Attitude toward the acceptability and practice of modern contraceptives among women of child bearing age in Jigawa state, Nigeria

Background : Despite recent improvements in the use of contraceptives amongst married women in Jigawa, the utilization rates are still far below the national figures in the emerging regions of the country. Therefore,


Introduction
Contraceptive methods are preventive methods which help women avoid unwanted pregnancies.They include all temporary and permanent measures to prevent pregnancy resulting from coitus.Although family planning is not synonymous with birth control, planning, provision and use of birth control are called family planning methods.Some contraceptives prevent against sexually transmitted infections (STI).Within the same society, contraception varies amongst people of different socio-cultural, educational, religious or occupational affiliations.Family planning was cited as essential to the achievement of the erstwhile millennium development goals (MDG) because it has a direct impact on women's health and consequences on each pregnancy.It is believed that high fertility dis-empowers women.Globally, unplanned pregnancies and STI persist as significant threats to women's reproductive health.The level of awareness to contraceptive varies from place to place.Among Nigerian bankers aged 21-45 years, it showed that about a 100% of them are aware of at least one method of contraception.A similar study in Osogbo, Nigeria put the awareness of modern contraceptives to be 90.3%among respondents with a mean age of 28.6 ± 6.65years.A study among Ethiopian adults showed a high knowledge of contraceptives among respondents (Durowade et al., n.d.).
The mean age of the respondents was 28±6.The majorities (92.8%) of the respondents were aware of family planning, 68.9% of them possessed good knowledge but only 53% of them demonstrated favorable contraceptive attitude.Less than half (33.0%) of those who had heard about contraception were current users of modern methods.Injectable (45.0%) and male condoms (30.0%) were the most prevalent contraceptive methods among the respondents (Ajibola et al., n.d.).92.8% of the respondents were aware of family planning by correctly mentioning at least two contraceptive methods; most (47.0%)obtained their information from hospital staff.While 49.1% of them knew both men and women could use family planning, 44.1% stated that only women could benefit from family planning services.Almost threequarters (71.2%) of the respondents knew there could be side effects of using family planning methods.Whereas 68.6% of the respondents possessed good knowledge of family planning, only 54.3% of them demonstrated favorable attitude to using family planning (Ajibola et al., n.d.).
Injectable and male condoms were the most prevalent contraceptive methods among the respondents.They were used by 45.0% and 30.0% of the current contraceptive users respectively.The most commonly identified side effect of contraception was weight gain which was mentioned by 55.0% of the current users.In 65.0% of women with more than four children were non-contraceptive users.Respondents with no formal education were significantly less likely to have used contraception compared to their educated counterparts (AOR=0.525,95%CI=0.284-0.972).Likewise, those with poor knowledge and negative attitude had significantly lesser odds of modern contraceptive use (OR=0.512,95%CI=1.242-1.968and OR=0.158, 95%CI=0.261-0.874).Almost all of the respondents were aware of family planning.High awareness level is expected to be associated with good knowledge of modern contraception, but this was not the case in the current study as 68.6% of the respondents had good knowledge.Slightly above half of the respondents had positive attitude towards modern contraception despite high awareness level.This is not unexpected since awareness has been shown to be a poor predictor of the behavioural domain of attitude.Thirty-three percent of the respondents were current contraceptive users.Our finding agrees with previous studies.For instance, a study by Adeyemi et al., in Ogbomoso, Nigeria, in 2016, revealed that all of the respondents were aware of contraception, but only 49.7% had ever used a method while 25.4% were current users (14).In another study conducted among Nigerian women attending antenatal clinic in Jos by Utoo et al., awareness level was 88.1%, but only 44.0% were modern contraceptive users

