Fertility rates are high in Nigeria's northern cities. The fertility rate is ... Abuja, Kaduna and Zaria, fertility rate
Research Brief
BASELINE FINDINGS FOR THE NIGERIAN URBAN REPRODUCTIVE HEALTH INITIATIVE: A RESEARCH BRIEF BACKGROUND
communities is a viable means of improving maternal health and saving mothers’ lives. By preventing unintended pregnancies and spacing births, family planning also reduces infant and child deaths.
Rapid urbanization in Nigeria has placed a burden on already insufficient infrastructure and services, leading to poor urban living conditions.
KEY FINDINGS • Fertility rates are relatively high in all six NURHI program cities, ranging from 3.4 children per woman in Benin City to 6.0 in Zaria. 2011 Bonnie Gillespie
In Nigeria, dense urban neighborhoods lack sufficient infrastructure and services, but they provide opportunities for rapid dissemination of information and social norms.
Home to more than 146 million people, Nigeria is the most populous nation in Africa. In 2010, half of all Nigerians were living in urban areas. That proportion is projected to grow to three-quarters by 2050. Planning and infrastructure have not kept up with this rapid urbanization. As recently as 2005, an estimated two-thirds of Nigeria’s urban population was living in slums lacking adequate amenities, such as sanitation and safe water.1 The Nigerian Urban Reproductive Health Initiative (NURHI) aims to significantly increase modern contraceptive use among Nigeria’s urban poor.
In urban Nigeria, modern contraceptive use is low, and fertility is high. Many low-income urban women are unlikely to receive prenatal care or skilled care during delivery, heightening their risk of maternal morbidity and mortality. Expanding access to family planning information and services among urban
• Most men and women know of a modern contraceptive method. • Modern contraceptive use is low across all six cities, ranging from just 6 percent of women in union in Zaria to 33 percent in Ibadan. • Some women in union who are not currently using a contraceptive method are in need of family planning. From 8 percent to 18 percent want to delay the next birth, and 4 percent to 11 percent do not want any more children, but they are not currently using contraception. • Family planning services are more likely to be integrated into maternal health services than child health or HIV services. • Television and radio are the most important sources of family planning information for both women and men. Both men and women have easy access to mobile telephones, representing an opportunity for increasing access to family planning information. • Barriers to family planning include widespread misconceptions about the health effects of contraceptives and lack of communication about family planning between partners.
Population Reference Bureau. DataFinder. Retrieved June 29, 2011, from http://www.prb.org/DataFinder.aspx 1
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NURHI aims to significantly increase modern contraceptive use in six cities in Nigeria: Abuja, Benin, Ibadan, Ilorin, Kaduna and Zaria. The objectives of the NURHI program are to: • Develop cost-effective interventions for integrating quality family planning with maternal and newborn health, HIV and AIDS, postpartum and postabortion care programs. • Improve the quality of family planning services for the urban poor with emphasis on high-volume clinical settings. • Test novel public-private partnerships and innovative private-sector approaches to increase access to and use of family planning by the urban poor. • Develop interventions for creating demand for and sustaining use of contraceptives among marginalized urban populations. • Increase funding and financial mechanisms and a supportive policy environment for ensuring access to family planning supplies and services for the urban poor. NURHI uses baseline survey data to design program activities.
The 2010-2011 Nigeria Baseline Survey for the Urban Reproductive Health Initiative2 provides NURHI with information needed to support evidence-based development and expansion of family planning programs. Conducted by the National Population Commission, the Measurement, Learning & Evaluation (MLE) Project and NURHI, the survey establishes a baseline for evaluating the NURHI program. Data were collected from a representative sample of 16,935 households. All eligible women ages 15 to 49 in selected households were interviewed, as were men ages 15 to 59 in half of selected households. The baseline survey findings confirmed many of the findings from the 2008 Nigeria Demographic and Health Survey (NDHS).3 For the full report, see http://www.nurhi.org/sites/nurhi.k4health.org files/2011_Nigeria_Urban_Reproductive_Health_Survey_FINAL.pdf 3 For a summary of trends from the NDHS from 1990 through 2008, see http://www.urbanreproductivehealth.org/publications/fertility-and-familyplanning-trends-urban-nigeria-research-brief 2
This brief summarizes key findings from the baseline survey across the six NURHI program cities.
