Terminal fertility control : Clients ’ own reason for the choice of the contraceptive method

Background: The prevalence of contraceptive use has increased worldwide due to the development and introduction of modern contraceptives and the establishment of organized family planning programs. In Nigeria, there is a very slow rise in contraceptive use prevalence, resulting in high fertility rate. Generally contraceptive is either used for birth spacing, or for the purpose of terminal fertility control to limit the number of children, and the choice of method for this purpose varies. Aims and Objectives: To determine the contraceptive methods of choice among clients seeking terminal fertility control, and their reasons for the choice of such methods. Materials and Methods: A cross-sectional study of clients attending the family planning clinic of Ladoke Akintola University of Technology Teaching hospital over a period of twenty-four months, between July, 2009 and June, 2011. All clients who had completed their family, and wanted a contraceptive method to limit their family size filled the semi-structured questionnaire after giving their informed consent. Clients’ own reasons for the choice of the particular contraceptive method were grouped, entered into SPSS work sheet, and analyzed using SPSS version 17. Result: There were five hundred and ninety-two new contraceptive method acceptors during the study period, of which 264 (44.6%) were for terminal fertility control. Progestogen-only injectable contraceptive was the method of choice for terminal fertility control by 145 (54.9%) of the clients, while 85 (32.2%) made intrauterine contraceptive device (copper-T) their method of choice, and the least chosen method was female surgical sterilization (2, 0.8%). Ease of administration, satisfaction with previous use, long duration of action, and husband’s preference were the reasons for the choice of the methods. Conclusion: There is awareness of terminal fertility control in Nigeria, especially in the southwestern region of the country, and this may be responsible for the decreasing prevalence of grandmultiparity in the region. However, reversible contraceptive method is the preferred option for this purpose.


INTRODUCTION
The prevalence of contraceptive use has increased worldwide due to the development and introduction of modern contraceptives and the establishment of organized family planning programs [1].The contraceptive prevalence rate in many developing countries rose from 9% in 1960 to 60% in 1997 [1], and this has helped reduce the total fertility rate of some developing countries from 6.0 in 1960 to 3.1 in 1997 [2,3].However in Nigeria, there is a very slow rise in contraceptive use prevalence.The proportion of Nigerian women of reproductive age using modern contraceptive methods rose from 3% in 1990 to 8% in 2003 [2]; this low contraceptive use in Nigeria results in high fertility rate.In the urban centers of Nigeria, many women are tending towards small family size so as to enable the family to provide better education for the children, and to increase women's participation in the labour force [4].Contraceptive use and choices vary widely in Nigeria; while intrauterine contraceptive device is the most widely use among the clients in the southwestern and north central Nigeria [5,6], progestogen only injectable contraceptive (POIC) is the most popular method among the southeastern clients [7].Generally contraceptive is either used for birth spacing, or for the purpose of terminal fertility control to limit the number of children [5].While some clients make sterili-zation their method of choice for terminal fertility control, others prefer reversible contraceptive methods.Studies abound on the choice of methods for the general population of contraceptive acceptors [5,7], however, there is a paucity of study on the method of choice of contraceptive among clients seeking contraceptive for the purpose of terminal fertility control; we are aware of only a study looking at this subpopulation of contraceptive acceptor [8].The aim of this present study therefore is to look at the methods of choice among clients seeking contraceptive method for terminal fertility control, and their reason for the choice of such method.

MATERIALS AND METHODS
The study is a cross-sectional study of clients attending the family planning clinic of Ladoke Akintola University of Technology Teaching hospital over a period of twentyfour months, between July, 2009 and June, 2011.All clients who had completed their family, and wanted contraceptive method to limit their family size filled the semi-structured questionnaire after giving their informed consent.Clients own reason(s) for the choice of the particular contraceptive method was grouped, entered into SPSS work sheet, and analyzed using SPSS version 17. Categorical variables were summarized using proportion and percentages, while continuous variables were summarized using mean and standard deviation.
Ladoke Akintola University of Technology teaching hospital serves Osun state, and the neighboring Oyo, Ekiti, Ondo and Kwara states.The family planning method services available in the hospital are: intrauterine contraceptive device (copper-T), injectable contraceptives, barrier methods, oral contraceptive pills, subdermal implants, male and female surgical sterilization.Counseling services is also available at the family planning clinic which is run Monday to Friday.Women pay for the commodity received.

