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Investigating claims of contraceptive failure among women of childbearing age in Nigeria: results of a national survey

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  • Save Public Health Research 2013, 3(5): 124-129 DOI: 10.5923/j.phr.20130305.03 Investigating Claims of Contraceptive Failure among Women of Reproductive Age in Nigeria: Findings from a National Survey Oladipupo Ipade ola1,*, Chinazo Ujuju2, Je nnife r Anyanti2, Samson Ade bayo3 1M alaria Action Program for States, Abuja Nigeria 2Society for Family Health, Abuja Nigeria 3National Agency for Food and DrugAdministration and Control, Abuja Nigeria Abstract Uptake o f contraceptives in Nigeria is low despite the several interventions and efforts on family planning in the country. Contraceptive failure among other factors may be responsible for this occurrence as wo men reason “why use it if it doesn’t work”. This paper investigates claims of contraceptive failure among wo men aged 15 to 49 years in Nigeria using data obtained from the 2007 Nat ional HIV/AIDS and Reproductive Health Survey. A total of 5360 wo men were interviewed in the study. Using the Chi Square test of association and the logistic regression, variables such as level of education, place of residence, geopolitical zones and exposure to mass media intervention on family planning were exp lored. Findings showed that more than 86% have ever been pregnant and about 10% had become pregnant while using contraceptive (P = 0.0992, CI =0.0888, 0.1096). Report of contraceptive failure was highest among wo men aged 25 years and above (85%), while self emp loyed group were more affected than women in other occupational groups. Also, women fro m rural areas reported more cases of contraceptive failure than their urban counterpart (54.1% to 45.9%). Da ily ora l pills accounted for about 21.5% of all reported contraceptive failures while condoms and Injectables accounted for 19.6% and 13.9% respectively. Women with secondary and higher levels of education are 1.7 times more likely to experience contraceptive failure than wo men of lower educational level. Significant spatial pattern was observed at the level of geopolitical zones. Intervention on client adherence to pills and introducing Cyclebeads to women who prefer trad itional methods may be exp lored. Keywords Contraceptives, Contraceptive Failu re, Family Planning, Injectables, Pregnancy, Logistic Regression 1. Introduction The provision of contraceptives for family p lanning and birth control has received more attention fro m the international co mmun ities and donor agencies in recent times. Most of these supports are provided to African countries especially the sub Saharan Africa. Nigeria , like any other African country, is faced with the challenges of high rate of unwanted or unplanned pregnancy which poses major health challenge to women of reproductive age. Statistics has shown that 210 million pregnancies occur world wide, with 80 million unplanned, and 46 million ending in abortion[1]. Studies have also shown that lack of awareness, lack of access, cultural factors, religion, refusal by partners or family members, beliefs of infertility and fear of health risks and side effects of contraceptives are some of the factors contributing to non use of contraceptives[2 - 5]. * Corresponding author: (Oladipupo Ipadeola) Published online at Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved Current contraceptive prevalence rate in Nigeria is 15%, while results from the NDHS 2008 report shows that use of any family planning method increases with age from 7% among wo men age 15-19 to 20% among wo men age 35-39, and then declines to 10% for wo men age 45-49[6]. Most wo men currently using contraceptive, use a modern method (11%), while 5% rely on trad itional methods. The male condom is the most common ly used modern method (5%), followed by the injectables and pills (2% for each), wh ile the intrauterine device (IUD) and female sterilisation are the least popular modern methods (less than 1% each). The rhythm method and withdrawal are the most common traditional methods (2% each). The contraceptive prevalence rate for modern methods has increased fro m 6% in 1990 to 13% in 2003 and 15% in 2008[6]. Rapid population growth and overpopulation are issues of great concern to many national governments and the international community[7 10]. Much of the research work done in this do main has associated high population growth rates with poverty, scarcity of land, hunger, environ mental degradation and political instability[11- 14]. Nigeria is the most populous country in Africa, with an Public Health Research 2013, 3(5): 124-129 125 estimated population of 150 million people[15]. The country selected rural and urban localit ies. Stage 3 involved the has one of the highest mortality rates in sub-Saharan Africa, listing of eligible individuals within households while stage the second highest number of maternal deaths in the world. 