Increasing access to modern contraception in Nigeria

Nigeria started the documentation of national Maternal, Newborn and Child Health statistics in the 1990s. Since then, maternal and child health indicators have been recurrently poor, particularly in under-five mortality, which has only seen a 1.2% reduction. The Millennium Development Goals 4 and 5 were not met by Nigeria as inequity within the population is a significant hindrance. Inequity is created when populations unfairly lack access to factors that protect them from undesirable conditions. While knowledge of contraceptive devices is high in Nigeria, 85% among women and 95% among men in 2013, only 15% of women reported using these methods. Therefore, awareness was not a significant distinguishing factor in inequality of access between the socioeconomic groups. The 2013 Demographic and Health Survey found that only 15.1% of married women were using contraceptives in Nigeria. Of these, only 10% used modern contraceptives. In addition, there is a 16% unmet need for contraception among married women in Nigeria. Due to inequity, use of family planning, particularly modern effective methods, is low among the low socioeconomic groups, namely the urban poor and rural communities. This lack of access to modern contraception hinders the safe spacing of pregnancies, which creates rapid population growth and risks maternal and child health.

Nigeria’s population growth is expected to affect urban areas disproportionately, where over 50% of the population is located. In a country that has one of the highest maternal mortality rates, illegal and unsafe abortions account for up to 40% of deaths. Effective contraception is a form of primary prevention that can reduce at-risk pregnancies and maternal death due to unsafe abortions. By extension, modern contraception can also improve economic development by increasing the available labour force and decreasing competition for resources.

Use of modern contraception has decreased from 2003 to 2013 among the lower socioeconomic groups. This is a serious issue because slums pose a significant health risk, not only to the affected community but also to other populations that come into contact with them. Modern contraception is also important as this population tends to be sexually active earlier, increasing their time at risk of pregnancy. In Nigeria, the average maternal age at first birth was 20 years and the average age at marriage was 19. Teenage pregnancies also increase the risk of maternal mortality. This trend was particularly prevalent in among the low socioeconomic groups proving that access to contraception disproportionately favours the higher socioeconomic population. Therefore, it is important for health promotion plans to increase access to modern contraception for women, particularly those in low socioeconomic groups.

The Ottawa Charter, established in 1986, aimed to achieve the goal of “Health For All” through health promotion based on 5 principles, namely building healthy public policy, creating supportive environments, developing personal skills, strengthening community action, and reorienting health services away from treatment and care, and improving access to health services. Its focus was “reaffirming social justice and equity as prerequisites for health, and advocacy and mediation as the processes for their achievement”. Under the charter, community engagement at all levels was identified as a factor that supports and promotes health by enabling people more control over and power to improve their health. This salutogenic approach, which focuses on health and overall well-being, is population-based and characterised by empowerment.

This report will focus on reorienting health services away from treatment and care, and improving access to health services so as to improve inequalities in access to modern contraception in Nigeria. Currently, the most widely available contraceptives in Nigeria are injectables, condoms, Progestogen-only pills and oral contraceptive pills. However, education, lack of access to these contraceptives and cultural factors particularly between the northern, more educated part of Nigeria, and the south are the main barriers facing the lowest socioeconomic groups. A recent study also found that contraceptive supply and access was dependent on the strength of service facilities, number of family planning clinics and their geographic distribution. Namely, there was an acute shortage of social amenities and insufficient infrastructure. This is particularly true for 63% of the urban population who inhabit overcrowded and unhygienic urban slums. It also found that while pharmacies and drug stores were more widely accessible, they could not provide quality contraception like that available in public and private health facilities. This is a significant barrier for the low socioeconomic groups, who cannot afford or don’t have access to health facilities, as the private sector has become the main source of contraceptives in Nigeria.

Access to education on modern contraception and family planning services within Nigeria’s traditionally male-dominated culture is dependent on various factors, including cultural trends and community practices, socioeconomic ranking and the influence of older family members. A survey found that the male opinion was most important to Nigerian women living in urban slums. However, a survey of men and women found that men were only likely to take up contraceptive use if it was financially feasible and if their wives requested it. However, women, especially those less educated and of lower socioeconomic groups, were unlikely to engage in communication as the topic is culturally associated with promiscuity, which can offend men and potentially lead to abuse. Therefore, we recommend that future interventions should move away from treatment and focus on using education to target negative perceptions of contraception among men. This will improve the education level among men, especially the urban poor, decreasing inequality between the socioeconomic groups. Furthermore, these interventions should aim to improve spousal communication between couples, and strategically target men of reproductive age and older community members who are stakeholders of influence at the family and community levels. It is equally important to interview men to determine factors that impact their view of contraceptive uptake, which can inform future interventions. With better information on male perceptions and spousal communication, trust can be fostered between couples, which can help turn men into agents of contraceptive promotion.