RESULT
There were five hundred and ninety-two new contraceptive method acceptors during the study period, of which 264 (44.6%) were for terminal fertility control.The age of the study group range between 23 and 45 years, with a mean of 36.2 ± 4.1.The number of living children of the clients range between 1 and 8, with a mean of 4.0 ± 1.1.Clients with parity of 4 and below were 186 (70.5%), while grandmultipara were 78 (29.5%).Many of the terminal contraceptive acceptors (170, 64.4%) had above secondary level educational status, and most of the clients were of Christian religion (185, 70.1%)Table 1.
Many of the clients (184, 69.7%) had previously been on a modern contraceptive method for birth spacing, while 80 (30.3%) had never been on a modern method of contraceptive.
Clients chose intrauterine contraceptive device (IUCD) mostly because of its long duration of action (32, 37.6%), and satisfaction with the previous use of the method (20, 23.5%).

DISCUSSION
The prevalence of terminal contraceptive acceptors in this study was 44.6%.This was a slightly higher rate compared with the 37.5% in a study from the same centre four years previously [5], this may mean increased awareness of the need to limit family size with the use of modern contraceptive method.The mean age 36.2 ± 4.1 years of the study group is still within the age range of contraceptive acceptors generally [5], and this is more so for terminal contraceptive acceptors [8].
Formal education had been shown to positively influence the use of modern contraceptive methods [9,10], therefore, it was not surprising that over 90% of terminal contraceptive acceptors in this study had formal education.The mean number of living children among the clients seeking terminal fertility control in this study was 4.0 ± 1.1, this was a lower figure compared with the 5.8 ± 1.4 by Fakeye from the north central region of the country [8]; this may show the regional variation in the use prevalence of contraceptive methods in Nigeria.The fertility rate of 4.0 ± 1.1 also correlate well with the low fertility rate in the southwestern Nigeria, compared with the northern part of the country: according to the 2003 Nigeria Demographic and Health Survey, the country's fertility rate was 6.0 -7.0 children per woman in the northern Nigeria compared with only 4.1 in the southwest [2].
Progestogen only injectable contraceptive was the mostly chosen contraceptive method by the clients.This is a deviation from the widely known fact that intrauterine contraceptive device is the mostly used contraceptive method in southwestern Nigeria [5,11].Studies have shown that POIC is the most chosen contraceptive by clients seeking terminal fertility control [7,12,13].The clients most important reasons for the choice of POIC were ease of administration and satisfaction with previous use of the method for birth spacing.Other reasons for the choice were: husband's preference, reduced frequency of menstruation and amenorrhea, and easy dis-continuation.Only 1.4% of the clients gave long duration of action as the reason for the choice of the method, hence, this dispels the belief that delay of return of fertility was the reason for the choice of POIC by terminal contraceptive acceptors [12].The ease of administration, in being non-coital related with two to three monthly spacing injections was the reason POIC was the most widely used contraceptive method by a rural community in southeastern Nigeria [7].
Intrauterine contraceptive device was the next commonly chosen by the clients, unlike in Ilorin, north central Nigeria, where it is the most chosen method by the terminal contraceptive acceptors [8].37.6% of the clients gave long duration of action as the reason for the choice of the method, while satisfaction with previous use for birth spacing was the reason given by 23.5% of the clients.Other reasons for the choice of IUCD were: ease of administration, no amenorrhoea which is a side effect associated with POIC, husband preference, no risk of weight gain, easy discontinuation.
The least chosen method by the clients was sterilization; while two women had tubal ligation, no man came for vasectomy.The given reasons for tubal ligation by the clients were complications with the previous methods used for birth spacing, and not being associated with weight gain.Female sterilization by tubal ligation is not a common or acceptable contraceptive choice in Nigeria.However, this method is commonly used worldwide, especially in developed countries and in some developing countries in Asia and South America [14].Many factors can influence decision-making about sterilization in Nigeria, including religion, ignorance, and superstition based on ancient beliefs, even among more literate members of the community [14].Male sterilization or vasectomy is a rarity among Nigerian men.There were only two cases of voluntary vasectomy performed over a 30year period at University College Hospital in Ibadan [15].In a study in Jos, northern Nigeria, only 10 cases of vasectomy were recorded over a 16-year period compared with 3,675 female sterilizations [16].Eighty percent of the men who underwent vasectomy were well educated, with 20% of them being medical practitioners [16].
A major limitation of this study is not providing answer why female and male surgical sterilization is not widely acceptable in southwestern Nigeria.Therefore, there is need for further study to unravel clients' own reasons while surgical sterilization is not a common option for terminal fertility control.

CONCLUSION
It can be concluded that there is awareness of terminal fertility control in Nigeria, especially in the southwestern region of the country, and this may be responsible for the decreasing prevalence of grandmultiparity in the region

Table 1 .
Socio-demographic characteristics of terminal contraceptive method acceptors.