Contraceptives
Study has examine the role of men in family planning on the background of an African culture where it had been shown that the male is the dominant force for decision making in most marital relationships.Considering that a man cannot make a sound decision outside his level of knowledge, the study focused on level of knowledge, positivity of attitude, previous use of contraception, spouse's use of contraception and preference for large family as factors which determined the role of men in family's uptake of family planning.The awareness of modern contraceptives in the community is very similar to 98.2% reported from a national survey.It is also similar to many local studies which reported up to 99% awareness in Nigeria and other African countries.The Injectable contraceptive was the highest known modern contraceptive method among the study population followed by the male condom which is different from other Nigerian and African studies, which found the male condom as the highest known contraceptive.This might be due to the way information was obtained in this study without prompting.Other local studies also showed that other contraceptive methods are not as popular with men.This means a woman's choice of contraceptive may be limited if the husband is not sufficiently educated and the woman ends up following the husband's preference which may not be the best option at the time.Low level of awareness by men, of other modern contraceptive methods and its side effects may also lead to high discontinuation rate which was evident in the studies community by a wide difference between those who have ever used contraceptives and those who are current users.This wide difference was also reported other studies.The level of positive attitude towards family planning was rather higher than expected when this was compared to low contraceptive uptake by men and their spouses.This is corroborated by other studies; however, another study in Nigeria had reported a lower value of 26% men who approved of going with their wives to family planning clinic, which is much lower than 73.7% reported in this study.This difference might be because this study was in a rural location compared with the contrasting report which was from a semi-urban setting.In addition, men's preference for a large family, a reason why most men do not use modern contraceptive method was corroborated by other studies in Africa and Nigeria.Older men were less likely to use modern contraceptive than younger men.This may be due to power imbalance between older men who marry much younger wives.Such wives may lack the will (as occasioned by culture), or empowerment to negotiate effectively with their husbands who may have poor knowledge about contraceptive (Fajobi et al., 2021).
The unmet need for family planning in Nigeria which is strongly associated with unwanted pregnancies has been the highest in the region since 2010, and remains high with a report of 19% in 2018.The trend of this indicator over the last 20 years has not been satisfactory.A reduction from 20.2% in 2008 to 16.1% in 2013 was not sustained despite the huge amount of resources invested into family planning programs and other interventions.Unmet need for family planning has become one of the global indicators to measure the uptake of family planning.Unmet need has been measured through women; however, it is a well-known fact in Africa, that men are the main decisions makers in their families.The reasons range from religion to cultural norm and greater economic power by men in many African societies.Evidence indicates that male involvement can lead to contraceptive uptake and thereby reduce the unmet need for family planning in many societies (Fajobi et al., 2021).Ninety-five percent (442) of respondents have heard about modern contraception while 4.7% (22) of the study population have not heard about it.The contraceptive method most mentioned was the injectable (62.5%) followed closely by male condoms (44.8%) and pills (40.5%).The least known methods were the emergency contraception, vasectomy and lactation amenorrhea (LAM) methods.There was no mention of female Condom by the respondents Awareness of Side-Effect and Causes of Contraceptive Failure Fortyeight percent of respondents are aware that there are side effects associated with the use of contraceptives, however, less than 10% of them were aware of breast tenderness, delayed childbirth or bleeding being known side-effects.The most common side effects of contraceptives known to respondents were menstrual changes (18%) and weight gain (16%).Twenty-three percent (91) men think incorrect use of contraceptive devices can cause contraceptive failure, while inconsistent use and incorrect timing can cause contraceptive failure according to 17.9% and 14% of men respectively.About 6% of men believed that the cause of contraceptive failure that is divine.

Community-based distribution (CBD) of contraceptives
Community-based distribution (CBD) of contraceptives can be used to supplement other government and private family planning services to meet the challenges of making the commodity widely available and accessible to those in urban slums, rural areas and hard-to-reach communities.CBD can be an important addendum or alternative to clinic-based services.Usually, it is cheap, easier for many people to reach and available in a wide range of settings.It is a complex concept involving varied operational design to suit local contexts.It is a programme involving non-clinical family planning service approaches that uses community organization, structure and institutions to promote the use of safe and simple contraceptive technologies.It expands acceptability and convenience of contraceptives and resolves the cost of service, thereby extending its use among clientele who seek contraceptives but will not use services that are confined to clinical settings.
CBD is thus a good example of the WHO's commitment of PHC by making essential health care available to individuals and families in the community in an acceptable and affordable way with their full participation.CBD is also compatible with the trend in many countries towards the decentralization of health services and the involvement of community in the provision and support of its own health services.The following factors are used to identify populations in need of CBD programme, all of which are applicable to SSA: • Low prevalence of contraceptive use • Lack of awareness of family planning • Low usage of existing family planning services • Are far away from family planning clinics • Cultural barriers that impede attendance at clinics