4 involved selection of actual respondents for interview and One of seven women (14%) has attempted abortion while 10% testing. Overall, 11,822 respondents were selected for ended in unwanted pregnancy[16]. In spite of the effo rts interview of which 11,521 were successfully interviewed made by the government in this direction, the uptake of resulting in a 2.5% non response rate. modern b irth-control in Nigeria remains grossly insufficient[17 – 19]. In Nigeria, contraceptives are made 2.2. Data Analysis available at a highly subsidized rate through social marketing. For the purpose of analysis, simple frequency tables were Awareness programmes through mass media, interpersonal used to describe the socio and bio-demographic communicat ions and outreaches are conducted on regular characteristics of the respondents. Bivariate Chi-square basis and knowledge of the benefits of family planning analysis was used to test for association between the uptake has increased among wo men in Nigeria. However, dependent and proposed independent variables, while the contraceptive efficacy remains a concern. One of the logistic regression was used to identify and quantify degrees determinants of use or uptake o f any health co mmodity or of contribution of each of the independent variables. The practice is the perceived efficacy of such product and model utilized ever e xperienced contraceptive failure against s erv ice. selected background characteristics such as age, education, There are claims that women get pregnant while using one marital status, social economic status knowledge of or other contraceptive. Programme managers in FP have contraceptives and types. reported that use of contraceptives may be dwindling as a The Chi-square statistic is calculated by finding the result of failure rate, “why use it if it doesn’t work?” We difference between each observed and theoretical frequency investigated the claims of contraceptive failure among for each possible outcome, squaring them, divid ing each by wo men in Nigeria tried to identify factors responsible with a the theoretical frequency, and taking the sum of the results. view to improving FP uptake. Logistic regression analysis extends the techniques of mu ltip le regression analysis to a research situations in which 2. Methodology the outcome variable is categorical.[20]. Variables considered in the analysis are marital status, age at the time 2.1. Data of pregnancy, level of education, socioeconomic status, place of residence, geopolitical zones and type of The Federal M inistry of Health (Nigeria) in collaboration contraceptives used. The response variable is the question with the Society for Family Health received funding fro m the whether respondents were pregnant while using United States Agency for International Develop ment contraceptives. All analyses were performed using SPSS (USA ID) and the Brit ish Department for International version 17 and STATA SE 10. We define the response Develop ment (DFID) to conduct the first national survey on variable as y, and denote the event y = 1 if respondent HIV/AIDS and Reproductive Health (NA RHS) in Nigeria in became pregnant while on contraceptives and y = 0 if 2003. NARHS aimed at assessing sexual and reproductive otherwise. Positive association was evident for all variables health (SRH) and the factors influencing the later as we ll as considered. All the tests were carried out at α level of 0.05. the impact of ongoing health interventions in Nigeria. The survey was repeated in 2005 and 2007. Wo men aged 5 to 49 years and men 15 to 64 years old were elig ible for 3. Results and Discussion participation in the surveys. Selection was based on a three-level mu lti-stage probability sampling technique. This 3.1. Socio Demographic Characteristic of Res pondents paper explores the 2007 dataset in investigating claims of The 2007 NA RHS dataset had responses fro m a total of contraceptive failures in Nigeria. 