Socio-demographic factors influencing contraceptive practice among married women attending the family planning clinic of UUTH, Uyo, south-south Nigeria

Iyanam VE¹, Udonwa NE², Udoh SB¹

¹Department of Family Medicine, Faculty of Clinical Sciences, University of Uyo, Akwa Ibom State,
²Department of Family Medicine, Faculty of Medicine and Dentistry, University of Calabar, Cross River State.

ABSTRACT:
Background:
Contraception is a topical issue globally considering its enormous benefits to individual users, families, communities, nations and the world at large. Its practice, especially among married women, is influenced by several factors at different settings. This study was done to find out the socio-demographic factors influencing the practice of contraception among married women age 15-49 years attending the family planning clinic of the University of Uyo Teaching hospital, Uyo, South-South  Nigeria and to identify sources of information on contraception among the married women.
Method: This was a cross sectional descriptive study involving 165 married women aged 15-49 years who attended the family planning clinic of UUTH, Uyo, between May and September 2013, recruited through simple random sampling technique. A semi-structured  interviewer  administered questionnaire was used to obtain information on socio-demographic factors and  sources of information on contraception among the  respondents. The data obtained were analysed using statistical package for social  sciences (SPSS), version 17.0.
Results: The mean age of the subjects were 32.22(±5.56). Results obtained  showed that higher contraceptive use  was found among older women,  higher educational level, higher employment status, higher income level, husbands higher educational and employment status, urban residence, lower parity,  Christian faith and  mixed sexes of the respondents children. However, only parity (P=0.001) and Christian religious grouping (P=0.000) had statistically significant influence on contraceptive practices among the married women. Most respondents (76.9%) obtained their contraceptive information from health care wokers while IUCD was the most preferred method of contraception (38.2%).
Conclusion: Contraceptive use among married women in the study is mainly influenced by their high social status. There is need therefore to step up information propagation to women across all social classes if the benefits of contraceptive use are to be achieved in the society.
Key words: Socio-demographic, Factors, influencing, Contraceptive Practice

INTRODUCTION
Contraception is the prevention of unwanted  pregnancy.¹ According to WHO, contraception allows individuals and couples to anticipate and attain their  desired spacing  and timing of birth.^2-3 Studies have  shown that by reducing unintended pregnancies and  abortions, and facilitating family planning/spacing of  births, effective practice of contraception provides both  health and socio-economic benefits to the mother, the  child, family, the society, nation and the world at large.^4,5 According to world wide  estimates, some 600,000 women die each year of pregnancy related causes and 75,000 die following  unsafe abortion. At least  200,000 of these maternal deaths are attributable  to  failure or lack of contraception.⁶ A United Nations Fund for Population Activities (UNDP) fact sheet in 2012 documented that use of modern contraceptives in developing world will avert 218 million unwanted pregnancies which will in turn  avert over 55 million unplanned births, 135 million abortion (40 million of  them unsafe), 25 million miscarriages and 118,000 maternal deaths, 1.1 million neonatal  deaths and  700,000 post neo-natal infant deaths.^7-9 In addition to several other benefits accruing from contraceptive practice, studies have identified links  between contraceptive practice and success of programmes such as the millennium development goals 4 and 5 (MDG'S 4 and 5), safe motherhood initiative (SMI) and  the prevention of obstetric near misses.^10-13
Despite the benefits accruing from the use of contraception, studies have shown that while  the awareness of contraception is globally high  among married women, the effective utilization is  poor.¹⁴ For instance contraceptive  prevalent  rate has been shown to vary between 3% in Chad to  90% in China, with global average of 63%.^15-16 In  Nigeria, while 68% of females know at least  one method of modern contraception, only 9% of women of reproductive age (15-49 years) use modern contraceptives. This is lower than sub-Saharan Africa average of 17%.¹⁷ Several factors have been found to influence the  practice of contraception among married women  at different settings. These include-socio-demographic factors such as age of the married  women, place of residence, educational level, employment and  income status,  religious factor, parity of the women, gender of the  children, husbands educational and  employment-status, family and socio-cultural factors.^18-21 In a study on  information on current  contraceptive  use among currently married women aged 15-49 years by Ghana demographic and health survey, Tawiah concluded that the approval of family planning by women, discussion of family planning with spouses and -women educational level are found to be the three most  important variables influencing  contraceptive choice  and practice among married women.²²
This study therefore aimed at describing the  various socio-demographic factors that influence the practice of contraception as well as identifying  sources of contraceptive information among married  women who attended the family planning clinic of  UUTH, Uyo, Akwa Ibom state.

