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1.1. Background Information
Family planning is one of the most ―health-promoting‖ and cost-effective activities in public health promotion and has the potential to avert approximately 30% of maternal and 10% of child deaths.1 Thus, FP contributes to achieving the Millennium Development Goals (MDGs) through
healthier birth spacing and by reducing mortality and morbidity associated with pregnancy.2 Decades of research and investment in family planning programmes have resulted in dramatically improved programme coverage and biomedical technologies as well as significant
(although uneven) increases in contraceptive uptake throughout most of the developing world.3 Contraceptive options—not all of which are available in many developing countries—include a variety of hormonal regimens and modes of delivery for women (e.g., pills, injectables, implants, patches, vaginal rings, medicated intrauterine devices) as well as improved male and female condoms, spermicides, cervical caps and other vaginal barriers, post-coital (emergency) contraception, improved fertility awareness-based methods, and simpler and more effective surgical techniques for tubal ligations and vasectomies.4
Nevertheless, Demographic and Health Surveys (DHS) reveal that in many countries- including some with quite high rates of contraceptive prevalence -40% or more of women who recently gave birth reported that the pregnancy was wanted later or not at all.5 Proportions of married women with an unmet need for contraception also range up to 30 to 40% or more in a number of countries.6 Both of these situations reflect, to variable degrees, programme- and method-related inadequacies, including contraceptive failures due to a variety of reasons, as well as personal and situational factors such as partner’s opposition or women’s experiences or fears of side-effects that need to be addressed.7 Contraceptive information, needs and motivations evolve through the life course as male and female adolescents become sexually active before marriage or cohabitation (perhaps with several partners) or at the time of their marriage, and as couples decide if and when to begin childbearing (if they have not already accidentally done so); accumulate experiences with contraception (or its absence) and with pregnancy and childbearing; think about spacing and stopping; and are potentially faced with 10 or 20 more reproductive years at risk. Some women and men will divorce, remarry and decide to have another child; others will bear children (wanted or unwanted) outside of marriage or be motivated to avoid it. The environmental and contextual scenarios are many; the individual trajectories even more diverse. The challenge for educational and health sectors is to meet these changing needs with comprehensive information about pregnancy risks, acceptable contraceptive options, and correct and consistent use. Interventions include countering beliefs in ineffective methods and overcoming unrealistic fears about contraceptive side-effects that adolescents may already have acquired.
A sustained service package adapted to the specific and changing needs of individuals and couples and linked with other sexual and reproductive health inputs must be offered.8 The evidence base is by now quite extensive on how to create more user-friendly family planning environments, enhance client-provider interactions and other aspects of quality of care, and involve men as well as women in the discussion of contraceptive choices with respect to ease of use and need for partner cooperation, possible effects on sexual expression (e.g., coitus- dependent or independent methods), safety, efficacy, side-effects, acceptability, accessibility and cost.9
Guidelines have been established for counseling clients such as unmarried adolescents who need dual protection; couples wanting to use a natural method; couples wishing to postpone their first pregnancy or space subsequent pregnancies; women or men who want to use a method without their partners’ knowledge; postpartum and breastfeeding women; women receiving postabortion care; women who have had unprotected intercourse (including rape victims); individuals or couples looking for long-acting reversible or permanent methods; and women approaching menopause.10 The evidence base has also expanded greatly with respect to the medical aspects of contraception for male and female users. Method-specific medical eligibility criteria have been established for women of all reproductive ages who have particular health problems, such as heavy smokers and those with chronic diseases receiving long-term drug treatments (e.g. antihypertensive agents, antiretroviral drugs).11 Ongoing investigations are assessing the protective and risk factors of particular methods with respect to certain diseases (e.g., breast, cervical or testicular cancers, cardiovascular disease, endometriosis).