5360 wo men of reproductive ages fro m the 36 states and A nationally rep resentative sample of females aged 15-49 FCT Nigeria. About 66% resides in the rural areas, 67% were years and males aged 15-64 years living in households in currently married or living with a sexual partner as at the rural and urban areas in Nigeria was drawn fro m the updated time of the survey, while 27% were single. Wo men less than master sample frame of rural and urban localities developed 25 years were about 40% of the total respondents and and maintained by the National Populat ion Co mmission constitute the highest in the age categorizat ion. About 50% (NPC). The study area consists of all the 36 states of the of the responsible mentioned that they Christians while the Federation and the Federal Capital Territory. Probability Muslim population among the respondents was also 50%. sampling was used for the survey. The sampling procedure About 30% had no formal education while 42% had was a (four-level) mult i-stage cluster samp ling aimed at secondary and higher levels of education. Over 50% of the selecting eligib le persons with known probability. Stage 1 respondents belong to the poorer socioeconomic class as involved the selection of rural and urban localities. Stage 2 observed through ownership of asset while on ly 10% belong involved the selection of Enumeration Areas (EA) with in the to the richest socio economic class. (See table 1). A mong the 126 Oladipupo Ipadeola et al.: Investigating Claims of Contraceptive Failure among Women of Reproductive Age in Nigeria: Findings from a National Survey respondents, mean age at sexual debut, first pregnancy, first marriage and first birth are 17.01 18.58, 17.75 and 18.99 res p ectiv ely . Table 1. Demographic Characteristics of survey population Variable Place of residence Urban Rural Geopolitical Zone North West North East North Central South West South East South South Marital Status Currently married/living with a sexual partner Single/Never married Sep arat ed/divo rce/wido w Age of respondent 15 – 19 years 20 – 24 years 25 – 29 years 30 – 34 years 35 – 39 years 40 – 49 years Religion Islam Ch rist ian ity Tradit io nal Educat ion No formal Education Quranic only Primary Secondary Higher Socio Economic Status Poorest Poorer Average Richer Richest Frequency n =5360 1847(34.5) 3513 (65.5) 1332 (24.9) 717 (13.4) 942 (17.6) 917(17.2) 639 (12.0) 800 (15.0) 3601 (67.2) 1460(27.2) 292 (5.5) 1190(22.2) 1084 (20.2) 936 (17.5) 741 (13.8) 546 (10.2) 863 (16.1) 2659 (49.6) 2663(49.7)) 31 (0.6) 1616 (30.2) 396(7.4) 1040 (19.4) 1873 (34.9) 429 (8.0) 526 (9.8) 2764 (51.6) 1578 (29.4) 424 (7.9) 68 (1.27) 3.2. Knowledge and Use of Contracepti ve Table 2 describes variables on knowledge and use of contraceptives. About 73% percent of the women knew at least one method of contraception compared to 82% of men who knew any method. Regarding modern contraceptive methods, 68% of wo men and 79% o f men knew at least one method. While 78% o f all the male and female respondents knew of at least one contraceptive method, 74% knew of at least one modern contraceptive method and 51% knew at least one natural family p lanning method. A mong the modern methods, the most known method by men and wo men were male condom (65%), inject ibles (37%) and female sterilizat ion (21%).The percentage of all female respondents that were currently using any modern contraceptive method as at the time of the survey was 10% while that of all men was 16%. Th irteen percent of all females and 18% of all males were recorded to be using any method of contraceptive/child spacing at the time of the survey. The proportion of non-users of contraceptives that indicated intention to use modern contraceptives was 20% among the males and 13% among the females. Almost half of the respondents (44%) indicated that decisions about use of family p lanning methods should be jointly undertaken by the couple, while a fifth (20% ) e xpressed the opinion that the husband should take the decision alone and 5% indicated that it should be the wife’s decision alone. A higher proportion of the respondents desired to have five or more children (35%) compared to those that desired maximu m of four children (24%). Ho wever, 34% o f the respondents expressed the opinion that the number of children they would want to have was “up to God”. (See table 2) Table 2. Description of selected variables on Family planning and cont racept ives Variable Ever used Contraceptive Currently using any modern family planning method Main method currently being used None Daily oral pills Aft er sex oral pills or Emergency Cont racept ive Condoms In ject ables Imp lant s IUCD Rhythm periodic abstinence Withdrawal method Lactation Amenorrhea method Ever experienced pregnancy while using family planning Method being used when pregnancy occurred Daily oral pills Aft er sex oral pills or Emergency Cont racept ive Condoms In ject ables Imp lant s IUCD Rhythm periodic abstinence Withdrawal method Lactation Amenorrhea method How often do u take pills Daily Less frequency Do you forget to take