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Community perceptions, beliefs and factors determining family planning uptake among men and women in Ekiti State, Nigeria: finding from a descriptive exploratory study
  1. Oluwafunmilayo Oluwadamilola Ibikunle1,
  2. Tope Michael Ipinnimo2,
  3. Caroline Ajoke Bakare3,
  4. Demilade Olusola Ibirongbe4,
  5. Adebowale Femi Akinwumi5,
  6. Austine Idowu Ibikunle2,
  7. Emman Babatunde Ajidagba6,
  8. Oluwafemi Oreoluwa Olowoselu2,
  9. Opeyemi Oladipupo Abioye2,
  10. Ayodele Kamal Alabi2,
  11. Gilbert Ayodele Seluwa3,
  12. Olasunkanmi Omotolani Alabi7,
  13. Oyebanji Filani1,
  14. Babatunde Adelekan8
  1. 1Ekiti State Ministry of Health and Human Services, Ekiti State of Nigeria Government, Ado Ekiti, Nigeria
  2. 2Department of Community Medicine, Federal Teaching Hospital Ido-Ekiti, Ido Ekiti, Nigeria
  3. 3Ekiti State Primary Health Care Development Agency, Ekiti State of Nigeria Government, Ado Ekiti, Nigeria
  4. 4Department of Community Medicine, University of Medical Sciences Ondo City, Ondo City, Nigeria
  5. 5Department of Community Medicine, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
  6. 6Royal Brainbox Academia, Akure, Nigeria
  7. 7Ekiti State Hospital Management Board, Ekiti State of Nigeria Government, Ado Ekiti, Nigeria
  8. 8United Nations Population Fund, Abuja, Nigeria
  1. Correspondence to Dr Oluwafunmilayo Oluwadamilola Ibikunle; funmiogunwuyi{at}yahoo.com

Abstract

Objectives To examine family planning through the community’s perception, belief system and cultural impact; in addition to identifying the determining factors for family planning uptake.

Design A descriptive exploratory study.

Setting Three communities were selected from three local government areas, each in the three senatorial districts in Ekiti State.

Participants The study was conducted among young unmarried women in the reproductive age group who were sexually active as well as married men and women in the reproductive age group who are currently living with their partners and were sexually active.

Main outcome measures Eight focus group discussions were conducted in the community in 2019 with 28 male and 50 female participants. The audio recordings were transcribed, triangulated with notes and analysed using QSR NVivo V.8 software. Community perception, beliefs and perceptions of the utility of family planning, as well as cultural, religious and other factors determining family planning uptake were analysed.

Results The majority of the participants had the perception that family planning helps married couple only. There were diverse beliefs about family planning and mixed reactions with respect to the impact of culture and religion on family planning uptake. Furthermore, a number of factors were identified in determining family planning uptake—intrapersonal, interpersonal and health system factors.

Conclusion The study concluded that there are varied reactions to family planning uptake due to varied perception, cultural and religious beliefs and determining factors. It was recommended that more targeted male partner engagement in campaign would boost family planning uptake.

  • Reproductive medicine
  • PUBLIC HEALTH
  • Health Services Accessibility
  • Health policy

Data availability statement

Transcripts cannot be shared to protect the confidentiality of the data and the participants.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • This study used exploratory methods of data collection to provide a better understanding of family planning usage through the lens of the community.

  • This study provided better insight into the impact of religious and cultural beliefs on family planning uptake.

  • The effects of intrapersonal, interpersonal and health system factors on family planning uptake were also explored.

  • This study was conducted among a limited number of participants from the community.

  • It may be difficult to form a causal association in this study as a longitudinal study design was not used and participants were not followed up.