Family planning is an important preventive measure against maternal and child morbidity and mortality. It is an essential component of primary health care and reproductive health. It plays a major role in reducing maternal and neonatal morbidity and mortality. It confers important health and development benefits to individuals, families and communities and the nation at large. It helps women to prevent unwanted pregnancies and limit the number of children, thereby enhance reproductive health.12 By this, it contributes towards achievement of Millenium Development Goals (MDGs) and the Target of the Health for all Policy.13 The MDGs call for 75% reduction in maternal mortality and two-thirds reduction in child mortality between 1990 and 2015.14 As such effective utilization of family planning services is critical for the attainment of these goals thus improving health and accelerating development across the regions.15Access to family planning also has the potential to control population growth and in the long run reduce green gas house emission with it associated risk.13 Similarly it has been estimated that preventing unwanted pregnancies by the use of family planning would avert a total of 4.6million Disability Adjusted Life Years.16 Despite the importance and benefits of family planning, it has been estimated that about 17% of all married women globally would prefer to avoid pregnancy but are not willing to use any form of family planning.17 As a result, 25% of all pregnancies are unintended particularly in developing region of the world. This results to an estimated 18million
abortion taking place each year, thereby contributing to high maternal morbidity and injuries.14,17
Sub-Saharan Africa which is home to only 10% of the world’s women, contributes annually, 12million unwanted or unplanned pregnancies and 40% of all pregnancy related deaths worldwide.14 The contraceptive prevalence in sub-Saharan Africa is low, estimated at 13%, in spite of the evidence of the pivotal role of family planning, while in Nigeria the estimation is 8.0% with 17% unmet need for family planning.17,18 This greatly contributes to the high rate of unintended pregnancies leading to induced abortion with its consequent complications.17 Despite the fact that Nigeria constitutes only 2% of the world’s population, it has being shown to account for 10% of the world’s maternal deaths. There is relatively high fertility rate in suburban and rural Nigeria despite the efforts of government and other non-governmental family planning services providers. Even though the fertility rate is high, acceptance and utilization of modern family planning methods has been low due to various reasons. In Africa, provision of family planning services is hindered by poverty, poor co-ordination of the programme and dwindling
donor funding.14,19,20 Additionally, traditional beliefs favouring high fertility, religious barriers, fear of side effect and lack of male involvement have contributed significantly in weakening
family planning interventions.14,20,21
1.2 Problem Statement
The number and timing of pregnancies in a woman's reproductive lifespan affects the maternal mortality risk; other factors include the presence of co morbidities, and obstetric care. The effect of these factors is quantifiable by four measures: the number of maternal deaths, the maternal mortality rate (MMRate), the maternal mortality ratio (MMRatio), and the lifetime risk of maternal death.
The MMRate is the yearly number of maternal deaths per 1000 women of childbearing age (15– 49 years). The MMRatio has the same numerator, but is expressed per 100,000 live births. Lifetime risk of maternal death is the cumulative probability of a woman dying of maternal causes during her reproductive life, and is a measure of pregnancy-related female death. Both the MMRate and lifetime risk of maternal death respond directly to fertility rates and thus quantify the risk of maternal death per woman, whereas the MMRatio is indicative of risk per pregnancy due to poor access to and quality of obstetric services. A fall in the number of pregnancies lowers the number of maternal deaths because, self-evidently, in the absence of pregnancy, the risk of maternal death is non-existent.
Although the MMRatio is linked directly to improvements in maternity care, it also responds to fertility rates, which can affect the proportion of births to women with greater-than-average obstetric risk—ie, those who are younger than 18 years or older than 34 years, those with only one child or more than three children, and those whose births are closely spaced.
Increased contraceptive use and subsequent fertility decline results in decreased obstetric risk, mainly by reducing unwanted pregnancies in women of high parity. The risks associated with high parity are seen in parity-specific MMRatios, most of which, in developing countries, are derived from hospital delivery records. MMRatios tend to be raised at parity 1, then become lowered at parities 2–3, then raised again at 4–5, and highest at parities greater than 6. Raised maternal mortality risks at high parities have been seen in Pakistan, Senegal, and west Africa.
In terms of birth spacing, an analysis of more than 450 000 births in Latin America and the
Caribbean between 1985 and 1997 identified an adjusted odds ratio (OR) of 2·5 (95% CI 1·2– 5·4) for maternal death when the interpregnancy interval (the length of time between pregnancies) was less than 6 months. However, a systematic review of 22 studies, a third of which were done in developing countries, examined birth spacing and maternal outcomes and showed inconsistent effects from short interpregnancy intervals on maternal mortality. The investigators reported a strong relation between short birth intervals and poor pregnancy outcomes and maternal morbidity, but a weak relation with maternal mortality, a paradoxical pattern warranting further research.
Another category of high-risk pregnancies are those that end in unsafe abortion. It has been reported that there were 208·2 million pregnancies worldwide in 2008. About 185·4 million of them occurred in developing regions, of which two-fifths (40%) were unintended, with 16% ending in live birth, 19% in abortion, and 5% in miscarriage. It has been estimated that 42 million pregnancies were aborted worldwide in 2003, of which 19·7 million (48%) took place in unsafe conditions. About 97% of unsafe abortions occur in developing countries, and an updated estimate puts the number in 2008 at 21·6 million, with increased rates in sub-Saharan Africa and Latin America since 2003. About 47 000 maternal deaths (13% of all maternal deaths) in developing countries are caused by complications of unsafe abortions. Contraceptive use can prevent recourse to induced abortion and eliminate most of these deaths.
