|Year : 2020 | Volume
| Issue : 1 | Page : 21-27
Trends in contraceptive uptake at a tertiary health facility in Ibadan, Nigeria
Oluwasomidoyin O Bello, Adebayo D Agboola
Department of Obstetrics and Gynaecology, University College Hospital, University of Ibadan, Ibadan, Nigeria
|Date of Submission||16-Oct-2019|
|Date of Decision||15-Nov-2019|
|Date of Acceptance||12-Jan-2020|
|Date of Web Publication||03-Apr-2020|
Dr. Oluwasomidoyin O Bello
Department of Obstetrics and Gynaecology, University College Hospital, University of Ibadan, PMB 5116, Ibadan.
Source of Support: None, Conflict of Interest: None
Background: Low utilization of modern contraceptive is one of the key determinants of high fertility in Nigeria. Objective: The objective of this study was to determine the yearly prevalence and trend of contraceptive use among women of reproductive age-group who attended a family planning clinic in Ibadan, Nigeria. Materials and Methods: A clinical audit of contraceptive uptake was undertaken at the family planning clinic of University College Hospital, Ibadan, Nigeria, from January 1, 2011 through December 31, 2018. Information on the client’s age, type of contraceptive utilized, and total number of each contraceptive method used per year was obtained. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20.0. Results: A total of 13,023 women utilized at least one form of contraceptive with mean age of 35.53 ± 9.1 years. Implant (31.2%) was the most widely utilized contraceptive, whereas bilateral tubal ligation (0.4%) was the least utilized. Other methods were intrauterine contraceptive device, injectable, condom (male and female), and oral contraceptive accounting for 26.9%, 19.3%, 16.7%, and 5.5%, respectively. A significant decrease was observed in the trend of use of modern hormonal contraceptive methods as compared to the nonhormonal methods over the 8 years studied (P < 0.001). Conclusion: Implant being the most utilized indicates that it is the most accepted and approved by clients in our clinic. The knowledge of contraceptive utilization trends can be used to monitor and appraise the acceptance and approval of each method and family planning programs over a period.
Keywords: Contraceptive uptake, family planning clinic, trend
|How to cite this article:|
Bello OO, Agboola AD. Trends in contraceptive uptake at a tertiary health facility in Ibadan, Nigeria. Int J Med Health Dev 2020;25:21-7
|How to cite this URL:|
Bello OO, Agboola AD. Trends in contraceptive uptake at a tertiary health facility in Ibadan, Nigeria. Int J Med Health Dev [serial online] 2020 [cited 2020 Oct 22];25:21-7. Available from: https://www.ijmhdev.com/text.asp?2020/25/1/21/281887
| Introduction|| |
Contraceptive use in sub-Saharan Africa is still very low, where the levels of fertility and unmet need for family planning are high. Utilization of contraceptives has been shown to improve child survival by optimizing child spacing and lengthening birth intervals and also reducing sibling competition for scarce family and maternal resources.,,,
On the basis of the recent estimates, Nigeria has a population of approximately 200 million with a national growth rate of 3.2%, total fertility rate of 5.5 children, and maternal death rate of 545 per 100,000 live births., In addition, 6.8 million pregnancies occur annually with 16% ending in spontaneous miscarriage, 11% in induced abortion, whereas 4% of all births are unwanted and 7% are mistimed.,
The utilization and choices of contraceptive method vary by type of health facility, residence area (urban or rural settings), and geopolitical zone in Nigeria. Contraceptive use ranges from as low as 3% among married women in northeast zone to as high as 38% in southwest zone with more than one-quarter of married women in urban areas using any method compared to 9% of women in rural areas and a modern contraceptive prevalence rates (mCPRs) ranging from <1% to 27%. Various factors, related to both supply and demand, account for these variations and contribute to the low levels of contraceptive use and choices in Nigeria.,
There is a significant unmet need for family planning in Nigeria with 16% of married women having an unmet need, of which 12% are for spacing and 4% for limiting births., In developing countries, 867 million (57%) women in reproductive age-group who are sexually active and not desirous of a child in the next 2 years are in need of contraception and about a quarter—222 million (26%)—of them do not have access to modern methods of contraception, resulting in significant high unmet need. Globally, the most widely used forms of fertility control are sexual sterilization and the intrauterine device (IUD); however, in developing countries, the most commonly used are pill and injectable.