MATERIALS AND METHOD
Study Area
The study was carried out at the family planning clinic of the University of Uyo Teaching Hospital, UUTH, Uyo between May and September 2013. The University of  Uyo Teaching Hospital is -the only tertiary health institution in Akwa Ibom State. It  serves a  population of over four  million people in  the south –south and south-east geopolitical zones of Nigeria including Akwa Ibom, Cross River, Abia, Ebonyi and Rivers states. The family planning clinic is  located  centrally within the  hospital and  runs from  Mondays to Fridays from 8am to 4pm, except on public holidays.

Sample Selection:
A total of 165 married women  aged 15-49 years old who attended the family planning clinic of  UUTH were recruited into the study, using the  formala:²³
n = Z2P(1-P),
m²
where;   Z –  Confidence level at 95%
(standard value of 1.96)  at
M – 5% acceptable margin of error
(standard value 0.05)
P – Estimated prevalence of contraceptive use among married women in Nigeria (calculated using average of some national and local studies^24-27) = 11.1% thereby giving minimum sample size of approximately 150.
This was rounded to 165 to compensable for non-response and incomplete responses. A simple random sampling by balloting was used to select the respondents. The inclusion criteria were married female subjects between 15-19 years who attended the family planning clinic during the period of the study who consented to participate in the study. The exclusion criteria were those below 15 years and above 49 years, non- consenting subjects and non-married women.

Data Collection
The  data for the study were obtained from the  respondents using semi-structured questionnaire  which was administered to eligible respondents―by the author and trained assistants after the  purpose, general contents and confidentiality of the  study were explained to the  respondents, and―a signed consent―obtained from them. The  data  contained―in the questionnaire include socio-demographic  and other variable that influenced contraceptive―practice as well sources of contraceptive information among the married women.
A pre-test study involving  10 subjects in a different setting was carried out before the study commenced.

Data Analysis:
The data collected  from the study  were analysed using statistical package for social sciences (SPSS), version 17.0.  Frequency and percentages of socio-demographic and other variables were determined. Tables and  charts were  used to show distribution of data as appropriate. The level of statistical significant was taken as P<0.05.

Ethical Clearance:
Approval for the study was obtained from the research and ethical committee of the University of Uyo Teaching  Hospital before the commencement of the study.

Consent
A signed consent was obtained from each respondent after careful explanation of the contents of the questionnaire and the purpose of the study. Participation in the study was voluntary and confidentiality was upheld.

Results
A total of one hundred and sixty five (165) married women were recruited for the study. The results obtained from the respondents are presented below:

As shown in table 1 above, the respondents  age ranged  from 15-49 years, with the mean and standard  deviation of 32.22± 5.56. Majority of the married women were in the age bracket 31-40 years. About three quarter (73.9%) of the women resided in the urban areas while  26.1% of them resided in the rural areas. Most (58.8%) of  the respondents had post secondary education while  41.3% had lower levels of education (secondary, primary and no formal  education). A substantial proportion (37.6%) of the women  were professional workers while 62.4% of them were  non-professional (skilled, unskilled workers and  unemployed). Almost all (97.6%) of the respondents were Christians.

From the above table, majority of the Christians (56.5%) were Pentecostals. Greater percentage (75.2%) of the  respondents was  Ibibio/Annang/Oron ethnic groups while others were of Hausa, Yoruba, Igbo and unspecified tribes. Most of the married women  (50.32) were Para 3 to 4. About  three quarter (74.5%) of the respondents had children of both sexes.