Introduction

Maternal mortality remains a major challenge in Nigeria with the country contributing close to one-fifth of all maternal deaths worldwide.1 Pregnancy-related mortality contributed significantly to this statistic. A quarter of the estimated 10.3 million pregnancies in Nigeria were unintended, with more than half of these unintended pregnancies ending in abortion2 which occur mostly under unsafe conditions.2 Contraception utilisation, a major public health intervention, is known to improve women’s sexual and reproductive health by helping to prevent pregnancy-related health risks of women, especially maternal mortality.3–6

Nigeria government and donor organisations had implemented policies, strategies and programmes in efforts to create a favourable and conducive environment to boost contraceptive uptake, including policy on free contraceptive and life-saving maternal and reproductive health commodities, accelerated implementation of activities around the long-acting reversible contraceptives method, Nigeria family planning blueprint (scale-up plan), Family Planning 2020 initiative, renewed commitment to FP2020, Sustainable Development Goals and Saving One Million Lives Program for Results.7–12 These strategic programmes were targeted at achieving a national contraceptive prevalence rate of 36% in 201812 and modern contraceptive prevalence rate of 27% by 2020.2

However, despite huge investments, several million women who desire contraceptives are not using it.2 4 According to a report of national survey, the unmet need for family planning among women of reproductive age group in Southwest Nigeria is 17.8%.7 In Ekiti State, Nigeria, only one in every four married/in-union women are currently using any modern contraceptive methods.13 Additionally, the unmet need for family planning had remained the same over the years.7 13 14 Factors known to influence contraceptive uptake are region, age, religion, education, economic status, opposition by spouses, health concerns and poor knowledge.3

The socioecological model was adapted for the study design to explain the complex interplay of factors constraining utilisation of contraceptive services by women. This study attempts to offer a better understanding of the barriers to family planning uptake in Ekiti State so as to offer programmatic guidance on the provision of family planning services. This study examines family planning uptake through the community’s perception, belief system and cultural impact; in addition to identifying the determining factors for family planning uptake among men and women in Ekiti communities.

Methods

Patient and public involvement

There was no patient involvement in the development of the research question and outcome, design, recruitment and conduct of this study as it focused on sexually active women of reproductive age as well as married men in the community. Ekiti State Government and the State Ministry of Health who have access to this report will engage the communities involved.

Study design and area

This descriptive qualitative study was conducted in Ekiti State, Southwest Nigeria. Ekiti State has a projected population of about 3.4 million people.15 The State is made up of three senatorial districts, namely Ekiti Central, Ekiti North and Ekiti South. The senatorial districts are further divided into local government areas (LGAs) which are 16 in all; six in Ekiti South, and five each in Ekiti Central and Ekiti North senatorial districts. The inhabitants of the State are mainly Yorubas and practise Christianity. The State is largely agrarian with a few artisans and civil servants.16

Sampling and participant recruitment

A total of three LGAs were selected through simple random sampling techniques by balloting from the LGAs in each of the senatorial districts. At the LGA level, either one town or village was selected from each selected LGA by balloting resulting in the selection of two towns and one village across the three LGAs where the focus group discussions were eventually conducted. The two towns had a fair representation of the indigenes of Ekiti State while the one village captured information from members of one of the minority groups (Fulani) living in the State.

The focus group discussions took place in the selected three communities of the State and a total of eight focus group discussions (FGDs) were conducted. One FGD for men, one FGD for younger women (18–24 years) and one FGD for older women (25–49 years) were conducted in each of the two towns while one FGD for men and one FGD for women (25–49 years) were conducted in the village (due to the tribe involved), making a total of three FGD groups for males and five FGD groups for females. Details of these are presented in table 1. We got to saturation with the FGDs conducted as enough data have been collected to make the necessary conclusions, and collecting more data will not yield valuable insights. Each FGD group consisted of 8–10 participants and sessions lasted for about 40–60 min.

Table 1

Details of the selection of location and participant including total number of FGDs

The participants for the FGD were recruited from the communities on the basis of their residence within a 2 km radius of the nearest primary health facility providing family planning services. The community health extension workers and/or public health nurses from the primary health facilities helped in the identification of potential participants. Only individuals who met the predetermined criteria mentioned earlier were invited to participate in the FGDs.

Target population and participants

The study targeted young unmarried women in the reproductive age group who were sexually active as well as married men and women in the reproductive age group who are currently living with their partners and were sexually active.

The participants for the FGDs were selected from the community and included women between the ages of 18 and 49 years, married and living with their husbands, or those in a sexual union who would not like to get pregnant at the time of the study as well as men between the ages of 18 and 65 years who were married and living with their wives. They must have been residing in the community for more than 1 year prior to the commencement of the study.