Ross and Blanc estimate that fertility decline between 1990 and 2008 in developing countries averted 1·7 million maternal deaths, corresponding to a 54% reduction in the MMRate. Because increased contraceptive use accounts for 73% of fertility declin), a 40% reduction in the MMRate during these 18 years can be attributed to contraception. Darroch and Singh estimate that 43·8 maternal deaths are averted per 100 000 modern-contraceptive users every year. This ratio implies that, in the absence of contraception, the number of maternal deaths in 2008 (about 355 000) would have been 74% higher, at 619 114. A subsequent analysis with a different approach gave an almost identical estimate of the proportion of maternal deaths in 2008 in developing regions averted by contraceptive use.
Because contraceptive use is estimated to have averted 43–44% of maternal deaths in 2008, and to account for an additional 3·7% reduction in maternal deaths due to its indirect effect on obstetric risk, contraceptive use in developing countries prevents 47–48% of maternal deaths per year. Its effect is further amplified if near-miss cases (severe but non-fatal maternal morbidity episodes) are considered along with maternal deaths.
Conde-Agudelo and colleagues reported the results of a comprehensive systematic review and meta-analysis of observational studies investigating the association between interpregnancy interval and adverse perinatal outcomes. 67 studies whose results were adjusted for at least maternal age and socioeconomic status, including more than 11 million pregnancies, met the strict inclusion criteria. 26 of these studies provided data for meta-analyses, 16 provided data for preterm birth, ten for low birthweight, 13 for small for gestational age, seven for fetal death, and four for early neonatal death.
For preterm birth, low birthweight, and small for gestational age, the highest risk was for intervals shorter than 20 months and longer than 60 months. For both fetal and early neonatal death, the highest risk was for intervals shorter than 6 months and longer than 50 months. Infants conceived 18–23 months after delivery of the previous child had the lowest risks of adverse perinatal outcomes and were used as the referent category. Infants born to women with interpregnancy intervals shorter than 6 months had pooled adjusted ORs of 1·4 (95% CI 1·2–1·6) for preterm birth, 1·6 (1·4–1·9) for low birth weight, and 1·3 (1·2–1·3) for small for gestational age, compared with infants born to women with intervals of 18–23 months. Likewise, infants born after an interval of 6–17 months were 5–14% more likely to have these adverse outcomes than were the referent group. Intervals longer than 59 months were also associated with a significantly greater risk for these three adverse perinatal outcomes (OR 1·20 [95% CI 1·17– 1·24] for preterm birth; 1·43 [1·27–1·62] for low birth weight; 1·29 [1·20–1·39] for small for gestational age). Subgroup analyses according to study setting revealed that the negative effect of interpregnancy intervals shorter than 6 months on the risk of both preterm birth and low birth weight was significantly greater in developing countries (adjusted ORs 2·3 [95% CI 2·2–2·4] and 2·1 [2·0–2·3], respectively) than in developed countries (adjusted ORs 1·3 [1·2–1·3] and 1·5 [1·4–1·6], respectively). This shows that interpregnancy intervals shorter than 18 months and longer than 59 months were significantly associated with increased risk of preterm birth, low birth weight, and small size for gestational age.
Of the possible demographic effects on child health, birth spacing has been the main focus. A comprehensive analysis by Rutstein examined the effect of the length of time from the birth of the preceding child to the conception of the index child using pooled data for more than 1 million births from 52 Demographic and Health Surveys. A large number of demographic and socioeconomic factors were controlled through regressions. For infants (children younger than 1 year), the shorter the interval (18 months or less), the greater the mortality risk. Very long intervals of 60 months or more were associated with higher risks. In the 52 surveys, about 50% of second births and 70% of third-order (or higher) births were conceived after intervals of less than 24 and 36 months, respectively, and the population attributable risk suggested that infant mortality would fall by 7·5% if women avoided conceiving during the 24 months after a preceding birth (equivalent to a birth interval of less than 33 months). Expressed in terms of interbirth intervals, children born within 2 years of an elder sibling have a 60% increased risk of infant death, and those born within 2–3 years a 10% increased risk, compared with those born after an interval of 3 years or longer.
Maternal health outcomes in Nigeria are among the worst in the world, with Nigeria second only to India in the number of maternal deaths.22,23 In Northern Nigeria, the maternal mortality ratio (MMR) is estimated to be appreciably higher than the national average24 with recent estimates for the north over 1,000 deaths per 100,000 live births, compared to MMR estimates for the southern region below 300 deaths per 100,000 live births.25,26 In Nigeria, the rise in maternal mortality has been accompanied by a decline in antenatal care utilization and deliveries with a skilled birth attendant.