WHAT ARE FERTILITY PATTERNS? Fertility rates are high in Nigeria’s northern cities.
The fertility rate is high in all six program cities. It is highest in Zaria, where the total fertility rate (TFR) is six births per woman (Figure 1). The TFR is lowest in Abuja, Benin City and Ibadan, with fewer than four births per woman. Figure 1. Total Fertility Rate, 2010-2011
6.0 3.8
3.4
3.7
4.2
4.2
Abuja
Benin City
Ibadan
Ilorin
Kaduna
Zaria
Women’s education and wealth affect fertility levels in every city.
In Abuja and Kaduna, fertility rates decline as educational attainment increases. In the other cities, fertility rates peak among women with primary schooling and decline with further education. In Abuja, Kaduna and Zaria, fertility rates decline with rising levels of household wealth. In the other cities, fertility rates peak in the middle wealth quintile. Teenage pregnancy rates are higher in northern cities.
Teen pregnancy rates are low in Abuja, Benin City and Ibadan (ranging from 1 percent to 4 percent); higher in Ilorin and Kaduna (7 percent and 10 percent, respectively); and highest in Zaria (18 percent) where early marriage is common.
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HOW COMMON IS MODERN CONTRACEPTIVE USE? In general, use of modern contraceptive methods among women in union is low.
The percent of women in union4 using a modern method ranges from 6 percent in Zaria to 33 percent in Ibadan (Figure 2). In most cities, modern contraceptive use is especially low among the youngest women and women in the lowest wealth quintile. Figure 2. Women in Union Currently Using a Modern Method, 2010-2011
Abuja and Benin City. In Benin City, Ibadan, Ilorin and Kaduna, more women obtain their methods from PMSs than any other source. Relatively few women (ranging from 5 percent to 15 percent) obtain their contraceptives from private health facilities. Figure 3. Source of Contraceptive Methods Among All Women Who Use Modern Methods, 2010-2011 Zaria Kaduna Ilorin
12%
26%
15%
32%
20%
29%
10%
15%
25%
7%
43%
17%
12%
34%
4%
Any Modern Method
Ibadan Benin City
33%
32% 23%
27%
Abuja
Benin City
Ibadan
Ilorin
Kaduna
In Abuja and Ibadan, the next most widely used modern method is the IUD and in the other cities, the daily pill.
WHERE DO WOMEN OBTAIN MODERN CONTRACEPTIVES? In all cities, women who currently use modern contraceptives most commonly obtain them from public health facilities, pharmacies and patent medicine stores (PMSs).
In Abuja and Zaria, public health facilities are the most common source of contraceptives (Figure 3). Pharmacies are a popular source of contraceptives in Women in union include both married women and women living with a partner.
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5% 4%
Public
Pharmacy
PMS
Private
Other*
Zaria
In all six cities, male condoms and injectables are the two most widely used modern methods.
4
15%
33%
43%
20% 6%
Abuja
9% 6%
40%
29%
18%
8% 2%
48%
13%
29%
*Other sources of contraceptive methods include faith-based hospitals, homes or health centers; other non-governmental organization (NGO) hospitals or clinics; mobile clinics; bars; and kiosks, shops or markets.
WHAT ARE FERTILITY PREFERENCES? In all cities, the vast majority of births were wanted.
The percentage of births that were wanted ranges from 88 percent in Ibadan and Kaduna to 94 percent in Zaria. Only 4 percent to 5 percent of births were reported as mistimed and 1 percent to 6 percent were unwanted. These data suggest low demand for family planning until fertility desires change. Cultural preferences for more children contribute to high fertility.
Three-quarters of women in Abuja, Benin City, Ibadan, Ilorin and Kaduna, and almost 90 percent of women in Zaria, want another child. However,
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few (from 16 percent in Kaduna to 22 percent in Abuja) want another child within the next two years, suggesting that many women have a need for contraception to space their births. Figure 4 shows the average ideal number of children that married women would like to have. The average ideal family size is lower in Abuja, Benin City, Ibadan and Ilorin, at just over four children, than in Kaduna, where women want approximately five children, and Zaria, where women want about six children.