Table 3 shows that a significant proportion (27.9%) of the married women earned more than  ninety thousand  naira a month while 2.9% earned less than ten thousand  naira a month. Majority (83.64%) of the respondents sourced  their light from public power supply and generator while five respondents (3.03%) sourced their light from generator only. More than  half (52.1%) of the  respondents  owned television while  47.9% owned either radio or television. Most (52.7%)  of the married women used electronic media often while two (1.2%) did not use electronic media of all. Husbands of about two third (60.6%)of the women had higher (post secondary) education while husbands of  four (2.4%) married women had no formal education.

Husbands of majority (51.5%) of the married women in the study belongd to occupation class 1 while husbands  of 12.1% of the married women belonged to class 4, according to Borofftka and Olatuwaru system of occupational classification.28

NB: Some married women obtained contraceptive  information from more than once source.
As shown in figure 1, majority (76.90%) of the married  women got their  contraceptive information from health workers,  22.4% from electronic media (television /radio), 10.3% from friends, 3.6% from relations  while 1.2% obtained  the information from other sources.

Figure 2 Contraceptive methods used by the respondents
The various contraceptive methods  used by the respondents in the study are shown in figure 2. Significant proportion (38.2%) of the respondents  used IUCD, 20.9% used norplant,19.2% used pills,17.5% used injectables, 3.0% used condoms(all reversible  methods) while 1.2% used female  sterilization (irreversible method).

Table 5 shows association between some socio-demographic factors and contraceptive  methods used by the respondents. Only respondents parity (P = 0.00) and Christian religious group (P = 0.012) were statistically significantly associated with the types of contraceptives  used by the respondents.