The Nigerian government identified the issue of population growth in the 1980s, however, their initial response was to improve the economy. Current Nigerian reproductive health policies stem from the 1994 International Conference on Population and Development. The conference solidified national focus on reproductive health so as to promote sustainable development. In addition, regular Demographic and Health Surveys are conducted to identify family planning and reproductive health factors in urban Nigeria. This led to the formation of a National Reproductive Health Policy and Strategy in 2001 and the Urban Reproductive Health Initiative (NURHI) in 2011. The NURHI focused on state and local social norms changes to promote smaller families with fewer children, and encourage later and spaced out pregnancies to address the issue with supply and demand of family planning services. A Family Planning Providers Network of clinical and non-clinical service providers was implemented. The NURHI also used the media to disseminate information stressing the importance of family planning.

The NURHI was successful in encouraging state and local governments to increase financial support for family planning, creating awareness through media reporting and increasing support of family planning among community leaders. Although it managed to increase the use of modern contraceptive methods, available statistics show that the situation in Nigeria is still poor. This is due to low access to education and use of services, supporting the need for attention to this sector of the Ottawa Charter.

At the national level, cooperation between different sectors and the government is important to increase the accessibility and availability of contraception to women in urban slums. This includes the expansion of current health services to include sexual and reproductive health, and the provision of contraceptive devices. A study found that the main source of contraception in urban Nigeria were drug shops and pharmacies, which were unable to provide the quality service provided at clinics or hospitals. However, pharmacies and drug stores were geographically more widely accessible than clinics or hospitals, which generally served the high-income population. Therefore, this plan recommends that drug stores and pharmacies should be better equipped to provide quality services and clinics and hospitals should be more easily accessible throughout Nigeria. In terms of funding, another study found evidence supporting the implementation of an altruistic community strategy where the higher socioeconomic groups donated funds for the purchasing of contraceptives for the lower groups. This form of community support is already in place in Nigeria in other spheres. This method could be extrapolated in terms of using community strategy to fund the improvement of drug stores and pharmacies.

However, it is important to remember that cultural practices take time to change. Therefore, to protect girls by minimizing time at risk of pregnancy, we recommend national policies that mandate continued female education be implemented so as to delay sexual activity in girls. This will decrease the strain on reproductive resources, improving accessibility in general.

Postcolonial Critique

A postcolonial perspective exposes the colonial assumptions that impact inequality due to its imposing and dominating traits. Often, assumptions of the ‘colonized’ or marginalized are made from the perspective of the ‘colonizers’ or majority. Therefore, post-colonialism is important as it looks at the way global health was visualized during the Ottawa Conference, leading to the formation of the Ottawa Charter. This helps health promotion practitioners plan future interventions that are inclusive. Based on the needs of the Global North, the invisibility of the marginalized in background research is exemplary of the inequalities in health and resulted in a view of health promotion that favors developed countries. The aforementioned plan assumes that with access there is a willingness to use contraception as cultural ideologies are not accounted for.

Cultural studies have shown that access is not the only barrier, misconceptions about side effects, religious beliefs and other cultural sensitivities are under-reported in background research. For example, some women believe that contraception prevents them from having the number of children God intended for them or that contraception may lead to infertility. This skewed understanding benefits the urban majority who may not be subject to stringent cultural rules, or who have better access to education and can make a more informed choice with increased contraceptive access. The marginalized are the urban poor, who are disadvantaged financially and in terms of education. Within this community, the women are further marginalized as cultural trends give males decision-making power. However, due to this, by educating males on the importance of contraception, it is also possible to engage this population to lead the uptake of contraception by women.

Coming from multi-racial Singapore where I was a minority race and also as a woman, I can, to an extent, understand the plight of the voiceless and marginalized. Therefore, when I constructing this plan, I was aware of the cultural limitations and time needed for these perceptions to change. Therefore, I included recommendations to protect young girls by ensuring they remain in school where they can receive reproductive education.

Coming from an Asian country, I understand the pressures and taboos of talking about contraception. In Singapore, despite being a developed nation, sexuality is spoken of to warn rather than advise upon. However, I am also aware that because I have not faced the issue of lack of access to services, I am limited in how I might inform this plan to tackle such issues from a cultural perspective. Therefore, I incorporated studies that interviewed women on their views and lived experience. While this was helpful in constructing this plan, I noticed a significant lack of male voices within the literature. In general, women were asked about their male partners’ perceptions rather than a first-hand account. This introduces the possibility of information bias due to poor communication, which can skew the evidence that informs this plan. Therefore, it is important for future plans to consider the perspective of the man and determine what factors impact their view of contraceptive uptake. This can be done as an extension of this plan, which recommends the educating and interviewing men.

On the other hand, by educating men and empowering them to make a change in women’s access to contraception, there is the possibility that they may subvert the female autonomy. As men become more involved in the family planning process, there is the possibility that men might use it as a means to maintain authority in their relationship. Therefore, this plan advocated building trust between couples, which can build communication, improve education and promote long-term cultural change.

In conclusion, several factors lend to the widening gap in access to modern contraception between socioeconomic groups in Nigeria. Education, spatial accessibility and men’s perceptions are some of the major barriers disproportionately affecting Nigeria. This plan aims to shift health services away from treatment and care and use empowerment to improve long-term access in Nigeria. However, it is also important to consider the ethical implications of this plan, particularly the lens of the health promotion practitioner. Therefore, health promotion plans must be constantly monitoring, improving and reorienting to the current situation.