Research instrument, training of research assistants and data collection

The FGD guides were designed and developed by the research team in English language using previous literature17 and experience as reproductive health experts and public health physicians. The guide was designed to create rapport and allow space for the emergence of themes by using open-ended questions to explore themes included in the guide. These guides were translated into the local language (Yoruba) for field use and back translated into the English language with the assistance of Yoruba linguists from a University in the State to ensure correctness and consistency of meaning. A pretest was done in order to accommodate cultural validation.

The FGDs were conducted in Yoruba language and the data were collected by trained researchers. The recruited research assistants were university graduates fluent in Yoruba language with experience in qualitative data gathering and were trained in family planning and reproductive health concepts as well as data collection via FGD. They were initially trained for 4 hours over 3 days before the pretesting, and this was subsequently consolidated after the pretesting. The research assistants served as the moderator facilitating the FGDs.

The FGDs were conducted in places that had easy access to participants and where they felt comfortable such as town halls and school halls and classrooms after school hours. Due to cultural sensitivities, the FGDs were conducted separately with male and female participants. The interviews were conducted in Yoruba language by the research assistants. At least three research assistants were involved in each FGD session, the most experienced usually served as the moderator, the second was responsible for the audio recording, while the third was the note taker noting both verbal and non-verbal gestures of the participants. All three research assistants were same sex with the participants.

Data analysis

The audio recording of the FGDs was transcribed verbatim including pauses and triangulated with the notes. These were translated from Yoruba into English language by the Yoruba linguists and used for analysis. Using thematic content analysis, analytical framework and codes were developed using QSR NVivo V.8 software for Windows. The codes were further refined, combined and grouped to develop additional codes for a detailed analysis. Themes and subthemes were generated to address the study objectives and the results were presented in prose format.

Ethical consideration

Informed consent was taken from all the participants before carrying out the FGDs. The audio recordings and hard copies of the transcripts were kept under lock and key and only the lead investigator has access to them.

Results

78 married and unmarried men and women participated in eight FGDs. 50 of the participants were women and 28 were men. The majority were married. The age range of the male participants was 18–65 years while women of reproductive age group (18–49 years) were targeted for the FGDs. Five groups were all females and three groups all males. The sample was ethnically diverse with majority being Yoruba.

The major themes of the analysis are presented as follows.

Knowledge on family planning

The majority of the participants had the knowledge on the benefits of family planning and contraceptive. However, limited knowledge was found among the Fulani participants.

I see family planning as maybe the number of children we want to have and the number of years we want to have between them maybe 3 years. So, with family planning, there is the opportunity to prevent pregnancy… (40-year-old married Yoruba man)

Modern contraception is a program designed by the government to help families in spacing their children. It is a way to space your children either 2 or 3 or 4 years. It also helps women to have peace of mind which will help us have good health. It prevents unplanned pregnancy. (45-year-old married woman)

Family planning is a program the government established for women to be able to put gap between our children, that’s the first one, point 2, when you are through giving birth to all the children you want to give birth to, you can stop it so that you won’t have unwanted pregnancy… (20-year-old unmarried Yoruba woman)

…We, Fulanis don’t do it, we don’t even hear it before. But as the world is evolving, we started hearing about it because you can’t see a Fulani in waywardness or something. It’s the number of children that each of us will give birth to that we will give birth to and there is no taking of any drugs. (30-year-old married Fulani woman)

In addition, some of the participants were familiar with the various family planning methods and also had knowledge of the various family planning methods but there were misguided perceptions about family planning method side effects.

And our nurses use to tell us that there is different type of contraceptives. Injection type, pills type, they also call another one implant, they put it on the arm, then there is IUCD which they put in the vagina, then there is condom. These and many other types have been explained to us by our nurses. (38-year-old married Yoruba woman)

…. a woman used IUCD and when she and her husband had something together the thing went inside her, and she got pregnant, and the thing went to prevent the child from development, and it resulted to operation for the child to bring the child out. So, they believe it was the cause of the CS delivery. (23-year-old unmarried Yoruba woman)

…I know 5 methods that are sure; there is arm method (implants), there is vagina (IUCD), the injection (injectables), gold circle (condoms). (19-year-old unmarried Yoruba woman)

Community perception

Many participants held the view that family planning is meant only for the married so as to help foster love between the couple and help protect against unwanted pregnancy.