The 2013 Nigerian Demographic and Health Survey (NDHS) reported 11.1% Nigerian women currently using a modern contraceptive method, which is just a slight increase from 10.5% in 2008 despite the fact that low contraceptive use is associated with high rates of unwanted pregnancies, abortions, and maternal and perinatal morbidity and mortality.,, Unmet need for family planning is one of the indicators for tracking progress on improvement in maternal health, and the modern contraceptives are preferred because they are more efficacious and are associated with lower failure rates., Even though evidence revealed high level of awareness and knowledge of modern contraceptive methods, yet its prevalence of use in Nigeria has remained low.,,, In view of this, Nigeria adopted several strategies including a free commodity policy in 2011, thus making contraception commodities available and free to all women in reproductive age-group at all public facilities so as to attain the goal of increasing the mCPR to 28.4% by 2018 from 9.8%. This was estimated to be able to prevent 400,000 infant and 700,000 child death as well as 1.6 million unplanned pregnancies, thus reducing the infant mortality by 66% and maternal mortality by 75% by 2018., However, the mCPR increased to 13.1% in 2017 but then the outlook assessment of not attaining the 2018 goal of 28.4% propelled an updated obligation to increase the mCPR to 27% by 2020 by the Ministry of Health.,, Conversely, the CPR increased to 15.1% in 2013 with a commitment to 2% yearly increase to achieve 36% by 2018.,, In Oyo state, the CPR among married women showed a decrease from 24.4% to 22.6% in 2013 and 2018, respectively., This reflected in the increased unmet need of family planning from 10.2%% in 2013 to 30.6% in 2018 among women in reproductive age-group in Oyo state., This situation might be mediated by low demand or utilization of family planning. Thus, this clinical audit aimed at determining the yearly prevalence and trend of contraceptive use among women of reproductive age-group who attended the family planning clinic in University College Hospital (UCH), Ibadan, Oyo state, Nigeria.
| Materials and Methods|| |
An 8-year retrospective chart review of contraceptive uptake was undertaken from January 1, 2011 to December 31, 2018, in the family planning clinic of the UCH, a public health tertiary facility in Ibadan, Oyo state, southwestern Nigeria. The family planning services coordinated by the Fertility Research and Endocrinology Unit of the obstetrics and gynecological department, UCH, commenced in 1965, and ran an 8-h clinic each day Monday through Friday with an average attendance of 357 clients per month for either counseling, contraceptive uptake, follow-up, or removal. Data sources were family planning unit records. Information on the types of contraceptive utilized and the total number of each of the methods used per year was retrieved from the records. Time–trend analysis was performed with time categorized as 2-year periods; 2011–2012, 2013–2014, 2015–2016, and 2017–2018, and the prevalence of contraceptive methods for each period was expressed as moving averages. Data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20.0.
In the family clinic, a detailed history on the sociodemographic characteristics, reproductive and medical history, and previous experience with any form of contraceptives is usually obtained from clients at presentation. The client’s height, weight, and blood pressure are measured and documented. Clients are counseled and any method opted for is provided if she is confirmed not to be pregnant via a serum or urine pregnancy test or if menstruating at presentation. All contraceptive methods are provided free; however, a token of a 1000 naira was collected for consumables from clients seeking provider-dependent methods.
After the uptake of any family planning method that is provider dependent, the women were followed up with initial monthly visit and then yearly visits to the clinic if on long-acting contraceptive. They were, however, advised to return to the clinic any time they experienced any adverse effect with the method or they wanted to discontinue its use. During each follow-up visit, the provider enquired about any side effects and measured the weight, height, and blood pressure.
| Results|| |
A total of 13,023 contraceptive uptakes were observed during the 8-year study, giving a mean acceptor rate of 1627.9 per annum. The highest preponderance of contraceptive uptake during the study was in 2014 followed by 2016 and 2012 with 2607 (20.0%), 2211 (17.0%), and 1922 (14.8%) clients, respectively [Table 1].
|Table 1: Yearly percentage distribution of clients with contraceptive uptake|
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The contraceptive mix in this study consisted of oral contraceptive, injectable, intrauterine contraceptive device (IUCD), condom, implant, and bilateral tubal ligation (BTL). Implant was the most commonly utilized method accounting for 31.2%. Approximately a quarter (26.9%) used IUCD, whereas the least utilized method was BTL (0.4%) [Figure 1].
