Perspectives on Unmet Need for Family Planning in West Africa: Nigeria

Transcription

1 Perspectives on Unmet Need for Family Planning in West Africa: Nigeria Conference on Repositioning Family Planning in West Africa 18 February 2 Accra, Ghana The conference is hosted by the Government of Ghana and has been organized by the United States Agency for International Development, Advance Africa, the Action for West Africa Region Reproductive Health and Child Survival (AWARE-RH) Project, the World Health Organization, and the POLICY Project. Introduction The countries of West Africa have some of the highest levels of unmet need for family in the world. During the six year period following the 1994 International Conference on Population and Development (199-2), there were an estimated 12 million unintended pregnancies in the 18 West Africa Regional Programme countries. 1 Yet family programmes are currently low on most national agendas, with no concerted effort to address the expressed need for family. To reduce the health and development consequences of unplanned and unwanted pregnancies in West Africa, policymakers and planners need to study the characteristics of women with a demonstrated unmet need for family and use that information to improve policies and programmes. This series of briefing papers is designed to contribute to that effort by offering some perspectives on the nature and dimensions of unmet need based on the findings of Demographic and Health Surveys (DHS) in 11 West African countries: Benin, Burkina Faso, Cameroon, Cote d Ivoire, Ghana, Guinea, Mali, Niger, Nigeria, Senegal, and Togo. This brief focuses on Nigeria. What is unmet need for family? According to the DHS definition used in this series of briefs, a woman has an unmet need for contraception if she is able to bear children, sexually active and not using any contraceptive methods, and does not want a child for at least two years ( spacer ) or wants no more children ( limiter ). This produces a conservative estimate because the DHS definition excludes groups who are arguably in need. For example, many traditional method users who wish to delay or prevent pregnancy, but who are at risk of unwanted pregnancies, are using traditional contraception for lack of access to more effective methods. Amenorrheic women who say they wanted their last birth are omitted even if they wish to delay their next pregnancy. One study shows that, if an expanded definition of unmet need is used, the proportion of married women with unmet need in Sub- Saharan Africa would be 43 percent rather than 26 percent. 1 WARP is a USAID-funded regional programme. The 18 countries are Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Cote d Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, and Togo.

2 2 Why should policymakers and programme managers be concerned about unmet need? Policymakers in all sectors should be greatly concerned about the consequences of failing to meet unmet need. The reproductive health status of women and girls in West Africa is extremely poor compared to other regions and is further undermined by unplanned and unwanted pregnancies, which sometimes result in deaths and injuries from abortions provided in unsafe conditions. Closely spaced and ill-timed pregnancies and births contribute to some of the world s highest infant mortality rates, and infants of deceased mothers have a greater risk of mortality and poor health status. Unintended fertility at the individual level collectively fuels a rate of population growth that is outpacing the region s efforts to meet the social needs of its citizens and achieve national development goals. By the mid- 199s, population increases had outpaced economic gains and increases in food production, leaving the average African 22 percent poorer than in 197. Helping people to prevent unintended pregnancies and births also reduces the need for household and government expenditures on such services as treatment of post-abortion complications and care for maternal orphans while contributing to healthier families who can earn more and save more a primary goal of poverty eradication plans and essential to economic development. West African countries are signatories to international agreements that commit them to improving the status of girls and women and to ensuring the right of couples to freely determine the size and spacing of their families while providing them with the means to do so. Unintended fertility can lock girls and women into a cycle of early childbearing and poverty, and governments failure to address family needs ignores individual rights. Unmet family needs provide policymakers in all sectors with a unique opportunity to respond to the expressed fertility preferences of their populations while simultaneously improving health, slowing the rate of population growth, and contributing to achievement of national and millennium goals. The reproductive revolution and unmet need for family In the early 196s, women in developing countries had, on average, between six and seven children apiece. Now, just 4 years later, they average about three children each. In the early 196s, only about 6 percent of women in developing countries were using modern contraception; currently, more than percent use some form of modern contraception. This astonishing change in behaviour in a relatively short period of time is sometimes referred to as the reproductive revolution. Despite these changes, some countries have lagged behind the reproductive revolution. In these countries, fertility remains high and contraceptive use is still low. It is in these countries that we find the highest levels of unmet need for family and greatest urgency to rapidly expand family information and services to respond to the particular conditions that create that need. One of the important lessons of the reproductive revolution is that successful family programmes can be developed and expanded even in challenging social and economic environments. When the consequences of high levels of unmet family need for health and development are well understood across all branches of government and in the private sector, there is greater support for resource mobilization. What is the situation in West Africa? West Africa has lagged well behind the reproductive revolution. Modern contraceptive prevalence is low in most of the region, except for Cape Verde (46 percent). After that, the highest modern contraceptive prevalence rate is in Ghana, at 19 percent. This is high relative to the rest of West Africa but low compared to other regions. Unmet need for family services to space and limit births is high in West Africa. Considerable opportunity exists to respond to this need by strengthening family programmes, particularly if the factors that prevent use of services can be better understood. The