It fosters love in the home between the husband and wife. Because in the past when there is no family planning, after giving birth to 3 or more children, a woman will be looking unattractive, but the introduction of family planning methods has helped women look more attractive and their husbands are even happy with them. (35-year-old married Yoruba woman)

However, some (especially men) held the view that contraception use by married women and singles promotes promiscuity.

The community people call singles going for family planning prostitutes. (23-year-old unmarried Yoruba woman)

Beliefs and perceptions of the utility of family planning

Participants held diverse beliefs about the utility of family planning. Some of the positive beliefs on family planning mentioned by the participants were that family planning secures the health of the mother and child by reducing untimely deaths in the family.

…it reduces the untimely death of women in the society. When there is no family planning, and a woman gets pregnant when she is not supposed to and she goes for abortion, it usually leads to untimely death. But when family planning came, and women are doing different types, it was observed that untimely death reduced amongst our women. It also gives her peace of mind to take care of the children she has on ground. They also have good health in their body. (45-year-old married Yoruba woman)

I have seen a family that conceive just 7 months after the first child, and it prevented the woman from caring for the first child properly. It’s affecting the child on ground that the child is not smart. But if they use family planning the child will not have that challenge. (35-year-old married Yoruba man)

Another positive belief about the utility of family planning was that it promotes peace, love and unity between couples and the household. It was also noted that family planning uptake helps with development of the society in addition to reducing poverty by allowing engagement in profitable employment boosting economic empowerment of women.

…we can see that family planning has reduced the rate of divorce in marriage. In the past, you know that sex causes a lot of fight between the husband and the wife in the home but now everything is going on fine, and the rate of divorce has reduced. Also, it allows peace between the husband, wife and even the children. (38-year-old married Yoruba woman)

It fosters love in the home… It prevents untimely death… It helps to take care of the children… It helps to contribute to their society… It will help their trained children to contribute positively to the society and their homes also. (21-year-old unmarried Yoruba woman)

If one is working may be business or selling goods and making money, and what they have is only enough for 3 children so that they will not suffer, if she doesn’t do family planning, she will just be giving birth anyhow. But if she does family planning the money will be enough to take care of them. that’s what I know. (24-year-old unmarried Yoruba woman)

However, some male Yoruba and the Fulani participants had negative beliefs about the utility of family planning. They noted that family planning uptake promotes promiscuity among married women and young girls and there might be the possibility of negative effects of method of choice.

The disadvantage is that our wives should not go and do it on their own because some are doing it because of adultery. ‘The second is that parents that are taking their children to do it usually become wayward’. (45-year-old married Yoruba man)

And again, there are some people that friend can confuse that if you go and do this thing, see someone’s mother, she did it and started falling sick, she will be scared that if she does it and sickness comes on her, what is its benefit to her? (50-year-old married Yoruba man)

…You see if we Fulani do family planning, they will say it’s for adultery, that’s why we don’t want to do it. If you, do it, they will say this person has done family planning and she is available, any man that sees her are calling her here and there… (40-year-old married Fulani woman)

Cultural and religious impact on family planning

Mixed reactions were gotten from participants with respect to the impact of culture and religion on family planning uptake. Most Yoruba participants stated that their culture and religion permit family planning uptake, but the opposite was with the Fulani participants.

About our culture, our idol worshippers are also supporting family planning now. Everyone wants a comfortable life, a progressive life. A lifestyle of education is what everyone wants. So, culture is not against it at all. (40-year-old married Yoruba woman)

…It’s the religion that accepts it very well, even the pastors used to preach that it’s the number of children you can care for you should have because if you don’t there is no one that will help you cater for them. (23-year-old unmarried Yoruba woman)

People think family planning is sinful; it means that the child that God has designed to come you are stopping it and even some clerics are enforcing it. (30-year-old married Fulani man)

Surprisingly, some of the participants held the view that even if their culture or religion does not support family planning uptake, they would still engage in it. Some also noted that it is individual’s level of religious beliefs that determines their uptake of family planning.