For three consecutive years, no woman underwent female sterilization (2014–2016). Oral contraceptive had its peak uptake in 2018, both injectable and implant in 2017, IUCD in 2016, condom in 2012, whereas female sterilization had its highest uptake in 2013 [Table 2].
Initially, the uptake of oral contraceptive was low at 1.6%, increasing steadily to peak at 7.1% but thereafter decreased to 6.3% during 2017–2018. Injectable contraceptives utilization was 6.7% in the first 2 years of the study, with an exponential increase to 31.0% during the year 2017–2018. With regard to IUCD, a fluctuation was observed in its uptake during the years studied. In 2011–2012, it was utilized by 29.3% contraceptive users, decreasing to 26.1% in 2013–2014, and thereafter increased to 31.6%, but its use declined remarkably to 18.9% during 2017–2018.
Male and female condom uptake had a sharp decline from 38.4% to 21.4% and 0.9% from 2011 through 2016 then it increased during 2017–2018. The implant uptake steadily increased in the contraceptive mix from 23.3% to 29.0% and then 36.7%, but there was a little decrease in its uptake to 35.8% in the year 2017–2018.
Generally, there was a minimal uptake of BTL when compared with that of other contraceptives with the highest proportion of 0.7% during 2011–2012, and no woman opted for it in 2015–2016 [Table 3].
|Table 3: Trends of specific contraceptive methods for 2-year interval periods|
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A significant decrease was observed in the trend of use of hormonal contraceptive methods (oral contraceptive, implant, and injectable) as compared to the nonhormonal methods (IUCD, BTL, and condom) (P < 0.001) [Table 4].
|Table 4: Association between 2-year intervals and types of contraceptive methods: hormonal and nonhormonal|
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| Discussion|| |
This audit explored the prevalence of contraceptive method uptake and the trend of utilization of each method at the UCH, Ibadan, Nigeria, from 2011 through 2018.
Over the 8-year study, contraceptive frequency uptake fluctuated with its highest utilization in 2014, after which, it continually reduced with a prevalence of 7.7% in 2018. The most utilized contraceptives were implant (31.2%), IUCD (26.9%), and injectable (19.3%). The implant being the most utilized in this study is in keeping with the findings in similar studies in different geopolitical regions in Nigeria., This is probably because of the expertise of the providers, its availability, and effectiveness with low discontinuation rate., However, in a study conducted in the south-south and northwestern zones in Nigeria, implant was the least utilized contraceptive, which agrees with the NDHS data with the findings of implant being almost the least utilized, followed by BTL in most of the geopolitical zones including southwestern regions.,, This low utilization might not be unrelated to the limited skills of family planning providers on implant insertion and removal as reported in some studies.
On the contrary, some studies including the national survey of contraceptive users reported condom as the most utilized.,, It is, however, the fourth most used in this present audit, corresponding with the findings from a similar study in the northwestern region of the country. This could be due to the fact that condom is not provider dependent, and this review only included those that collected it from the clinic relying on the fact that they will use it. The availability, non-provider dependent, cost, dual function as a family planning method and a means of preventing sexually transmitted infections, variety of types and colors, and the fact that it is more advertised could be the reason for its high utilization.
In addition, several Nigerian studies documented injectable as the most utilized contraceptives.,,, However, it was the third most utilized in this study by the clients, trailing behind implant and IUCD, and the second most utilized according to NDHS, 2013. Notably, a yearly consistent increase was observed in the utilization of injectable and implants during the clinical audit period with an increase of 24.3% and 12.5%, respectively, between 2011 and 2018. This brings to light the reality of the earlier assumption of increase in the use of long-acting reversible contraception (LARC), implant and injectable, from 2014 to 2018, due to policy changes and LARC strategy in Nigeria. These include allowing community health extension workers to administer injections and increasing the number of trained health-care providers who administer LARC—implant and IUD.
