuming a central location in the community and spinning a pen to decide the direction from which the first house and household were chosen. Thereafter, the subsequent household was the consecutive household. Where two households were equidistant from one another, the one on the right was chosen. This procedure was continued until the required sample size for that community was realized. In each of the household selected for the study, the survey target, all consenting women of reproductive age (15-49) years were interviewed.

Data Collection and Data Analysis
Data was collected in September 2012, using a pre-tested and standardized intervieweradministered questionnaire developed by the Centre for Infectious and Zoonotic Diseases of the University of Calabar and University of Port Harcourt. The questionnaire was uploaded unto mobile data capture devices (smartphones) and fed into a central server. It was pre-tested on 38 volunteers in another community (Nkpolu community), that was not earmarked for the study, and which was at least about 15 kilometres away from any of the participating communities. This was done to ensure face validity of the data. The questionnaire was then administered by 8 Resident doctors who were earlier trained in its usage. It was administered in English, but where necessary, the popular pidgin English widely spoken in the State was used to elicit information from the participants. All data entries were cross checked for consistency and analysed using the SPSS version 20 statistical software package. The chi -square test was performed to determine the association between contraceptive use and demographic other variables. Statistical significance was determined by a p-value less than .05. Logistic regression was used to identify determinants of contraceptive use. Outputs for logistic regression were presented as Odds Ratio (OR) and confidence intervals (CI). CI not crossing one was assumed to be significant.

Determinants of Contraceptive Use among Women
A multivariate analysis using multiple logistic regression identified age and awareness about contraception as the most significant determinants of contraceptive usage among the women. Women aged 15-24 and 25-34 years, respectively, were six times more likely to use contraceptives than those aged 45 years and above; O.R (95% C.I) = 5.97 (1.56-22.90) and 5.96 (1.63 -21.71). (Table 5) In addition, women who knew about contraception had a 19% higher likelihood of using contraceptive than those who did not O.R (95% C.I) = 0.19 (0.09-0.40) (Table 5).
Finally, the only significant deterrent to contraceptive use reported was the desire for more children (χ 2 =6.83, df=1, p= .01). Religious persuasions, spousal objections, fear of complications and ignorance about contraception were all not found to be deterrents to contraceptive usage (Table 4).

DISCUSSION
The study showed a high level of awareness about modern contraceptives among women living in semi-urban communities. The result conformed to the findings of a study on the acceptability of modern contraceptives across Nigeria, where Rivers state ranked among those with highest acceptability rates [23]. It was also similar to studies in other parts of Nigeria [5,24] and Africa [25,26]. The awareness might be credited to the modest contributions of the State health care system towards family planning and maternal mortality reduction, as well as the intervention of international health care organizations and civil society groups in response to the high prevalence of HIV/AIDS in the State [27]. However, some studies in Nigeria have consistently reported disparity between contraceptive awareness and contraceptive usage [18,28]. The point prevalence of contraceptive use rate in our study was considerably higher than the national average, [5] but was less than the value among rural women in Osun State, in western Nigeria [29] and in rural Ethiopia [30]. When further compared to what obtained in developed countries like the United States of America, a huge difference was noticed, with nearly all of the women in the USA using at least one method of contraception [31].
Results from logistic regression models showed first, that young age and awareness about contraceptives were significant determinants of contraceptive usage among the women. Women aged 15-34 years were six times more likely to use contraceptives than those aged 45 years and above. This relationship might be linked with the fact that most of the young women in the study were single, of school age and probably more concerned about preventing unintended pregnancies. However, some have argued that younger women were less enthusiastic about contraception for obvious reasons that they were likely to be newly married and thus desire to have children [28]. That position is more likely to represent the experience in most of the northern parts of Nigeria, where early marriage is an entrenched cultural practice, with younger women in early marriage being less enthusiastic about contraception [17].   Second, women who knew about contraception had much higher odds of using contraceptives than those unaware. This result corroborates those from other studies that have demonstrated that women who were more knowledgeable about the benefits of contraceptives and knew how best to acquire and use them than the less knowledgeable women [32,33]. It thus emphasizes the significance of women's education as an inspiring factor for acceptability of contraceptives. The finding, however, differed from a study that was conducted among rural women in western Nigeria, which showed no significant association between educational status of women and the use of contraceptives, [29] probably as a result of other socio-cultural reasons, like a partner`s objection, phobia of the side effects of contraceptives or hostile religious beliefs [34,35].
The desire to have many children acknowledged in the African culture was the only significant deterrent to contraceptive usage among the women. This might lend credence to reports that women in rural and semi-urban communities were sometimes reluctant to accept modern contraceptives. This might be linked to the widely held view in most African cultures that children were a source of economic support for their parents during old age [9,10]. Other less common reasons for rejecting contraceptives such as ignorance, fear of complications, spousal objection and religious beliefs were all not significant in our study [11,12].

STUDY LIMITATIONS
The scope of the study was limited to the determinants of acceptability of contraceptives and not sustenance of its usage, which we recommend for future investigation among this population. Response bias might have limited the validity of the study, since the information was obtained through self-reports. However, we applied measures that improve the quality of information in such circumstances, such as establishing good rapport with respondents, simplifying the questions and allowing respondents to answer at their own pace [36].

CONCLUSION
This study underscores the importance of young age and knowledge about contraceptives in promoting its acceptance among women. We therefore advocate for an early introduction of curriculum-based family planning education in schools and the promotion of community-based family planning initiatives through local media, community dialogues and peer education to create awareness of the benefits of contraceptives among women.

ETHICAL APPROVAL
Ethical clearance for the study was obtained from the Research Ethics Board of the University of Calabar and the Federal Ministry of Health, Abuja. Given that sexual and reproductive health practices of individuals are quite sensitive in nature and often kept away from public view, efforts were made to establish good rapport with the participants, reassuring them of the confidentiality of their responses and that they were at liberty to decline participation at any stage of the study without any reprimands. Thereafter, written informed consent was also obtained from all consenting participants.