Qualitative Assessment of Knowledge, Attitude, and Practice of Contraceptives among Women Attending Postnatal Care in a Health Facility in Jos, Plateau State, Nigeria ()
1. Introduction
Contraception is commonly used to prevent unintended pregnancy, either within or outside of a family [1] . Family planning is focused on helping couples achieve their fertility desires and goals. This may include contraception to delay or prevent pregnancies, infertility treatment, adoption, or abortion. Many users commonly use the word family planning to mean the use of any practices, methods, or devices to prevent pregnancy from occurring in a sexually active woman [2] . It can also be termed birth control, pregnancy prevention, fertility control, or contraception. Family planning is not just restricted to the use of contraception it may also involve the use of other techniques to control the timing of reproduction [3] [4] . Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling, and management, and infertility management [3] [5] . Unexpected or unplanned pregnancy presents a significant public health challenge for women of reproductive age, especially in developing countries like Nigeria [6] . With more than 175 million people, Nigeria is the most populous country in Africa and the seventh most populous country in the world [1] . With an annual population growth rate of 3.2 percent and a total fertility rate of 5.5, Nigeria is projected to be the third most populous country behind India and China by 2050 [1] . Nigeria’s health indicators remain among the poorest in the world. According to NDHS 2018, Maternal Mortality Ratio (MMR) was 512/per 100,000 live births which accounts for 10% of global maternal deaths, and Infant Mortality Ratio was 47/per 1000 live births [1] . Nigeria is noted for high-risk pregnancies, high-risk births (nearly two-thirds of births fall into this category) and high-risk fertility behaviors. [4] [7] [8]
In the developing world, women’s earnings, assets, and their children’s schooling and health all improve with greater access to birth control. Women must have a positive attitude and knowledge regarding contraception since birth control increases economic growth because of fewer dependent children, more women participating in the workforce, and less use of scarce resources. Part of the reason why many women of reproductive ages are without birth control is that many countries limit their access to it, due to religious or political reasons [9] . Due to restrictive abortion laws in Sub-Saharan Africa, many women turn to unlicensed abortion providers for unintended pregnancy, resulting in about 2% - 4% obtaining unsafe abortions each year [10] [11] [12] . Contraceptive acceptance in the society has been a huge challenge for communities in developing countries [11] [12] . There is a need to support the increase in the utilization of contraception and family planning services [3] [4] . In all this, good knowledge and practice of contraception services and the different types help women to select the best methods. The efforts of governments and development agencies have been useful in improving the levels of awareness among women. The translation of this knowledge to actual practice is usually a big gap [13] [14] [15] . The utilization of contraception methods remains a challenge to public health experts as despite this, women are able to indicate the use of one or more forms of contraception based on affordability and informed choice. The effectiveness of the choice of contraceptives is a huge concern and impacts the continuous reliability of the chosen method. Utilization of contraception often depended on having a positive attitude and willingness to use the method. Also, in communities in Nigeria, husbands’ approval regarding the choice of contraception method was essential for its use [1] [13] [16] [17] . This study sought to qualitatively assess knowledge, attitude, and practice of contraceptive use among women attending postnatal care in a Tertiary Health Facility in Jos, Plateau State, Nigeria.
2. Materials and Methods
This study was conducted in Jos North Local Government Area of Plateau state in September 2019. Jos North is one of the seventeen LGA in Plateau state. It was estimated that 3000 pregnancies occurred per annum. The LGA shares boundaries to the west with Bassa LGA, to its North, with Toro LGA of Bauchi State, to its East with Jos East LGA and Jos South LGA southward. The Birom tribe who are both Christians and Muslims inhabits them predominantly. There are about 71 health care centers of which twenty-nine (29) are primary health care (PHC) centers in Jos North. This includes the Plateau Specialist Hospital, Jos University Teaching hospital, and over 40 private institutions including Bingham University Teaching Hospital, Our lady of Apostle Hospital, and Faith Alive Foundation. There are two teaching hospitals in Jos, Plateau State namely Jos University Teaching Hospital and Bingham University Teaching Hospital.