DISCUSSION
This study has shown the influence of socio demographic factors on contraceptive practice among married women attending the family planning clinic of UUTH. Taking the age  of the respondents, for instance, the study has shown that  even though there was no statistically significant association between the age of the respondents and contraceptives use (P = 0.284), finding in this study have revealed  that contraceptive use was highest among women of higher age group (31-40 years) compared with those  of lower age groups. Although contraceptive practice is common among women of reproductive age―(15-49 years), there  seems to be variation in utilization among the  various age brackets.  The findings in this study agrees with findings in other studies.^18,29-31 Olugbenga – Bello, et al showed in a study done in western Nigeria that greater percentage of women who used contraceptives were 35 years old  and  above while lower percentage were of lower age.³⁰
The study also showed that although place of residence had no statistically significant association with methods of contraception practiced by the respondents  (P = 0.589), majority of the married women (73.9%) were of urban―residence  compared to the fewer percentage who resided in  the rural areas. Again, this  finding was in agreement with similar  studies done previously.^19,32,33 Nazir, et al in a survey data from developing countries in Africa, Asia and Latin  America, showed that areas of residence constitute an important factor that identify women who are most likely to use or not to use contraceptive method.³⁴ It has been severally pointed out that urban residence affords ready access to electricity, good roads, electronic and print  media, contraceptive sales outlets which enable  urban dwelling women access to information on health education and contraceptive benefits, thereby enhancing contraceptive practice among the urban dwellers.^19,22
In this study, majority of the respondents―(58.8%) had higher (post secondary) education while lower percentage―(41.2%) had lower educational  levels, even though education as a  variable  had no statistical significant association with methods of contraception used by the respondents  (P= 0.481). Moreover , women whose husbands  had higher (post secondary) education were majority (6.6%) among the respondents. This trend  corresponds with studies done in other settings.^19,33,34
Moreover, in this study, women who were employed constituted the  highest proportion of  contraceptive  users (73.3%) compared with those who were not employed (26.7%). Also the study has  shown that most of the married women who practiced―contraception were higher income  earners (>30,000 naira/ month), compared to those with low income level (< 30,000 naira/month) who were in the minority. Husbands of most  respondents (79.4%) belonged to professional groups (1 and 2) of occupational classification. Although  employment status  and income level had no  statistically significant association (P = 0.177 and  P = 0.139), the findings in this study were similar to previous studies.^35-36 Iman, et al had  established similar association between higher contraceptive  utilization among women of higher  educational  and employment status in Iran.³⁶
Majority of the respondents  (96.4%) in this study were of  Christian faith. Within the  Christian group, the  orthodox and Pentecostal  women (36.5 and 57.2%) used contraceptives more than the  Catholics (2.5%) and the Jehovah  Witnesses (3.7%).  Although there was no statistical significant association between religion as a  variable and contraceptive methods practiced by the respondents(P=0.123), there was  however a significant  statistical association between Christian groups and the various contraceptive methods (P = 0.012). Further analysis showed that  the Pentecostals were the  highest users of  hormonal methods (67%), the orthodox faithful were the only users of female  sterilization (3.3%). These findings agree with  findings in other studies.^31,37-39 The high  proportion of Christian married women in the  study could be attributable to the fact that  the study was conducted in a  state with predominantly Christian religion. That the  Catholics  were the  least users of contraceptives among the Christian groups in this study further  confirms the restriction imposed by the church in the use of certain contraceptives among its  adherents.
The study also  showed that most respondents  (78.8%) were of lower parity (para< 5) compared to those with higher parity (Para≥ 5)/ grand  multipara  who were in the minority. Also most respondents (74.5%) had mixture  of male and female children. Again there  was a  significant  statistical  association between parity of the  married women and  the  contraceptive methods practiced (P = 0.001). Moreover, there seemed to be an inverse relationship between the parity of the respondents and the use of hormonal methods as Para 1-2 women had the highest use  (72.3%), followed by Para 3-4 (57.8%) while the least users  were  para ≥5 (37.1%). On the other hand use of IUCD was  directly proportional to parity as  Para 1-2 respondents had the least use  (19.1%) while Para ≥5 had the highest  use  of  IUCD (62.9%). While the highest  users of barrier  methods were Para 1-2, it was surprisingly found out that Para 1-2  women constituted  the only users of female  sterilization. This trend in contraceptive practice has been reported in previous studies.^35,40-41 Adeyemi, et al had shown  in a  study in western Nigeria that  highest contraceptive users were among the lower parity women while the least use was  among the grand  multi-parus women.⁴¹ Gindher, et al had however documented  in a  study in Ludhlana that uses of irreversible contraceptive methods were  found more among the grand multi – parous women.⁴² Therefore the few Para 1-2 women who used irreversible contraceptive, documented in this study, could be  those with serious health challenges that  prevented them from further conception.
The study revealed that most of the respondents (76.9%) got the  contraceptive  information from health workers while some got from other sources including  radio/television, relatives and other sources. Again, this agrees with previous studies. In their  separate studies done in Uyo, southern Nigeria, Abasiatai, et al and  Umoh, et al showed that most of the contraceptive practitioners  obtained their  contraceptive information from health wokers.^18,35
Finally, this study has shown that significant  percentage of the married women (38.3%) preferred the IUCD, followed by  norplant (20.9%), then the contraceptive pills (19.2%), injectables  (17.5%), condoms (3.0%) and female sterilization (1.2%). This pattern of contraceptive  utilization corresponds with findings documented in  previous studies. For instance, studies conducted in Nigeria  consistently found out that while the oral contraceptive  pills were the most popular  fertility control method  on a  national level, the IUCD was  the method  most frequently selected by women who obtain  contraceptives from the family planning clinic.⁴¹ Also,  at the regional level,  Adeyemi, et al showed that the  IUCD was the most popular method in western Nigeria  followed by  the injectable,⁴¹ while Chiagbu, et al identified the  hormonal injectable as the  most popular  method in eastern Nigeria, followed by the IUCD.⁴² In  south-south Nigeria, Umoh, et al  and  Abasiattai, et al  found out that while the male  condom was the most  popular method, the IUCD was the   next preferred  method.^18,35 Therefore the finding in this  study is a  reflection of national trend in contraceptive practice in Nigeria among married women who obtained contraceptives at family planning clinic.