According to NDHS 2013, only 15 percent of currently married women in Nigeria are using a contraceptive method, indicating only a two percentage point increase from the 2003 NDHS. The majority of contraceptive users rely on a modern method (10 percent of currently married women), and 5 percent use traditional methods. Among the modern methods, injectables (3 percent), male condoms (2 percent), and the pill (2 percent) are the most common methods being used. The practice of all other modern methods is far less (under 1 percent). Interestingly, 3 percent use withdrawal as a method of contraception.
The use of contraceptives varies by women’s background characteristics. The proportion of currently married women who are currently using any method of contraception rises with age from only 2 percent among women age 15-19 to 22 percent among age 40-44. The use of contraception then decreases among women who are age 45 and older. Among modern methods, use of condoms is more popular among women under age 35, while injectables are more popular among women age 35-44. Currently married women in urban areas are considerably more likely to use any method of contraception (27 percent) than women in rural areas (9 percent). Use is higher in urban than in rural areas for each of these methods. Contraceptive use among currently married women aged between 15 to 49 years in North West Nigeria is 4.3% while that of North East and North Central are 3.2% and 15.6% respectively. Use is higher in Southern Nigeria with South East (29.3%), South South (28.1%) and South West (38.0%). Gross disparities occur among the six (6) geopolitical zones as well as among states. Kano State has contraceptive use of 0.6% (lowest in the North) with only 0.5% using any modern method (pill- 0.2%, IUD- 0.2%, injectables- 0.1% while 0.0% use implants, male condom, LAM, standard days methods and
Educational attainment is positively associated with the use of contraception. The use of contraception rises with the educational attainment of women. For example, only 3 percent of women with no education use a method of contraception compared with 20 percent with primary education, 29 percent with secondary education, and 37 percent with more than secondary education. In general, women do not begin to use contraception until they have had at least one child. Contraceptive use increases as the number of living children born to a woman increases. Two percent of women who have no children are currently using family planning methods compared with 13 percent of women with one to two children. The contraceptive use peaks at 21 percent for women with three to four children before decreasing to 16 percent for those with more than five children. This pattern is true for use of modern as well as traditional methods. There is a direct relationship between the outcome of pregnancy and family planning. The demographic transition theory states that only when fetal, infant, and child mortality rates are reduced it is likely that a family will accept family planning.29 Thus, improvement of maternal and child health services is a prerequisite for family planning. As a result, child spacing is a critical factor which influences the outcome of pregnancy. When women adhere to the World Health Organization recommended minimum inter-birth interval of 33 months between two consecutive live births, the incidence of prematurity reduces. Thus, prevention of rapid series of many pregnancies provides a greater possibility of reducing maternal, fetal, infant, and childhood mortality.30 In general, child spacing provides greater opportunities for nurturing the individual child thereby providing the possibility of preventing complications such as gastrointestinal infections and malnutrition during infancy and early childhood.30 Family planning may also improve the quality of life and raise the standard of living by decreasing the number of dependents requiring intensive personal care, education, food, shelter, and clothing, among others. Nevertheless, where family planning services may be available, its use may be limited due to a number of factors such as low literacy levels, socio-cultural beliefs favoring large families, and unavailability of services due to dysfunctional health services.31 Along with these dynamics in maternal care and contraceptive use patterns, there has been less progress in improving infant and child survival and primary care utilization. As of 2008, the North West and North East regions were the regions with the highest proportions of children 12-23 months who had never been vaccinated, 48.7% and 33.9%, respectively, and fewer than 15.0% had a vaccination card. Vaccination coverage rates in the four northern states of Zamfara, Katsina, Jigawa, and Yobe were all 5.4% and below.27 When their young children became sick with pneumonia, malaria or diarrhea, under half of all sick children were taken to a health facility for treatment. Infant mortality rate was 139 deaths per 1,000 births in the North West region and 126 deaths per 1,000 live births in the North East region, while under five mortality rate was 217 and 222 deaths per 1,000 live births, respectively.27
1.3. Relevance of study to Public Health
High fertility rate and inadequate spacing between births, can lead to high maternal and infant mortality. An estimated 600 000 maternal deaths occur worldwide each year; the vast majority of these take place in developing countries. WHO estimates that 13% of these deaths are due to unsafe abortion. Worldwide, where approximately 50 million women resort to induced abortion, frequently results in high maternal morbidity and mortality.32,33 Thus, family planning and spacing among births are one of the methods to avoid these deaths. Promotion of family planning and contraceptive use is highly adopted by the international community as one of the strategy to reduce the maternal mortality and to reach the Millennium Development Goals.34-36 Africa characterized by high rate of lack to contraceptive access reaching 57% and this lack lead to
unwanted pregnancies, increased demand to abortion and death related to unsafe abortion.37
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