Knowledge, attitude and practice of family planning
The dividends accrued from improvements in reproductive health are cumulative and key to achieving sustainable development goals (SDGs) by improving maternal health, reducing child mortality and eradicating extreme poverty.Family planning brings transformational benefits to the women, families, communities and nations.In the twenty-first century, the maternal mortality in the continent is still unacceptably high.The lifetime risk of maternal mortality of women in SSA is 1 in 39 live births, the highest when compared to other regions.Despite recent increases in contraceptive use, sub-Saharan Africa is still characterized by high levels of fertility with TFR of 5 (number of births per woman) and a considerable unmet need for contraception.Sub-Saharan Africa is still undergoing demographic transition (i.e. a shift to low death rate and birth rates).This is largely due to high birth rates with low contraceptive use.It is estimated that 90% of abortion-related and 20% of pregnancy-related morbidity and mortality together with 32% maternal deaths could be prevented by the use of effective contraceptive (Access, n.d.) use among study participants attending the centre is low despite good knowledge of modern contraception.Factors associated with contraceptive use should be used by all tiers of Government to organize sustained publicity awareness campaigns in order to improve acceptability and usage (Zaria, 2015).Contraceptive knowledge as awareness was found to have a significant positive impact on the adoption of modern contraceptive methods for FP practices.These findings were in line with previous studies findings.This is because contraceptive knowledge among women encourages them to adopt modern methods for FP services and choose suitable method for practice.A good level of contraceptive knowledge improves the modern contraceptive prevalence.Contraceptive knowledge modifies people's perceptions about FP practices.Furthermore, the majority respondents were literate, so they valued contraceptive knowledge as an important factor for FP practices.Thus, it is quite logical to infer that the adoption of modern contraceptive methods for FP in Pakistan can be enhanced by increasing comprehensive knowledge about contraceptive measures among women (Shah & Lee, 2021).
Within the context of contraception practice, the intrauterine contraceptive device was the most frequently used method followed by oral pills, while the safe-period method was the least frequently used.More than 50% of the females obtained their contraceptives from public health centers and/or hospitals.In addition to that, more than half of the respondents changed their contraception methods mainly due to adverse effects or safety profiles associated with the methods (Aldabbagh & Al-qazaz, 2020).
The study showed that 2394 (82.8%) of the participants had knowledge of at least one contraceptive method.Only onethird (33%) knew six or more (half of the list) contraceptive types.Overall, the mean knowledge score of FP was 4.3 (± 3.4 SD), and 1254 (43.4%, 95% CI: 41.6%, 45.2%) of the respondents had good FP knowledge.Good knowledge was significantly higher among women from BG region (62.7%, p<0.001) followed by Gambela (41.1%, p<0.001).The most commonly known contraceptive methods amongst participants were injectables (72.3%), followed by pills (67.6%) and implants (51.7%).Health Extension Workers (HEWs) were the major source of family planning for 45.2% of the respondents, with health-care providers (28.8%) and friends (24.7%) following as sources for the participants (Table 2).
The mean score for overall attitude of FP was 4.0 (±2.5 SD), and more than half (52.3%, 95% CI: 50.5%, 54.1%) of the respondents had a favorable attitude (above mean score) towards FP.The mean attitude score of FP also differed by location of residence where 4.5 (± 2.4 SD) for urban residents and 3.8 (± 2.5 SD) among rural dwellers.Meanwhile, there was a high regional variation in attitude mean score of FP with the lowest score in Somali (2.4 ± 1.8 SD) and highest score in BG (5.8 ± 2 SD).

Factors Associated with Knowledge and Attitude of FP
Women in the age group of 25-34 years were 1.5 times [AOR (Adjusted Odds Ratio) =1.5, 95% CI (1.2, 1.8)] more likely to have good knowledge than those aged 15-24 years.In addition, the odds of good knowledge was 1.4 times higher among Christian women [AOR=1.4,95% CI (1.1, 2.0)].Concerning educational status, women who were educated to the secondary level and above were 3.6 times [AOR=3.6,95% CI (1.6, 7.9)] more knowledgeable than those who had no formal education.Likewise, women having partners educated to the primary level were 1.4 times [AOR=1.4,95% CI (1.1, 1.9)] more likely to have good knowledge compared to those with no formal education.Occupation was also a predictor-merchant women were 2.4 times more knowledgeable than women engaged in daily laborer [AOR=2.4,95% CI (1.3, 4.3)].
Women from the BG region were 1.6 times [AOR=1.6,95% CI (1.1, 2.3)] more likely to have good knowledge compared to women from the Somali region.Similarly, women who lived in urban areas were found 1.6 times [AOR=1.6,95% CI (1.2, 2.2)] more knowledgeable than their counterparts.Women from households with a monthly income of 1000 Ethiopian Birr (ETB) and above were 1.4 times more knowledgeable than those with less than 1000 ETB [AOR=1.4,95% CI (1.1, 1.8)].Regarding media exposure, women who listen to radio/ watch TV were 2.2 times [AOR=2.2,95% CI (1.6, 2.8)] higher to have good knowledge compared to their counterparts.
Size of family was a consistent predictor of knowledge of FP; women from a family size of 6-10 persons were 30% less likely to have good knowledge compared to those from a family size of less than five [AOR=0.7,95% CI (0.5, 0.9)].Similarly, women who wanted to have five and above children were found to be 40% [AOR=0.6,95% CI (0.5, 0.8)] less likely to have good knowledge compared to those who wanted to have less than five children.
The results of the attitude assessment showed that women who were in the age group of 24-35 years had 1.9 times [AOR=1.9,95% CI (1.4,2.6)] more favorable attitude than those in the age group of 15-24 years.Furthermore, women whose husbands were educated up to the secondary level and above were found to have 2.6times [AOR=2.6,95% CI (1.5, 4.3)] more favorable attitude than women whose husbands had no formal education.Occupation wise, student women were 60% less likely to have a favorable attitude compared to daily laborers [AOR=0.4,95% CI (0.2, 0.7)].Women from the BG region had 8.8 times [AOR=8.8,95% CI (5.6, 13.8)] more favorable attitude than those who were from the Somali region.On the other hand, women who had exposure to radio/TV were 1.6 times [AOR=1.6,95% CI (1.2, 2.3)] more likely to have a favorable attitude than those who had no exposure.In addition, women who want to have five and more children were found 40% [AOR=0.6,95% CI (0.4, 0.8)] less likely to have favorable attitude of FP compared to those who want to have less than five children.Moreover, women with better knowledge of contraceptives had 4.3 times [AOR=4.3,95% CI (3.3, 5.7)] more favorable attitudes than women with poor knowledge (Bekele et al., 2020).
The current study also showed that knowledge and attitude of reproductive age women were related to FP utilization.Those reproductive age women who had good knowledge were utilized FP better than from those who were less knowledgeable.Those participants with favorable attitude were practicing better than those who had unfavorable attitude.This is might be due to the fact that knowledge and attitude for specific activities are the key factors to start behaving and maintaining it continuously (Kasa et al., 2018).