The study was carried out in Bingham University Teaching Hospital (BHUTH) which is a faith-based tertiary health institution with 150-bed space, located at 23 Zaria Bypass, off Polo roundabout, Jenta, Jos North, Local Government Area of Plateau State. It was established in 1959 by the then Sudan Interior Mission (SIM) missionaries but is presently owned by Evangelical Church Winning All (ECWA). Some of its specialties include ENT, Surgery, Internal Medicine, Pediatrics, Obstetrics and Gynaecology, Ophthalmology, Vesicovaginal fistula surgery, HIV care, and Antiretroviral treatment programmes [8] . The Obstetrics and Gynaecology unit runs Antenatal and Postnatal care services with ANC recording about 795 new pregnancy visits each year, with increased visits usually recorded in May. The ANC clinic holds on Mondays and Thursdays with booking on Fridays. The study population consisted of women receiving post-natal care at Bingham University Teaching Hospital, Jos North LGA who were able to communicate in Hausa, Pidgin, or English. The study was done over of five months; four months for data collection and one month for analysis and write-up of the final work. The study was designed to qualitatively assess the knowledge, attitude, and practice of contraceptive use among women attending postnatal care at Bingham University Teaching Hospital, Jos North, Plateau state, Nigeria. Participants were selected using Purposive Sampling technique.
A focused group discussion was conducted for Thirty-Six (36) women. There were four (4) sessions involving nine (9) women per session. This was done during the postnatal care session at Bingham University Teaching Hospital. A structured focus group discussion guide was used to examine the perception of contraceptive use among women attending ante-natal care. The researcher facilitated the discussion using the FGD guide while two trained research assistants took notes and recorded the responses using a recorder. The FGD participants were recruited by purposive selection, and they were interviewed in a quiet environment to ensure privacy. Participation was voluntary and the session was conducted in English, Pidgin, and Hausa. The sitting arrangement in the FGD was such that there was easy eye contact and hearing between the researcher who was the principal facilitator and the participants. The participants were encouraged to talk freely and spontaneously, and the session lasted for 20 - 30 minutes as allowed by the participants. Within 24 hours after the session, the recordings were carefully translated and transcribed. Knowledge was categorized as Poor knowledge—those unable to describe contraceptive and give at least one (1) example or methods; Good knowledge—those who were able to correctly describe contraceptives and list one (1) or more examples, with some methods of contraception and highlight both traditional and modern methods of contraception.
Before to data collection, permission was sought and obtained from the Chairman medical advisory committee of Bingham University Teaching Hospital. Informed verbal consent was sought and obtained from the Head of Department Obstetrics and Gynaecology. Consent was also sought from each respondent after the purpose of the study was clearly explained to them. They were also informed that participation in the study was voluntary and that they could decide to withdraw their participation at any point in the interview. To ensure confidentiality, serial numbers rather than names were used to identify respondents. Ethical approval to conduct this study was obtained from the research ethics committee of Bingham University Teaching Hospital (BHUTH) Jos, Plateau State. Language barrier in interviewing clients from minor Nigerian tribes (Table 1).
3. Result
Most 17 (47.2%) respondents were between the ages 25 to 34 years, 12 (33.3% were 35 - 44 years. Majority 9 (52.8%) attained Tertiary level of education, 9 (25.0%) attained secondary level, 2 (5.6%) had no formal education. Majority 31 (86.1%) were Christians, while 5 (13.9%) were Muslims.
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Table 1. Sociodemographic parameters of respondents.
Most 18 (50.0%), women attending postnatal clinic were civil servants, 10 (27.8%) were traders, 5 (13.9%) were housewives, 1 (2.8%) were farmers, 2 (5.6%) were artisans.
4. Focused Group Discussion
4.1. Opinion about Contraceptives
A majority (88.9%) of the women gave a positive response regarding their perception of contraception. They described it as a drug or injection used to prevent pregnancy or plan the family with their partners.
A participant said.
“…Contraception is a drug or injection taken to prevent pregnancy for some time based on a plan which will have to be with my husband…”—a 29-year-old married para 1.
Another participant stated.
“…Based on my opinion oh… family planning is a drug that prevents unwanted pregnancy at an early stage…”—a 34-year-old married para 0.
Another participant stated;
“…Family planning is the way that a woman and her husband plan their home and the number of children that they want to have…”—a 28-year-old married para 0
4.2. Benefits of Contraception
All Participants (100%) agreed that contraception and family planning is beneficial to families and communities, especially in spacing children, economic and health planning of the family. The benefits of contraception and family planning are demonstrated by the responses obtained during the discussion.
A participant said.
“…It is beneficial. It helps someone to space their children and plan, even the money to train the children is planned…”—a 29-year-old married para 1
Another participant stated.
“…Yes! It is beneficial because it helps prevent pregnancy. One month, if I misbehave another baby go come and sometimes we are not ready for it…”—35-year-old married para 5
4.3. Societal Acceptance of Contraceptives
Contraceptive acceptance in the society spurred a mixed response as a majority of the respondents felt that the acceptance of contraceptive is not widespread enough in the vast majority of the population. A majority (61.1%) felt that communities are yet to accept contraception. However, they felt that its acceptance is gradually increasing due to good exposure, economic adjustments, and education.