3 3 Unmet need for family services in West African countries Benin Burkina Faso Cameroon Cote d lvoire Ghana Guinea Mali Niger Nigeria Senegal Togo Unmet Need for Family Planning Services by Country most recent DHS show that more than 3 percent of women of reproductive age in three countries Ghana, Senegal and Togo report an unmet need for family. In six other countries Benin, Burkina Faso, Cameroon, Cote d Ivoire, Guinea, and Mali 2 to 3 percent of married women of reproductive age report an unmet need. Unmet need is 17 percent in both Nigeria and Niger. Nigeria Demographic and Health Survey, 23 Nigeria Demographic and Health Survey 23 (NDHS 23) is the most recent source of information that can be used to look at the unmet need for family services in the country. For statistical purposes, NDHS 23 divides the country into six regions: North Central: Benue; FCT; Kogi; Kwara; Nasarawa; Niger; Plateau 17% 17% 2% 2% North East: Adamawa; Bauchi; Borno; Gombe; Taraba; Yobe North West: Jigawa; Kaduna; Kano; Katsina; Kebbi; Sokoto; Zamfara South East: Abia; Anambra; Ebonyi; Enugu; Imo South South: Akwa Ibom; Bayelsa; Cross River; Delta; Ido; Rivers South West: Ekiti; Lagos; Ogun; Ondo; Osun; Oyo % 27% 29% 1% 29% 32% 34% 3% 3% 3% Fertility, contraceptive use, and unmet need in Nigeria Information from different surveys suggests that the fertility rate, or the average number of children per woman, has dropped only modestly over the past two decades. The Nigerian Fertility Survey showed a fertility rate of 6.3, while NDHS 23 reported the fertility rate to be.7 children per woman. Fertility is highest in the North East (7.) and North West (6.7) and lowest in the South East (4.1) and South West (4.1). Modern contraceptive prevalence remains low; only 8 percent of married women of reproductive age use a modern method. Modern contraceptive prevalence is highest in the South West (23 percent), which includes Lagos, and lowest in the North East (3 percent) and North West (3 percent). Nigeria has a demonstrated unmet need for family. NDHS 23 reports that 17 percent of Contraceptive prevalence is highest in the southern parts of the country, but relatively low everywhere Modern Contraceptive Prevalence Rate North Central North East North West South East South South South West Region 23% 3%

4 4 About one out of six married women in Nigeria has an unmet need for family married women of reproductive age can be classified as having an unmet need. Spacers are more common than limiters. About 12 percent of women with unmet need would like to space their next birth for at least two years, while percent would prefer not to have any more children. If Nigeria were better able to identify the characteristics, preferences, and intentions of these women, it could make significant strides in expanding and improving family services. of Reproductive Age Other married women 7% Spacing 12% Limiting % Urban Using modern method 8% Unmet Need for Family Planning Services, by Residence 17% 17% Rural Unmet need for family services 17% Unmet need is about the same in urban and rural areas Unmet need to space births is highest among younger women % 16% 16% What are some of the characteristics of women with unmet need in Nigeria? Residence. There is a need to expand and improve family services in both urban and rural areas. Unmet need is about 17 percent in both the cities and the countryside. Age. The relationship between unmet need and age depends on whether the need is for family to space or to limit 14% <1% Unmet Need to Space Births, by Age of Women <1% 1% Age of Woman in Years Unmet need to limit births is highest among older women % 8% Unmet Need to Limit Births, by Age of Women 1% % 14% Age of Woman in Years 2% 9% births. The unmet need to space births is very high among the younger age groups (-34) and much lower among women in their late 3s and 4s. By contrast, the unmet need for limiting is low among younger women and high among women ages 3 and older. This suggests that there are opportunities to address family needs by promoting methods to space births among younger women and promoting methods for limiting among older women.