Research design
A cross-sectional descriptive research was conducted.

Research setting
Jigawa state.

Study Population
Mothers residing in Jigawa state during the period.

Sampling technique
A multistage sampling technique was used to select the study subjects from Twenty seven LGAs of Jigawa state and Four Hundred and four respondent were recruited.

Tool
Structured self-prepared questionnaire was used.

Ethical considerations
The provisions of the HELSINKI declaration were respected (Shehu,et al., 2019).All privacy and confidentiality was also guaranteed during and after the data collection.The result depicts that most (27.9%) of the respondents belong to the age group 35-49 years.The mean ± SD age of the respondents was 22.01 ± 8.124 years.Majority (81.3%) of the respondents were Muslim.Most (72.7%) of the respondents were literate.Regarding the occupation, majority (80.3%) of the respondents were self-employed.Twothird (64.1%) of the respondents was from nuclear family.Most (64.6%) of the respondents had a family income of less than N 30,000 per month.Most (64.6%) of the respondents were married for more than five years and few (11.0%) were married for less than 2 years.About (58.5%) had parity less than 3. Regarding age of the last child, (55.9%) of the respondents had children of less than 5 years.Most (59.6%) of the respondents had age gap of the last two children in the range of 2-4 years.Only few (6.1%) respondents had a history of abortion.Regarding the distance, majority (77.1%) had walking distance of less than 30 minutes from their home to the nearest health center.The result reveals that majority of the respondents (92.3%) had heard about the contraception while (7.70%) had not.Injection Depo-Provera was the most (85.6%)known method of contraception whereas pills and condom recorded 84.8% and 82.7% respectively.Lactational Amenorrhea (8.2%) was the least method heard.The study shows that majority of the respondents had got information of contraception through mass media (33.2%) and health workers (28.1%).Only few (9.6%) got the information through relatives.The study result shows that avoiding unwanted pregnancy was the most (24.3%)known benefit of contraception However, only 14.3% respondents reported decreases the economic burden of the family as the benefit of family planning.The finding reveals that majority (53.7%) of the respondents had a positive attitude and few (46.3%) respondents had negative attitude regarding contraception