pills Oft en So met imes Rarely Never What do you do when you forget to take pills Quickly take it Double the required dose No thing Forget about it Avoid sex with spouse Use my menstrual calendar Take lemon drink Use condoms Tot al 1192 (22.4) 719 (13.4) 464 (38.6) 78 (6.5) 20 (1.7) 301 (25) 80 (6.6) 6 (0.5) 33 (2.74) 108 (9.0) 63 (5.2) 28 (2.3) 317 (9.9) 75 (22.0) 16 (4.7) 66 (19.5) 49 (14.4) 1 (0.3) 11 (3.2) 57 (16.7) 31 (9.1) 12 (3.5) 47 (60.3) 26 (33.3) 10(12.8) 27 (34.6) 11 (14.1) 30 (38.5) 20 (41.7) 14 (29.2) 2 (4.2) 6 (12.5) 7 (14.6) 7 (14.6) 2 (4.2) 2 (4.2) 3.3. Contracepti ve Failure by Method Result showed that users of traditional methods experienced more contraceptive failures than users of Public Health Research 2013, 3(5): 124-129 127 modern methods. Also pills accounted for the highest failu re emergency/after sex oral pills. About 3.2% were using IUCD reports as about 27% of respondents with failed while 14% were using injectib les. Chart 1 summarises the contraceptives were either using the daily oral pills or the cases of failure with respect to contraceptive method used. 25 22 20 19.5 16.7 15 14.4 10 9.1 4.7 5 3.2 3.5 0 Daily oral pills After sex oral pills or Emergency Contraceptive Condoms Injectables 0.3 Implants IUCD Rhythm periodic abstinence Withdrawal method Lactation Amenorrhea method Chart 1. Percentage distribution of Contraceptive failure by method used Table 3. Result s of logist ic regression for Contracept ive failure Variables Rural (ref. category) Urban Primary Education (ref. category) Secondary & Higher North West (ref. category) North East North Central South West South East South South Less t han 20 years (ref. cat egory) 20-24 years 25 – 29 years 30 – 35 years 35 – 39 years 40 – 49 years Poorest (ref. category) Poorer Middle Richer Richest Single (ref. category) Married Odds ratio 1.058 1.662 1.119 2.097 1.383 2.045 1.645 1.945 2.608 2.333 2.370 2.768 1.839 2.043 2.203 2.723 1.057 Std. Error 0.147 0.242 0.273 0.416 0.307 0.494 0.365 0.699 0.915 0.836 0.870 0.989 0.551 0.640 0.790 1.653 0.257 P-value 0.684 0.001 0.645 0.000 0.145 0.003 0.025 0.064 0.006 0.018 0.019 0.004 0.042 0.022 0.028 0.099 0.821 Listen to One thing at a time 1.278 0.252 0.215 Listen to FP formula one formula two 2.700 0.809 0.001 _cons 0.013 0.006 0.000 95% Confidence Int erval 0.806 1.389 1.248 2.213 0.693 1.420 0.895 1.273 1.064 1.805 3.095 2.136 3.284 2.544 0.961 1.311 1.156 1.155 1.374 3.933 5.188 4.707 5.867 5.574 1.022 1.106 1.090 0.824 3.306 3.773 4.451 8.951 0.656 1.704 0.867 1.882 1.501 4.857 0.004 0.032 128 Oladipupo Ipadeola et al.: Investigating Claims of Contraceptive Failure among Women of Reproductive Age in Nigeria: Findings from a National Survey 3.4. Test of Association Out of 5360 wo men involved in the study, more than 86% of them have ever been pregnant and about 9.9% of these reported they had become pregnant while still on contraceptive therapies. This proportion was found to be statistically significant (P = 0.0992, CI = 0.0888, 0.1096). Women above 25 years were found to have reported the highest number of contraceptive failure cases (85%) wh ile self emp loyed wo men were more affected than any other occupation group (about 41%). Result also showed women fro m rural areas were mo re affected than their urban counterpart (54.1% to 45.9%) while more than three quarter of the reported cases were fro m the currently married wo men (87.3%). The type of contraceptive methods used at the time of pregnancy was considered, daily oral p ills accounted for about 21.5% of contraceptive failures, while condoms and Injectables accounted for 19.6% and 13.9% respectively. The traditional methods accounted for the highest failure as about 29 percent of users of traditions methods (periodic abstinence, withdrawal and Lactation amenorrhea method) reported contraceptive failure. 3.5. Output from Logistic Regression Table 3 shows output of the logistic regression. Level of education, age of respondent, geopolitical zones and listening to radio program were significant pred ictors of contraceptive failure among the respondents. Significant and positive association was evident with poorer (OR=1.838, p=0.042), middle (OR=2.042, p=0.022) and richer (OR=2.203, p=0.028) wo men. Thus, wo men in the poorer, middle and richer classes of socioeconomic status are more likely to experience contraceptive failure co mpared to wo men in the poorest class (P value <0.05) while wo men with secondary and higher levels of education are about 1.7 times more likely to experience contraceptive failure than wo men of lower educational level (P value < 0.001). Wo men older than 25 years are more likely to experience contraceptive