A participant said
“…Me o before I got married, I really didn’t believe in family planning because it was not well accepted but now, with some enlightenment and knowledge, I believe it is important we adopt the methods…”—27-year-old married para 1
Another participant stated.
“…Not all people have adopted the idea of contraception and they try to convince others who have not too, it is gradual…”—a 34-year-old married para 0
Another participant said;
“…So many families have adopted it especially when it comes to feeding, provision and education for the children of the family, school fees is high now and we should have children we can cater for…”—a 28-year-old married para 0
4.4. Knowledge about Methods of Contraception
Most (83.3%) of the women had good knowledge of contraception and were able to list some methods of contraception and highlight both traditional and modern methods of contraception.
A participant said.
“…Yes! I know a few methods ooo some of them like loop and injections even condom self and the natural one that is withdrawal…”—a 25-year-old married para 1
Another participant stated.
“…Yes I have heard about some types of contraceptives and some of them I have used they include calendar method, loop, implants and also injectables…”—a 35-year-old married para 5.
4.5. Use of Contraceptives
Three quarters (77.8%) of the women have used one or more forms of contraception in the past. About half (41.7%) of the women indicated current use of one or more forms of contraception based on affordability and informed choice. Some have even indicated failure of certain types chosen.
A participant said;
“…Yes… I have used a condom and one time I used a natural method that is withdrawal. I used them because of the fear of the side effects of the others…”—a 29-year-old married para 1
Another participant stated;
“…Yes o… I don use injections and implants for 5 years for child spacing but the last one been fail. I no know why…”—a 35-year-old married para 5
Another participant stated;
“…I have used this drugs in the past. Then, I also removed it after 2 years to have my baby. I don’t know if I can use it again. I will try and see if I can do it again…”—a 26-year-old married para2
4.6. Effectiveness of Choice of Contraceptive
The majority (77.8%) of the women felt that their choice of contraceptive was effective enough to provide adequate child spacing. And they were happy about their choice.
A participant said;
“…Yes I feel my choice was really good because it helped me for a long time and I could rest small from stress…”—a 34-year-old married para 3
Another participant said;
“For me I don’t think my choice was good because oga (husband) wasn’t really comfortable with it”—a 29-year-old married para 1
4.7. Attitude towards Contraceptives
Attitude towards adoption of contraceptives after current pregnancy was generally good as most (80.5%) of the respondents’ desire to go for one form of contraceptive or the other. Almost all (94.4%) of the women stated they were willing to use one of the family planning methods after their current pregnancy
A participant said;
“…Yes I will like to go for another family planning after this my pikin but I never know the type wey I go choose yet…”—a 29-year-old para 1
Another participant said
“…Yes my own is not even debatable. I must do the permanent family planning because we are locking shop (the number of children are enough)…”—a 38-year-old married para 5
4.8. Spousal Approval to Choose the Type of Contraception
There was a mixed reaction to the partner’s approval regarding the choice of contraception method adopted. About half (52.7%) of the participants stated they required spousal approval before they adopt a method of contraception, while the other half (48.3%) said, they decide themselves what method to use.
A participant stated;
“…No I don’t see the need for my husband to decide for me because I am the one carrying the baby when it comes…”—a 35-year-old para 5
Another participant said;
“…Yes we both decided on the type of family planning I should use because we both feel it’s our family and it is important…”—a 28-year-old married para 0
5. Discussion
Over half of the respondents during the Focused discussion group had a very good perception and attitude towards contraception as they said it played a major role in child spacing and complete recovery of a woman after a previous pregnancy. This correlates with the study done in Delta state, Nigeria where over fifty percent of the respondents believed contraceptives to be an essential tool for family planning [9] . And studies done in Enugu showed similar findings [18] . Our study findings about perception negate the study done in a refugee camp in Oru in 2010 where about half of the respondents see contraceptives as dangerous with susceptibility to secondary infertility [19] . A probable reason for the good perception of contraceptives among our respondents was due to education, occupation, religion and other. This finding, compared to the study above which negates our findings could be due to a lack of proper information about contraceptives and their profound health benefits. Good perception affects good attitude as seen in our study where most of the respondents showed interest in using one form of contraceptive after their current pregnancy. This will by extension reduce maternal morbidity and mortality.
The economic, health, and community benefits of contraception were highlighted, as all participants agreed on these benefits, but they felt that contraceptive acceptance in society was divergent as many of the respondents felt that the acceptance of contraceptives is not widespread enough. Most of the population (61.1%) felt that communities are yet to accept contraception. However, they felt that its acceptance is gradually increasing due to good exposure, publicity, economic adjustments, and education. This doubt is clearly expressed in the contraceptive prevalence and utilization. Studies [15] [16] [20] - [25] Studies have shown that utilization ranged between 9.8% to 40% in Nigeria. In contrast, developing countries in North Africa, Asia, and Latin America range from 50% to 80% [26] . Each varies depending on the location, culture, religion, and education. Public health experts can leverage the existing perception and perceived benefits to improve acceptance.