…It accepts it and if it doesn’t, we will collect it behind them. (20-year-old unmarried woman)

The bible says blessed is the servant that uses wisdom. (33-year-old married Fulani man)

…there is no religion that opposes it, but it depends on how each person perceives it. You know religion is individual, the two of us can be going to church and you will say that God told you not to do family planning that it’s a sin. And another person will accept it. (45-year-old married Yoruba woman)

Factors determining family planning uptake

A number of factors were identified during the FGDs and were grouped into three:

  1. Intrapersonal factors such as ignorance, fear of ineffectiveness and side effects of some contraceptive methods.

Some women don’t know anything about family planning, they are just hearing about it. So, ignorance also affects. (33-year-old married Yoruba woman)

The reason is because there are some women that did it and still got pregnant. (35-year-old married Yoruba man)

Some people are scared because of the report they are hearing, some will say they have collected it before and blood was rushing for some months, they will even add to it to make is fearful. So, it makes people scared. (20-year-old unmarried Yoruba woman)

Some have one child and because they want to enjoy their lives, they did it and when they are ready, and they removed it they will not be able to give birth again. It will create fear. (40-year-old married Yoruba man)

  1. Interpersonal factors such as absence of communication between the couple on the decision to uptake family planning, need for husband’s approval, lack of support from the husband and fear of committing sin and stigmatisation by the society.

Another person will say that her husband does not want her to do it. … She has it in her mind but her husband will not allow her. Some who are smart will do it and cover it. (35-year-old married Yoruba woman)

It’s not a sin but a grave sin if a woman comes home to say she did it without consent. It’s on her feet that she will explain if she went to do it with her father, or her sibling. That day, problem has started in that house. (50-year-old married Yoruba man)

Lack of cooperation between a husband and his wife. We have seen instances where the wife wants to do it, but the husband will not accept it or even hear about it. Some will come secretly for implant and if her husband asked that what happened to her, she will lie that it’s a tree that injured her. (45-year-old married Yoruba woman)

  1. Health system factor like poorly skilled health worker, poor communication about family planning by health workers, negative attitude of health workers and economic barrier.

…Some people will not do test and they will just do the one they know for the woman. So, they need adequate testing and training… it’s those that know about it that they should put there. (40-year-old married Yoruba man)

…there are different types of doctors outside. Some doctors because of the money they want to collect from them, he won’t ask any question. He will just ask are you ready and she will say I am ready; he will just inject her. And ask her to go. (35-year-old married Yoruba man)

…Every time they will say free drug but when you get there, they will say you should go and bring money. (23-year-old unmarried Yoruba woman)

Discussion

This study was aimed at understanding community perceptions, belief system and cultural impact as well as identifying other factors affecting family planning uptake among men and women in Ekiti State. The result reflected that despite the good knowledge of family planning methods among the participants, there were still misconceived opinions about the side effects and there were mixed reactions from the community’s perception, belief system and cultural impact. According to similar research conducted in Southwest Nigeria, it was found that the most common cause of low family planning uptake was misconceptions about the side effects.18

The high knowledge noticed among these participants is consistent with the National Demographic and Health Survey of 2018, which reported that knowledge of modern contraceptive methods among sexually active unmarried women was 98% and that of currently married women was 94%.19 The participants who belonged to the Fulani tribe were seen to have limited knowledge of family planning and contraceptive methods. This is in consonance with a previous study done in Nigeria,20 where a low level of knowledge about family planning was found among the Fulani participants. This may be due to cultural attitude to contraception among them.

Although the majority of the respondents held the view that contraception is meant for the married, some believe that singles who use family planning are prostitutes while a selected few believed that it promotes promiscuity among both the single and married. These community perceptions have made many willing persons shy away from the use of contraceptives. The idea that contraception promotes infidelity was also described in previous studies.21 22 While some believe that family planning protects both the mother and the child, as it allows the mothers to take care of their children and prevents untimely death, others believe that one can get ill from using family planning methods. There is a need to design behavioural change interventions to correct these misconceptions.