Figure 5. Unmet Need for Family Planning* Among Currently Married Women, 2010-2011 Spacing
8%
Currently Married Women, 2010‐2011
Zaria
5.44
Ilorin
4.33
Benin City
4.29 0
2
4
Ibadan
Ilorin
Kaduna
15%
Zaria
Knowledge of at least one contraceptive method is higher among men than women.
4.57
Abuja
Benin City
8%
12%
WHAT ARE BARRIERS TO CONTRACEPTIVE USE?
4.66
Ibadan
Abuja
12%
18%
*Percent of fecund, sexually active married women who say they want to limit childbearing or delay it for two or more years and are not using contraception
6.15
Kaduna
6%
4%
6%
11%
8%
8%
Figure 4. Ideal Number of Children Among Figure 4. Ideal Number of Children Among Currently Married Women, 2010-2011
Limiting
6
8
Mean ideal number of children
HOW WIDESPREAD IS UNMET NEED FOR FAMILY PLANNING? In every city, currently married women have a higher unmet need for spacing than for limiting births.
A considerable proportion of women are not using contraception even though they are sexually active and want to delay or avoid pregnancy—that is, they have an unmet need for family planning. Total unmet need for family planning is highest in Kaduna (25 percent) and Ilorin (23 percent) and lowest in Abuja (13 percent) and Ibadan (14 percent) (Figure 5). In all cities, married women have a higher unmet need for child spacing than for limiting births.
Spontaneous knowledge of any modern contraceptive method ranged from 62 percent of all women in Zaria to 86 percent of all women in Ibadan. With prompting, this increased to more than 92 percent of women in every city but Kaduna (75 percent). Among men, knowledge was nearly universal with prompting except in Kaduna where 81% of men knew of a modern method. In all six cities, most women do not intend to use contraception in the future.
Among women in union who are not currently using contraception, only 10 percent to 20 percent say they intend to use a method in the next 12 months (Figure 6).
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Figure 6. Intention To Use Contraception in the Next 12 Months,* 2010-2011 Does not intend to use
5% 6% 15%
12% 7%
Intends to use
6% 5% 12%
20%
74%
79%
Benin City
Ibadan
62%
Abuja
Does not know
9% 8%
11% 12%
20%
14%
64%
64%
Ilorin
Kaduna
Belief in myths about family planning is fairly widespread.
Women in Abuja and Ilorin are less likely than women elsewhere to believe in myths about family planning. In the remaining four cities, at least twofifths of women believe the following: • Contraceptives are dangerous to women’s health. • Contraceptives can harm the womb. • Injectables can cause permanent infertility.
Missing
4% 10% 10%
76%
Zaria
*Among women in union who know of at least one contraceptive method and are currently not using a method
Many women in union do not intend to use contraception in the future for fertility-related reasons, such as the desire for more children.
From 48 percent of women in union in Zaria to 84 percent in Benin City do not plan to use contraception in the future for fertility-related reasons—for example, they are already pregnant or want more children (Table 1). In Benin City, Ibadan, Kaduna and Zaria, another common reason for not intending to use family planning is opposition to contraception. In all of these cities, more women (10 percent in Ibadan to 26 percent in Zaria) cite their own opposition to contraception than opposition from their partners (10 percent in Ibadan to 22 percent in Zaria) or religious leaders (2 percent in Benin City to 23 percent in Zaria). Women also cite method-related reasons such as health concerns and fear of side effects as barriers. Other method-related issues such as cost of contraception and access to it were rarely named as reasons for non-use. Table 1: Reasons for Not Intending To Use Contraception Among Women in Union,* 20102011 Abuja
Benin City
Ibadan
Ilorin
Kaduna
Zaria
Fertility-related reasons
83%
84%
80%
77%
62%
48%
Opposition to use
13%
31%
19%
9%
32%
51%
Method-related reasons
13%
24%
24%
16%
28%
25%
Lack of knowledge Fatalistic
4% 2%
6% 1%
2%
1% 1%
4% 4%
5% 11%
1%
Among men, myths are less widespread in Abuja. In the other three cities where men were surveyed (Ibadan, Ilorin and Kaduna), more than 30 percent of men believe that using a male condom reduces a man’s sexual pleasure, in addition to some of the same myths that women believed, mentioned above.