CONCLUSION
This study has shown that contraceptive utilization among married women in this centre was mainly influenced by higher socio-demographic status among the respondents. Therefore the need to step up information propagation to women across all social classes of the society so as to ensure that contraceptive benefits accrue to all women is highly recommended.

References:

1. Oxford Concise medical Dictionary, 6thed. Oxford University Press 2003; 156.
2. Shaw D. The ABC’s  OF Family Planning. Available  from: http://www.who.int/pinnch/media/memb   ernews/2010/2010 322-d-shaw-oped/en/.Accessed on 2/6/13.
3. Mishra AK. Contraception: Choices. Available from: eastkentgput.co.uk/contraception. ppt. Accessed on 3/ 6/13.
4. Stacy D, Glasofer DR. Contraception. Available at: About. comhealth. updated 14/12/2014. Accessed on 12/5/2015.
5. Malcom RK, Fetherson SM. Contraception. J Assoc Health  Proff. 2013; 18(3): 54-56.
6. Kaunitz A. The importance of Contraception. Available from: www.glown.com 10374. Accessed on 17/2/13.
7. Shaikh BT, Azmal SK, Mazhar A. Family Planning contraception in Islamic countries: A critical review. J Pak Med Ass. 2013; 63(3-4): 62-72.
8. National Academy Press. Contraceptive benefits and risks. Available from: http://www.nap.edu/openbook.php?recor    d-id=142. Accessed 15/6/13.
9. Sing S, Darroch JE. Adding it up: cost and benefits of  contraceptive services, estimates for 2012. Guttmacher institute UNFPA. Available at: http://www.guttmacher.org/pubs/AIU-2012-estimates. Accessed on: 11/3/2013.
10. Costa FG. Non-contraceptive  benefits of contraceptives. US National Library of Medicine. Available from:      http://www.ncbi.n/m.nih.gov/pubmed/12179257. Accessed 9/6/13.
11. WHO. Millennium Development Goals (MDG’s), 2012. Available from: http://www.who.int/topic/millenium-development goals. Accessed 15/6/13.
12. WHO. The Partnership for Maternal, new born and child  health, 2011. Available from: http://www.who.nt/ponuch/media/Press maternals/fs/Ksl-ur. Accessed 18/8/13.
13. Mustafa R, Hashni H. Near miss obstetric events and  maternal deaths. J Coll Phys and Surg. 2009; 19(12): 781-785.
14. Seiber EE, Bertrand JT, Sullivan TM. Changes in contraceptive method  in developing countries. Int Fam Plann     perspect. 2007; 33(3): 117-123.
15. Moronkolola OA, Ojediran MM, Awosum A. Reproductive  health knowledge, belief and determinants of     reproductive  use among women attending family planning clinic in      Ibadan, Nigeria. Afr health Sci. 2006;     6(3): 155-159.
16. Population Division, Department of Economic and Social Affairs. United Nations, New York. Contraceptive use. Available  from: www. unpopulation.org. 2011. Accessed on: 13/8/13.
17. Ogunlela YI. An assessment of safe motherhood initiative  in Nigeria and the achievement of the Millenium development goals number 5. The Soc Scs. 2012; 7(3): 353-360.
18. Umoh AV, Abbah MG. Contraceptive awareness and practice  among antenatal attendees in Uyo, Nigeria. Pan Afr Med J.     2011; 10:3.
19. Agyei WK, Migaddle M. Demographic and Socio-cultural factors influencing contraceptive use in Uganda. J Biosoc Sci 1997; 27(1): 46-60.
20. Mon MM, Liabsuetrakul T. Factors Influencing married youth decision on contraceptive use in a  rural area of Myanmar. South-east Asian J Hosp Med and Pub Health 2009; 40(5): 1057-1064.
21. Samandari G, Speizer SI, O’ Cornel K. The Role of social support and parity in contraceptive use in Cambodia. Int perspect o sexual and Reprod Health 2010; 3693): 48-66.