Discussion
In the present study, information on knowledge of contraception was collected by asking respondents whether or not they have heard about different contraceptive methods.The knowledge of contraception was widespread with the respondents and at least one contraceptive method was nearly universal in the study which is similar to the study finding of NDHS (2011) and Durowadeet al., (2017) who conducted a study in Ekiti, Nigeria.The majority (92.3%) of the respondents had heard about contraception.Despite the wide social marketing of contraceptive method, still 7.7% of the respondents had not heard about the contraception and the finding is similar to a study done in Dhankuta District of Nepal (Rayamajhi et al., 2013).This clearly shows that the messages about the importance of contraceptives have not yet reached to the distant places though they have been already included in Niger state.Concerning the methods known, most (92.7%)popular method known was Injection Depo-Provera followed by oral contraceptive pills and condom.Least (8.8%) known method was LAM.Emergency contraceptives was also least (23.3%) known by the respondents.The corresponding findings from NDHS (2011) shows Female sterilization (99%), Injection Depo (98%), male sterilization (95%), the pill (93%), condoms (98%) and emergency contraception are known by a relatively smaller (29%) percentage of women.With respect to abstinence and withdrawal, (39.4%) and (35.2%) of the respondents revealed to be hearing these methods in the present study which varies from the data of NDHS (2011) that states withdrawal and the rhythm method heard by 58% and 46% of the respondents respectively.NDHS report also states that overall women knew 7.9 contraceptive methods on average and a similar finding was found in the present study that showed 7 methods known on average by the respondents.al., (2017) ina study from Ekiti, Nigeria revealed that the common contraceptives known by the women include male condom491 (99%), natural methods457 (92.1%), pills 449 (90.5%), injectables426 (85.9%), and IUCD 275 (55.4%).However, Ibrahim and Ibrahim (2019) in Kano reported that Intrauterine devices were the most commonly used method (46%) followed by condom (22%), female sterilization (21%) and oral contraceptive pills (11%).Osaro, Tobin-West and Mezie-Okoye, 2017) added that the most commonly known methods were the male condom (n = 255; 67.1%) and injectable (n = 190; 50.0%).Those in current use of any Modern Contraceptives method were 140 (36.8%)while only 86 (22.6%) used it consistently.
A question related to the benefits of contraceptives to the respondents, avoiding unwanted pregnancy (79.3%), maintaining birth spacing (71.5%), limiting number of births (68.9%), improving the health of mother and child (59.6%) and decreasing the economic burden of the family (46.6%) were identified as the main benefits of contraception.Similar findings were discovered in a study done in Sunsari, Nepal (Paudel and Budhathoki, 2011) while the respondents of the study done in Bharatpur also revealed further benefits like anaemia can be reduced by using OCP and STDs can be prevented by using contraceptives like condoms (Manandhar, Singh, Patowary and Krishna, 2006).Non contraceptive benefits were also identified in other studies.In a study conducted by Durowadeet al.,(2017) conducted a study in Ekiti, Nigeria identified prevention of unwanted pregnancy 276 (79.8%), suitability and reliability of methods192 (55.5%), accessibility 170 (49.1%), affordability 106(30.6%)and little or no side effect, 63 (18.2%) as the benefit of contraceptives.Respondents with no formal education were significantly less likely to have used contraception compared to their educated counterparts (AOR=0.414,95%CI=0.173-0.861).Also, those with less than 29 years of age were significantly less likely to have used contraception than those with 30 years and above age (AOR=0.563,95%CI=0.331-1.018).Likewise, those with poor knowledge and negative attitude had significantly lesser odds of modern contraceptive use (OR=0.411,95%CI=1.131-1.857and OR=0.147, 95%CI=0.151-0.763).Kana et al., (2016) in their studies reported the main determinants to contraceptive usage included age <35 years (odds ratio [OR] = 3.0; confidence interval [CI] = 1.0-8.9;P = 0.028), Christian religious affiliation (OR = 2.4; CI = 1.1-4.9;P = 0.025), and spousal support (OR = 55.1;CI = 16.0-189.8;P = 0.000).The qualitative data also reinforced the crucial role of sociocultural factors, especially men in decision-making and contraceptive uptake.However, Chimah et al., (2016), who used both gender as the respondent, found no statistically significant difference between the male and female respondents (P = 0.338) as a determinant to contraceptive use.

Conclusion
The findings from this study will help to develop programs that can improve knowledge of females and services provided by the health-care system and can reduce adverse effects from contraception and the incidence of unplanned pregnancies.

Recommendations
Based on the findings of the study, the following were recommended: • Government and Non-Governmental organizations should encourage health workers to enlighten women on how to handle the side effects experienced in order to promote compliance.This can best handle during antenatal and postnatal visits as well as via mass media.• Government should collaborate with traditional and religious leaders to ensure contraceptive practice reach at least 90% in the next two years.This can be achieved when the program is taken to the household and proper education is given about it

Limitations
• Study participant might decide to withdraw from the study at any time in the course of this research; • Time, financial and logistic constraints

Table 2
Mothers Knowledge on Contraception (n = 376) * Multiple responses recorded thus; percentages represent proportion of the responses obtained

Table 3
Grading of Women's Knowledge toward Modern Contraceptive (n= 376)

Table 4
Grading of Women's Attitude toward Modern Contraceptive (n= 376)