WHAT ROLE DOES MASS MEDIA PLAY IN CONTRACEPTIVE AWARENESS? Men have greater access than women to all media, with especially big gaps for newspapers and the Internet.
Women are more likely to have access to mobile phones (from 76 percent to 90 percent) than any other form of communication. In Abuja, Benin City and Kaduna, television is the next most widely accessed medium among women, with 68 percent to 77 percent watching at least weekly. In Ibadan, Ilorin and Zaria, more women (from 36 percent to 62 percent) access radio regularly than television. Television viewership increases with wealth; differences by wealth are far narrower for radio. Women’s access to newspapers and magazines is extremely limited, except in Abuja and Benin City. The popularity of newspapers and magazines increases with wealth in most cities.
*Data are among women in union who know of at least one contraceptive method. Women could report multiple reasons for not intending to use contraception.
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2010 Bonnie Gillespie, Courtesy of Photoshare
In northern Nigeria, women at a Radio Listeners’ Club meeting listen to a drama that includes reproductive health messages. Radio dramas can weave educational content into an entertainment format, motivating behavior change as they entertain.
In all four cities that surveyed men, access to a mobile phone is high. More than 90 percent of men watch television and listen to the radio. A considerable proportion of men read newspapers (40 percent to 70 percent), but magazines are far less popular (14 percent to 33 percent).
HOW LIKELY ARE COUPLES TO COMMUNICATE ABOUT FAMILY PLANNING? Communication between partners about family size varies by city.
The majority of women in Benin City (77 percent), Ibadan (68 percent) and Abuja (66 percent) say they have discussed the number of children they want with their partners. In contrast, most women in Zaria (81 percent), Kaduna (53 percent) and Ilorin (51 percent) have never discussed this topic with their partners. Many women have never discussed family planning with their partners.
In four of the six cities, the majority of women say they have never discussed family planning with their partners (Figure 7). Of women who have discussed family planning with their partners, the majority of women in half the cities say they initiate the discussion; in the other cities, the majority of women say either they or their partners initiate the discussion.
More men than women were exposed to family planning messages in the mass media.
More than 95 percent of all men were exposed to a family planning message in the past three months over the radio, on television or in a newspaper, while one-third to one-half of all women had not received any family planning messages via these sources (Table 2). Newspapers reach a much smaller proportion of women and men than the broadcast media.
Abuja
Benin City*
Ibadan
Ilorin
Kaduna
Zaria*
Women/Men
Women
Radio
40% / 66%
36%
45% / 68%
50% / 74%
30% / 46%
58%
Television
45% / 94%
52%
38% / 91%
19% / 91%
35% / 96%
21%
Newspaper
17% / 34%
17%
5% / 16%
7% / 26%
4% / 19%
3%
None of these
44% / 2%
40%
Media Source
2011 Bonnie Gillespie
Table 2: Exposure to Family Planning Messages in the Mass Media in the Past Three Months Among All Women and Men, 2010-2011
Women /Men Women/Men Women/Men Women
47% / 5%
46% / 4%
53% / 2%
Communication between friends and family influences people’s attitudes and behaviors.
38%
*Men were not surveyed in Benin City and Zaria.
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Figure 7. Women in Union Who Have Ever Discussed Family Planning With a Partner, 20102011
47%
50%
41%
2011 Bonnie Gillespie
55%
40% 19%
Abuja
Benin City
Ibadan
Ilorin
Kaduna
Zaria
Most women say they need permission before they can use family planning.
The proportion of women who say they need permission from someone to use contraception ranges from 55 percent in Benin City to 78 percent in Ibadan. Among women who have ever used a method, most say that they and their partners jointly decide on what method to use (from 50 percent in Benin City to 77 percent in Ilorin).