5 Region. Unmet need is high across the country, although it is relatively low in North West, at 11 percent. The South South region has the overall highest level of unmet need, at 2 percent. In the northern areas, a comparatively greater proportion of overall unmet need is for spacing. Unmet need is lower in the South West than in most other parts of the Unmet need is high in most of the country North Central North East North West South East South South South West 1 11% Unmet Need for Family Planning Services, by Region 9% Unmet need to space births is highest among women with one to five children Unmet Need to Space Births, by 2 Number of Children 9% 1% 1% 11% No or more children children children children Number of Children % 1 2 country because contraceptive use is higher there than elsewhere in Nigeria. This means that the South West has a higher level of met need than other regions. Education. Unmet need appears to be similar among women of all educational backgrounds. Women who have received some tertiary education have a lower unmet need than other women, but only Unmet need to limit births is highest among women with more children % Unmet Need to Limit Births, by 2 Number of Children 1 1% 7% 22% 12% 2% 11% 6% 17% 18% 19% <1% <1% 2 3 4% Spacing Limiting No or more children children children children Number of Children a small proportion of women achieve this level of education in Nigeria. Household wealth. NDHS 23 responses can be used to divide households into wealth classifications: lowest, second, middle, fourth, and highest. This does not mean that households in the highest quintile are wealthy, but rather that they have access to relatively more resources than the other households in the sample. In any case, no noteworthy relationship between household wealth and unmet need exists in Nigeria. Previous number of children. For women with an unmet need for spacing, unmet need is approximately the same regardless of the previous number of children. For those with an unmet need for limiting, the greatest need is among women who already have six or more children. Unmet need and intention to use contraception in the future NDHS 23 asks respondents, including women with unmet need, whether they intend to use Only about half of women with an unmet need intend to use contraception in the future Intention to Use Among Women with an Unmet Need Do not intend to use family 3% Intend to use family 47%

6 6 contraception in the future or not. It would seem logical that a large proportion of women with an unmet need for family services would intend to use contraception at some time in the future. In Nigeria, roughly half of women with an unmet need for family report an intention to use. Previous family use, knowledge, communications, and associations with intention to use Previous use of modern family. Previous use of modern family was a good indicator among spacers but not limiters. For example, 32 percent of those with an unmet need for spacing who intend to use in the future had previously used a modern method of family, but only 11 percent of those who do not intend to use in the future had previously used modern family. Among limiters, however, previous use of modern family is not associated with future intentions. Knowledge about modern methods. Knowledge about family methods was associated with future intention to use. About 76 percent of women with an unmet need who intend to use in the future knew at least three modern methods of family ; by comparison, 2 percent of women who do not intend to use were familiar with at least three modern methods. Knowledge about modern contraceptive methods is associated with future intention to use among women with unmet need Knowledge About Modern Contraception Among Women with an Unmet Need 1 24% 48% Percent % Intend to use modern methods 2% Do not intend to use modern methods Did not have knowlegde of three modern methods Had knowlegde of three modern methods Discussion of family with partner. Whether a woman has discussed family with her partner is also associated with her future intentions. About 6 percent of women with an unmet need who intend to use in the future had discussed family with their partners; however, just 2 percent of those who do not intend to use had discussed the subject with their partners. Exposure to media messages. The percentage who heard or saw family messages on the radio or television was associated with the intention of women with unmet need to use family in the future for spacers but not for limiters. For example, 3 percent of women with an unmet need for spacing who intend to use Discussing family with partner is associated with future intention to use Percent Discussion of Family Planning with Partner Among Women with an Unmet Need for Spacing 1 44% 8% % Intend to use family Did not discuss family with partner Had discussed family with partner 2% Do not intend to use family family in the future had heard a family message on the radio in the months preceding the survey; in comparison, just 31 percent of those women with an unmet need for spacing who do not intend to use had heard a family message. Previous use of maternal health services. In Nigeria, previous use of maternal health services also had some association with intent to use family in the future. Of those women with an unmet need who said they intend to use family in the future, about percent had delivered their last child in a health facility. By contrast, of those women with an unmet need who said they do not intend to