A positive belief that was depicted from this study was that it fosters love and unity among the couples, and it also prevents quarrels emanating from their sexual life. This is in tune with findings from a study conducted in Ogun State, Nigeria, where some of the participants stated that their reason for choosing family planning was to satisfy their partners sexually.23

Again, these studies showed that there are mixed reactions from the participants regarding the impact of culture and religion on family planning uptake. Most of the Yoruba respondents adjudged that their culture agrees with family planning while the Fulanis were in discordance as they claimed their culture does not support it. The Fulanis, a tribe majorly found in Northern Nigeria as well as in other African countries like Senegal, Guinea and Mali, among others, who are also majorly of the Muslim faith, believe that the more children a woman bears, the more the number of worshippers.24 However, the majority of the respondents who were of Yoruba ethnicity believed that no religion is against family planning. This is in contrast with that of a study conducted in Tanzania,25 where participants held views that family planning is against God’s will as women would not be able to give birth to the desired number of children that God has planned for them and also that the number of their members will reduce.

A large number of the participants aired the view that the husband’s approval was essential and compulsory on the subject of family planning. Additionally, it was found that communication between couples is vital to improving family planning uptake among the participants. This is in consonance with a study done in Osun State, Nigeria,17 where the majority of the participants believed that husbands should be the ones to make family planning decisions. As described in previous studies,22 25 many respondents also noted in this present study that most husbands would not agree with their partners to do family planning. A study done in Ethiopia reinforces the domineering influence of men in family planning-related decisions.26 These further bring to bear the importance of creating awareness and engaging men in family planning activities.

Other factors highlighted among the participants included the skills and attitude of the healthcare workers, poor communication between healthcare workers and the clients, as well as the affordability of the family planning methods. There had been several moves by the government to make family planning more affordable to the communities. However, this has not yielded so much fruit as many clients still pay out of pocket for healthcare services including family planning commodities.27 28 Literature has shown that young people have varied preference and dissatisfaction for public hopsitals due to lack of privacy and attitude of health workers.21 Similarly, in studies conducted in Kenya and the Democratic Republic of Congo, the availability and quality of family planning services in health facilities were implicated as part of the factors affecting uptake of family planning.29 30

Emanating from the study are some limitations that must be put into perspective. This study was conducted among a limited number of participants from the community and may not totally represent the view of the entire target population. Again, it may be difficult to form a causal association in this study as a longitudinal study design was not used and participants were not followed up.

Conclusion/recommendations

This study gives insight into the factors affecting family planning uptake including knowledge about contraception, community perception, religious and cultural beliefs, as well as intrapersonal, interpersonal and health system factors. With increased awareness and support from religious, opinion and community leaders, there can be improved sensitisation and a consequential increase in family planning uptake.

Also, men need to be targeted and more involved in the campaign for improved family planning uptake as the majority of respondents agree that the role of the approval of husbands in increasing uptake cannot be overemphasised. Lastly, the government and other stakeholders must improve funding and economic access to family planning services as well as improve the overall quality of family planning services in health facilities.

Data availability statement

Transcripts cannot be shared to protect the confidentiality of the data and the participants.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by the Ethics and Research Review Committee of Ekiti State Ministry of Health and Human Services, Ado Ekiti, Nigeria (MOH/PRS/040). Participants gave informed consent to participate in the study before taking part.

References

Footnotes

  • X @DrGrandmaester

  • Contributors OOI conceived the study. OOI, TMI, CAB, DOI, AII, EBA and BA contributed to the conception of the design. OOI, TMI, CAB, DOI, AFA, AII, EBA, OOO, OOAb, AKA, GAS, OOAl and BA were involved in the planning and conduct of the research project. OOI, TMI, CAB, EBA and AFA contributed to the acquisition of the data, analysis and interpretation of the data. OOI, TMI, CAB, DOI, AFA, AII, EBA, OOO, OOAb, AKA, GAS, OOAl, OF and BA were involved in the drafting and reviewing of the manuscript. OOI, TMI, CAB, DOI, AFA, AII, EBA, OOO, OOAb, AKA, GAS, OOAl, OF and BA approved the final version of the manuscript. OOI is acting as the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.