WHAT IS THE QUALITY OF FAMILY PLANNING SERVICES? During visits, providers were more likely to inform women of alternate contraceptive methods than of potential side effects and health concerns associated with their chosen method.
In every city, the majority of women using sterilization, implants, IUDs, injectables and daily pills said that they were informed of alternate contraceptive methods that they could use. Users reported that providers were generally more likely to inform women using sterilization, implants, IUDs or injectables about contraceptive side effects and other health concerns than women using emergency contraceptive pills, daily pills or male condoms. In general, women do not have negative perceptions of family planning providers.
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In Ilorin, Nigeria, a provider counsels a client. Effective client-centered counseling enables clients to make wellinformed decisions.
Just 12 percent or fewer women in each city agreed or strongly agreed that family planning providers treat women badly, that women do not like the way they are treated in family planning clinics and that family planning providers make women feel bad when obtaining contraceptives.
IS FAMILY PLANNING INTEGRATED WITH OTHER HEALTH SERVICES? Integration of family planning with other health services varies among cities.
In general, family planning services are most likely to be integrated with maternal health services, less likely to be integrated with child health or HIV counseling and testing services, and least likely to be offered by a woman’s preferred pharmacy (see Table 3). Table 3: Integrated Family Planning Information and Services Received at Last Non-Family Planning Health Visit, 2010-2011 Abuja
Benin City
Ibadan
Ilorin
Kaduna
Zaria
Before and/or after last delivery
75%
77%
84%
74%
56%
58%
During last maternal health visit
44%
36%
67%
41%
44%
50%
During last child health visit
34%
37%
58%
34%
34%
23%
During last visit for HIV testing
21%
19%
34%
15%
21%
34%
From preferred pharmacy
6%
3%
6%
3%
6%
2%
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IMPLICATIONS FOR ACTION Increase intentions to use contraception by emphasizing the benefits of child spacing. Most respondents do not intend to use contraception in the next 12 months, mostly because they want more children. However, few women want another child within the next two years, suggesting that many women might be open to using contraception to space their births. Communication programs can focus on educating women and the community in general about the benefits of waiting at least 24 months after a live birth before attempting another pregnancy. Engage religious leaders in promoting family planning. While disapproval of contraceptive use by religious leaders was not cited as a major barrier to family planning, religious leaders can play an important role in promoting and legitimizing family planning for healthy families and communities. Because of the strong influence religious leaders can have on family life, programs should cultivate their public support of family planning. Address fears, misconceptions and myths. Side effects were cited as a major barrier to using contraception and appear to be more significant than a husband’s or religious leader’s opposition. Myths and misconceptions were widespread among men and women. Communication programs that aim to create demand for contraception must address the benefits of family planning and safety of modern methods.
Improve client counseling. Service delivery programs must ensure that providers offer effective counseling that prepares women for the possibility of side effects with contraceptive use and ways to manage the side effects. Counseling is also an important factor in shifting the method mix toward long-acting methods for birth spacing. Increase partner communication about family planning. The majority of contraceptive users report that either partner might initiate the conversation about family planning and that the decision on which method to use is made jointly. However, in four of the six cities, fewer than half of married women report ever having discussed family planning with their partner, and many women report needing someone’s permission to use a method. These data confirm the need to focus on improving partner communication. Increase referrals across service delivery types. Couples who use family planning rely heavily on methods provided by PMSs and pharmacies, namely condoms, daily pills and emergency contraceptive pills. In order to move these users to longer-acting and more effective methods, and to address health concerns and side effects that might arise, programs need to develop robust referral strategies that encourage providers to refer up the provider chain.
For more information about urban reproductive health, please visit www.urbanreproductivehealth.org and www.nurhi.org. This research brief was made possible by support from the Bill & Melinda Gates Foundation under terms of the Measurement, Learning & Evaluation Project for the Urban Reproductive Health Initiative and Nigerian Urban Reproductive Health Initiative. The authors’ views expressed in this publication do not necessarily reflect the views of the donor.
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