7 7 Contact with family providers is associated with intention to use among women with an unmet need for services Contact with Family Planning Providers Among Women with an Unmet Need Percent % 91% 24% Intend to use family 9% Do not intend to use family Did not have contact with family worker Had contact with family worker use, 32 percent had delivered their previous child in a health facility. Similarly, among those women with an unmet need who intend to use in the future, 76 percent received antenatal care for the previous pregnancy; however, among women with an unmet need who said they do not intend to use in the future, only about 9 percent had received antenatal care for the previous pregnancy. Contact with family workers. Among women with unmet need who intend to use, 24 percent had heard about family from a health worker or in a facility in the 12 months prior to the survey. However, among women with unmet need who do not intend to use, only 9 percent had heard a similar message. Preferred contraceptive methods among women with an unmet need for family who intend to use in the future Programme managers can design more effective interventions when they know the preferred methods of those women with an unmet need for services who intend to use contraception in the future. The preferred future methods are the same for both spacers and limiters. Overall, among women with an unmet need who intend to use in the future, 3 percent prefer injectables and 2 percent prefer pills. Norplant, a relatively popular method in other countries in the region, was the preferred choice of less than 2 percent of those women with an unmet need who intend to use in the future. About 19 percent did not identify a preferred future choice. Percent % 2% 4% Injectables Pills Female IUD Male Norplant sterilization condom 4% Reasons for non-use among women with an unmet need who do not plan to use family in the future Programme managers can also use information on why more than half of women with an unmet need for family do not intend to use family in the future. One-third of women with an unmet need for family for spacing purposes who do not intend to use in the future report fertility-related concerns, mostly their desire to have as many children as possible. This high proportion suggests that many women with an unmet need are concerned that contraceptive use may affect future childbearing. Another 3 percent cite religious, cultural, family, or personal opposition as the main reason that they do not intend to use family in the future despite their desire to space births. Injectables and pills are the preferred methods for future use among women who have an unmet need for family and intend to use contraception in the future Married Women with Unmet Need Who Intend to Use in the Future, by Preferred Method 3% Method of Contraception 2% Other 19% Don t know

8 8 Fertility-related concerns, opposition, and health concerns/side effects are major reasons women with an unmet need do not plan to use family in the future Lack of knowledge 14% Fertilityrelated 33% Don t know 1% Spacers Health concerns/ side effects Opposition 3% Among those women who would like to limit births but who do not intend to use family in the future, about 39 percent cite opposition as the main reason, while another 2 percent note method-related reasons, most notably health concerns and the fear of side effects. The pattern suggests that women need more information about different contraceptive methods, their safety and risks, and their impact on future childbearing if Nigeria is to achieve more widespread use of modern contraception. Summary Some key points emerge from this brief. First, strong evidence exists that there is a notable level of unmet need for family services in Nigeria. Expanding and improving family services would help respond to the expressed desires of Nigerian women and would be good public policy. Second, failing to respond to unmet need has serious Lack of knowledge 11% Fertilityrelated 17% Limiters Don t know 8% Health concerns/ side effects 2% Opposition 39% consequences. By addressing unmet need, countries can improve the health of mothers and their children and families, provide couples with the ways and means to decide the size and spacing of their families, and contribute to the overall social and economic development effort. Conversely, the failure to address unmet need would forfeit these advantages. Third, considerable information exists about the characteristics, intentions, and preferences of women with an unmet need for family services. These characteristics will differ from country to country, and it is important that programme implementers look at their own situation. Nigerian policymakers and programme managers need to use available information to develop appropriate policies, strategies, and programmes that will improve services and remove obstacles to family use by women with a demonstrated unmet need. It is important to the country that they do so. Selected sources Ashford, Lori. Unmet Need for Family Planning: Recent Trends and Their Implications for Programs. Washington, D.C.: Population Reference Bureau, 23. Global Health Council. Promises to Keep: The Toll of Unintended Pregnancies on Women s Lives in the Developing World. Washington, D.C.: Global Health Council, 22. National Population Commission (Nigeria) and ORC Macro. Nigeria Demographic and Health Survey, 23. Calverton, Maryland: National Population Commission and ORC Macro, 24. Population Reference Bureau. The Unfinished Agenda: Meeting the Need for Family Planning in Less Developed Countries. Washington, D.C.: Population Reference Bureau, 24. Population Reference Bureau. 24 World Population Data Sheet. Washington, D.C.: Population Reference Bureau, 24. Rosen, James E. and Shanti R. Conly. Africa s Population Challenge: Accelerating Progress in Reproductive Health. Washington D.C.: Population Action International, Ross, John A. and William L. Winfrey. Unmet Need for Contraception in the Developing World and the Former Soviet Union: An Updated Estimate, in International Family Planning Perspectives (3): Secondary analysis of Nigeria Demographic and Health Survey 23 database available from ORC Macro.