failure than those who are younger. Significant spatial pattern is observed at the level of geopolitical zones with p<0.05 except in the North West. 3.6. Discussion Contraceptive failure was reported mainly by wo men with secondary and university education, women in the middle social economic status and self emp loyed women. These wo men are likely to have busy schedules and fail to adhere to the instructions on use of the contraceptive method. Longer term methods and provider dependent methods which have been reported to experience lo w failure rate should be recommended for busy women to reduce the chances of contraceptive failure. Several studies suggest long term and permanent methods be made available for these wo men. Long term methods have also been proved to have reduced up-front costs and many wo men prefer them to shorter acting methods, an advantage that should be a convincing argument for govern ments and donors that subsidize contraception [21]. Investigating claims of contraceptive failure among wo men and the possible factors responsible for contraceptive failure is expedient as contraceptive failures impact on level of induced abortion. The unintended pregnancy as a result of contraceptive failure also affects the health and economic status of Nigerian families. Find ings fro m this paper will provide opportunity for government and donor driven programmes to enhance appropriate policy formu lation. Modern family planning methods have been proven to be very effective in preventing unplanned pregnancy when used properly. The effectiveness of the modern family planning methods depends on user’s compliance with instructions on use. On average, about 5 out of 100 couples will get pregnant in a year while using the daily oral pill[22]. Find ings show that daily oral pills were reported to have highest failure of all the modern methods. Failure could be attributed to inconsistent use as many of the users reported they forgot to take pills often. Traditional methods such as rhythmic periodic abstinence, withdrawa l and Lactation a menorrhea method accounted for about 29 percent of contraceptive failu re. Introducing Standard Days Method of family planning using Cyclebeads to women who prefer t raditional methods because of religious and cultural reasons may be an option[23]. Improvements in the use of traditional methods, for examp le using the Standard Days Method for periodic abstinence, can dramat ically decrease failures of these contraceptive meth o d s [24] . 4. Conclusions It is evident that a significant proportion of the wo men who were on contraceptives experienced pregnancy justifying the claims of contraceptives failure. Also daily oral pills and traditional methods accounted for the highest number of reported failure cases. Failure in the daily oral pills is as a result of users not adhering strictly to the doctor’s prescription or inconsistent use. Busy women should be encouraged to adopt the provider dependent modern family planning method. There is need for scale up of awareness campaign on uptake and proper use of the existing family planning methods and users of pills should be encouraged to involve their partners to support them in ensuring adherence which will benefit the fa mily as a whole. ACKNOWLEDGEMENTS The authors would like to ac knowledge Society for Fa mily Health and the Federal Ministry of Health, Nigeria, for making the data available. Conflict of Interest Public Health Research 2013, 3(5): 124-129 129 The authors declare no conflict of interest. Furthermore, no financial support was received for this work as the data used were secondary data. improving quality. Population Reports, Series J. Baltimore, Johns Hopkins University School of Public Health Population Information Program. p. 47. [13] Federal M inistry of Health and Human Services (1994). Annual Bulletin. Lagos Federal M inistry of Information (FMI) (1993) REFERENCES [1] WHO 2010. Emergency Contraception, dispelling the myth and misperceptions, Bulletin of the World Health Organization 2010;88:243-243. doi: 10.2471/BLT.10.077446 14 April 2010 [2] Sarkar NN. Barriers to condom use. Eur J Contracept Reprod Health Care 2008;13:114-22. [3] Dialmy A. Sexuality and Islam. Eur J Contracept Reprod Health Care 2010;15:160-8. [4] Decat P, Zhang W-H, M oyer E, et al. Determinants of unmet need for contraception among Chinese migrants: A worksite-based study. Eur J Contracept Reprod Health Care 2011;16:26-35. [5] Ülker K, Temur I, Gül A. Effects of modernisation and new population policies on reproductive health in Kars, Turkey. Eur J Contracept Reprod Health Care 2012;17:187-96. 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