22. Tawiah EO. Factors Affecting Contraceptive use in Ghana. J. Bio Soc Sci 1997: 29(2); 141-149.
23. Us department of Health and Human Services. Calculating sample size. Available from www.hhs.gov. Accessed  on: 12/8/12.
24. Utoo BT, Mutihir TJ, Utoo PM. Knowledge, attitude and  practice of family planning among women attending antenatal  clinic in Jos, North Central Nigeria. Nig J Med. 2011; 19(2): 214-218.
25. Nigeria demographic and  health Survey (NDHS). Nigeria Family planning analysis: Selected demographic and socio-economic variables. UNFPA, Nigeria office publication, 2010.
26. The Nigeria Urban Reproductive Health Initiative (NURHI) Survey. Nigeria: Key Indicators and Mile updates. 2012 end of year update.
27. Monjok E, Smesny A, Ekabua JE, Essien J. Contraceptive  practice in Nigeria: Literature review and recommendation for future policy decision. Open Access J Contracept. 2010; 2010(1): 9-22.
28. Borofftka A, Olatawura MO. Community Psychiatry in Nigeria: the  current status. Int J Soc Psychiatr. 1976; 23: 1154-1158.
29. Olugbenga–Bello AL, Abodunrin OL, Adeomi  AA. Contraceptive practice among women in rural communities in south western Nigeria. Glob J Med Res. 2011: 11(2): 1-7.
30. Tehran FR, Farahani FA, Hashemi MS. Factors influencing contraceptive use in Tehran. Fam Pract. 2001; 18: 204-208.
31. Rai P, Paudel IS, Ghimire A, Pokharel PK, Rijal R, Niraula SR. Effect of gender preference on fertility, cross–sectional study among women of Tharu community from south eastern region of Nepal. Reprod Health 2014; 11:15.
32. Rahamani MM, Akter S, Mondai MI. Contraceptive use among married women in Chuadanya district, Bungladesh. Middle East J Fam Med. 2008; 6(2): 420-428.
33. Firkree FF, Khan A, Kadir MM, Jajah R, Rahbar MH. What influence contraceptive use among Settlement of     Karachi, Pakistan.Int Fam Plann Perspect 2011; 27(3): 130-136.
34. Abasiattai AM, Etukumana  EA, Utuk NM, Umoiyoho A. Contraceptive awareness and practice among antenatal attendees in a  tertiary hospital in South – south Nigeria. TAF Pref Med Bulletin 2011; 10(1): 29-34.
35. Patro BK, Kant S, Barydalyne W, Gissiani AK. Contraceptive practice among married women in Settlement Colony of     Delhi. Health and Popup Perspect and Issues 2005; 28(1): 9-16.
36. Imam MT, Ghodrati SA. Study of relationship between socio-economic factors and satisfaction with family    Planning services in Iran. Sociat Today 2010; 8:1.
37. Hassan N. Knowledge, attitude and practice of contraception between Kampung Balok Jaja with regard to     educational and  socio-economic status. Euro J Med. 2013; 2(1): 208-209.
38. Osemwenkha JO. Gender issues in contraceptive use among educated women in Edo state, Nigeria. Afr Health  Scs. 2004; 4(1):40-49.
39. Romo LF, Berenson AB, Segars A. Socio-cultural and religious influence on normative contraceptive practices of Latino women in the United States. Contraception 2004; 69(3); 219-225.
40. Adeyemi AS, Adekanle AD, Komolafe JO. Pattern of contraceptive choice among the married women attending  the family planning clinic of tertiary health institute. Nig J Med. 2008; 17(1): 67-70.
41. Giroher S, Chaudhay A, Gill PK, Soni LK, Sacher R. Contraceptive practices and related factors among married women in a  rural settlement of Ludhiana. Internet J Health 2010; 12(1): 5428.
42. Chiagbu B, Onwere S, Aluka C, Okoro O, Feyi-Waboso P. Contraceptive choice of women in rural southern Nigeria. Nig Clin Pract. 2010; 13(2): 195-199.