Most (83.3%) of the women were able to list some methods of contraception and highlighted both traditional and some modern methods of contraception. This finding aligns with studies done in Zaria [27] , Port Harcourt [21] Jos [13] . This high level of knowledge was observed in studies done in Kintampo Districts of Ghana [28] . Knowledge of a range of effective methods is essential to informed choice of family planning and makes contraceptive use more likely. This knowledge was commendable and not surprising as there has been a National concerted effort to improve knowledge of contraception and move towards utilization. The level of knowledge of contraception also provides a useful measure of the success of information, education, and communication activities and may help to identify program areas that need to be strengthened [26] .
The high contraceptive knowledge, willingness to use and educational level did not reflect on the contraceptive usage level in this study as three-quarters of the women have used one or more forms of contraception in the past, while only about half (41.7%) of the women indicated current use of one or more forms of contraception. This is similar to findings from study a done in Port Harcourt, [21] Anambra [29] , Calabar [22] , Benin [15] , Zamfara [30] . There are much lower values in National studies 19.4% in the Multiple Indicator Cluster Survey conducted in Nigeria in 2011 [16] . The contraceptive prevalence use was 9.8% NDHS 2013 [20] , 9.7% in the NDHS 2008 report [20] and 17.0% in 2018 NDHS [1] report. The Government of Nigeria, through the Federal Ministry of Health (FMOH), has set a modern contraceptive prevalence rate (mCPR) target of 27% by 2020 [1] (NDHS, 2018). This has not been met yet, as efforts are still geared toward meeting this set goal. This low utilization may be due largely to misconceptions that are yet unresolved in the minds of the people and education on the various methods of contraception may be what is missing to unravel the myths and to state the realities or facts behind the various contraceptive methods. A deeper look into utilization shows that majority of the women felt that their choice of contraceptive was effective enough to provide adequate child spacing [30] . And they were happy about their choice [15] . Despite this confidence, the contraceptive prevalence is still below expectation. Furthermore, many women of reproductive age in sub-Saharan Africa do not use modern contraceptives due to various factors such as cost, side effects, availability, influence of the extended family, and lack of spousal support [14] [31] .
The current requirement is to transform the good attitude towards the adoption of contraceptive into actual use of contraceptives. This is because a majority of the women were willing to use contraceptives and change the type depending on the situation. This desire may just remain a “wish” if efforts to get a buy-in from the husbands who should see family planning as strategy to reduce the morbidity and mortality faced by their women. [29] Spousal approval before choosing the type of contraception may impede utilization. There were divergent opinions and reactions to partner’s approval regarding the choice of contraception method adopted. This is expected in a typical African setting, where permission is needed for the women to go for contraception. Spousal support is a critical component that can lead to improved contraceptive prevalence. In Africa especially Nigeria, women were the primary target for family planning but there is growing recognition that reproductive health is the joint responsibility of men and women [32] . Health education on the importance of the use of modern contraceptives should be given to women to encourage their use among them. This is a focused group discussion, thus there is a possibility that respondents may be quiet on sensitive questions or may be unable to freely voice out their opinion freely. This was managed by reassuring participants that their opinion was important and there is no punishment for honest responses.
6. Conclusions
Highlights of the discussion with the women showed that a majority (88.9%) had positive perception regarding contraception and all participants (100%) agreed that contraception and family planning is beneficial to families and communities. A majority (61.1%) felt that communities are yet to accept contraception. Most (83.3%) of the women had good knowledge of contraception.
Three quarters (77.8%) the women have used of one or more forms of contraception in the past and about half (41.7%) of the women indicated current use of one or more forms of contraception. A majority (77.8%) of the women felt that their choice of contraceptive was effective. Attitude towards adoption of contraceptives after current pregnancy was generally good as most (80.5%) of the respondent’s desire to go for one form of contraceptive or the other. About half (52.7%) of the participants stated they required spousal approval before they adopt a method of contraception.
7. Recommendation
To the Women and spouses:
1) Women should begin to take steps to leverage on their considerable high level of knowledge of contraception to the utilization or practice of contraception in other to reap the benefits.
2) Women should visit the nearest health facility to access contraceptive and family planning services.
3) Spouses should participate and support their spouses in choices of contraception.
4) Spouses should accept female independence in selecting and utilization of contraception methods.
To the health agencies, development partners, and government:
They should continue the heath education, community sensitization, and support for making contraception and family planning commodities available and accessible.