Remarkably, the IUD, a long-acting reversible contraceptive, ranked second in the contraceptive mix uptake. IUD uptake has been documented to be on the increase because of the availability and free accessibility of the progesterone-implanted IUD (Mirena), which has minimal side effects of abdominal cramps and heavy bleeding over the copper T IUD.,, Our findings corroborate the NDHS 2013 report on IUCD, the second most common modern contraceptive used among married women in the reproductive age-group in Oyo state, though IUCD was documented as the most utilized among contraceptive users in previous years.,,,
The audit further showed that the IUCD and implant were the most utilized methods during the four consecutive years: 2013–2016. This might be because they are both long-acting reversible contraceptives, convenient, and with a low failure rate., Furthermore, oral contraceptive pills contributed 5.5% of the total mix, which is lower than the previous studies.,
During the period of review, the least method used was BTL with only 0.4% of the clients utilizing it, which is also in keeping with the findings of several studies and the national demographic survey in Nigeria.,, This low utilization rate might be due to inadequate information, its irreversibility, fears, and misconceptions with regard to this form of contraceptive compared with other methods. Nonetheless, sterilization is known to be the most suitable contraceptive method for couples who do not want any more children. Thus, its low utilization shows that the clients in this study still have the intension of having more children, prefer the long-lasting reversible contraceptive as it is the most widely utilized, or have aversion for surgery as all the women were counseled before utilizing a method based on their choice and medical advice.
With regard to the trend of contraceptive use, there was an initial increase from 2726 (2011–2012) to 4262 (2013–2014), afterward a steady decline to 3574 (2015–2016) and finally to 2461 during 2017–2018. This decrease trend is similar to the downward shift revealed by Taingson et al. and NDHS report of a decrease IUD utilization in married women of 15–49 years in Oyo state from 6.1% in 2013 to 4.2% in 2018, whereas it is not in keeping with the findings of other studies in Nigeria.,,, The observed decrease in trend can be linked to the strike action by health staff in the facility during some of the period reviewed because studies have shown that majority of the provider-dependent family planning methods are received in the public health sector.,
In the meantime, the yearly contraceptive trend was also captured. It was observed that though female sterilization had its peak period in 2013, it was not utilized for three consecutive years. In 2015, female sterilization and IUD were the most common methods used by married or in-union women worldwide. This is in contrast with the findings of this study. IUCD and implant, which were the most utilized of the methods, had their peak during 2016 and 2017, respectively.
An acceptance rate of 1627.9 per annum was found in this study, which is considerably high with wider margin than 167.8 per annum reported in Sokoto, 399 per annum reported in Kaduna, and 453.8 per annum reported in the south-south.,, This high patronage may be attributed to the increase in awareness and knowledge of contraception among the general populace in southwestern Nigeria.,,, Also, there is an increase in the contraceptive usage in this region of the country among the married and unmarried sexually active women in reproductive age-group than that in the other regions in Nigeria, and the National Bureau of Statistics reported Oyo state as having the least proportion of married women who do not use contraceptive.,
The study was not designed to capture some sociodemographic and obstetric characteristics, which could have helped in predicting the factors associated with the trend and uptake of the different contraceptive methods. Also, the findings may not be generalizable because it was a hospital-based study. Future research should be conducted to fill these gaps. However, this study had a large sample, and data on trend were obtained.
| Conclusion|| |
The most commonly used methods of contraceptives are implants and IUDs. Implant being the highest utilized indicates that it is the most accepted and approved by clients in our clinic. Contraceptive uptake is important in promoting women’s health and protecting their rights, whereas the knowledge of its utilization trends can be used to monitor and appraise the success of the acceptance and approval of each method of family planning over a period. In addition, a high rate of contraceptive was used; however, there exists a significant decrease in the trend of hormonal contraceptive methods compared to the nonhormonal methods with only few of the women utilizing BTL.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]