Effects of a Community-Based Program on Voluntary Modern Contraceptive Uptake Among Young First-Time Parents in Cross River State, Nigeria.

BACKGROUND: Reproductive health programs for youth have largely overlooked first-time parents (FTPs)-defined as young women younger than 25 years old who are pregnant or already have 1 child, and their partners. To address this gap, we implemented and evaluated a program to improve child spacing, modern contraceptive use, and related gender outcomes among FTPs in Cross River State (CRS), Nigeria. This paper examines the effectiveness of FTP interventions in improving voluntary uptake of contraception. METHODS: We conducted small group sessions and home visits with FTPs from May to August 2018 in 2 local government areas of CRS. A pretest-posttest study examined the effectiveness of these interventions regarding healthy timing and spacing of pregnancy/family planning knowledge, attitudes, intentions, communication, decision making, and contraceptive use. We performed a bivariate analysis and logistic binomial regression to confirm change over time in the primary study outcome, current use of a modern method of contraception. We also performed analysis of demographic characteristics and secondary outcomes (e.g., birth spacing intentions and couple communication). RESULTS: We interviewed 338 participating first-time mothers (FTMs) and 224 participating partners at baseline and endline. Important indicators of contraceptive awareness, attitudes, and couples' communication increased significantly from baseline to endline. Voluntary current modern contraceptive use increased from 26% to 79% among nonpregnant FTMs (P<.000), and from 44% to 81% among partners (P<.000). After controlling for significant factors related to family planning use, FTMs were 3.3 times more likely (P<.001) and partners 3.7 times more likely (P<.000) to be using a modern contraceptive method at endline. CONCLUSION: Program participation was associated with significant improvements in voluntary uptake of modern contraceptive methods and multiple secondary outcomes. Even within a short timeframe, this intensive, multi-intervention effort achieved significant advancements across healthy timing and spacing of pregnancy and family planning outcomes for this vulnerable youth population.

Efficacy of a Digital Health Tool on Contraceptive Ideation and Use in Nigeria: Results of a Cluster-Randomized Control Trial.

BACKGROUND: Contraceptive prevalence in Nigeria remains among the lowest in the world, which substantially contributes to the country's high maternal and child mortality. Mobile phone technology penetration has increased considerably in Nigeria, opening opportunities for programs to use this medium for reaching their intended audience with health-protective information. METHODS: In 2017, the Health Communication Capacity Collaborative conducted a cluster-randomized control trial in Kaduna City to assess the efficacy of the digital health tool Smart Client on ideational and behavioral variables related to family planning. Twelve wards in the city were randomly assigned to intervention (6 wards) and control (6 wards) arms of the study. A total of 565 women aged 18-35 years were randomly selected from study wards and consented to participate in the study. At recruitment, the women completed a baseline survey. The women in the intervention group were registered to receive 1 welcome call, 13 program calls, and 3 quiz calls on their mobile phones. Each of the program calls had several segments, including introduction, drama episode, and friend-to-friend chat. The last quiz call included evaluation questions. Women in the control arm received no intervention. The efficacy of the intervention was assessed using both per-protocol and intent-to-treat differences-in-differences techniques. RESULTS: The intervention and control arms were equivalent in terms of key sociodemographic characteristics, with the exception of religion. Attrition was a major challenge in the study. On average, participants receiving the intervention listened to 7.2 drama episodes but only 2.6 personal stories and 1.1 sample dialogues. The results of both per-protocol and intent-to-treat analyses show that the intervention was efficacious in improving relevant ideational and behavioral outcomes. For example, the intent-to-treat results show that the intervention increased women's perceived level of confidence to discuss family planning with a provider by 27.7 percentage points and modern contraceptive prevalence by 14.8 percentage points. CONCLUSION: This efficacy assessment showed that using an interactive voice response-based digital tool that includes drama is a viable option for promoting positive ideation about family planning and increasing contraceptive use in Nigeria. Significant lessons learned from this efficacy trial include informing participants at the time of recruitment of what the opening segment of the calls will sound like to avoid the calls being mistaken for telemarketing calls and intensive testing prior to scale-up to avoid potential attrition due to technical issues.

Misconceptions and current use of contraception among women of reproductive age in six major cities in Nigeria.

OBJECTIVES: The aims of this study were to assess the determinants of family planning misconceptions and modern contraceptive use, and the influence of misconceptions on the use of modern contraceptive methods. METHODS: We reviewed and analysed data collected between October 2010 and March 2011 among a representative household sample of 13,575 women of reproductive age (15-49 years) in six urban cities in Nigeria. Multiple linear and logistic regression models were used to examine the predictors of misconceptions and current use of contraception and the association between misconceptions and modern contraceptive use. RESULTS: Catholic women were significantly more likely to have misconceptions compared with Muslim women (ß = 1.09; 95% confidence interval [CI] 0.58, 1.60; p < .001); women with higher education were significantly less likely to have misconceptions about contraception compared with women with no formal education (ß= -0.06; 95% CI -0.96, -0.29; p < .001). Unmarried women living with a partner were not significantly different from those who were not cohabiting (single, separated or widowed) in their current contraceptive use (adjusted odds ratio [OR] 0.91; 95% CI 0.79, 1.04; p > .05). Women with lower misconception scores were significantly more likely to adopt and use modern contraception compared with those with high misconception scores (adjusted OR 0.93; 95% CI 0.92, 0.94; p < .001). CONCLUSION: These findings suggest that programmatic efforts should be geared towards dispelling misconceptions by providing simple factual information related to the benefits of contraception and family planning.

Role of Religious Leaders in Promoting Contraceptive Use in Nigeria: Evidence From the Nigerian Urban Reproductive Health Initiative.

BACKGROUND: Despite the many supply- and demand-side interventions aimed at increasing contraceptive uptake, the modern contraceptive prevalence rate in Nigeria has remained very low (9.8%). Religion is an important part of the sociocultural fabric of many communities. As such, religious leaders have the power to inhibit or facilitate effective adoption of contraceptive methods to support family health. We assess the association of exposure to religious leaders' tailored scriptural family planning messages with contraceptive use in Nigeria. METHODS: This cross-sectional study used data from a Measurement, Learning and Evaluation Project survey conducted in 2015 in 4 Nigerian states-Federal Capital Territory, Kaduna, Kwara, and Oyo. The final study sample was restricted to 9,725 non-pregnant women aged 15 to 49 years. Data analysis included descriptive statistics and binary logistic regression analysis to explore significant relationships between current use of a modern contraceptive method, exposure to family planning messages from religious leaders, and selected background characteristics. RESULTS: About 2 in 5 women reported being exposed to family planning messages from religious leaders in the past year. Bivariate results revealed a higher uptake of modern contraceptives among women with high exposure to different NURHI interventions (35.5%) compared with respondents in the low or medium exposure categories (14.5% and 24.5%, respectively). The multivariable analysis revealed significantly higher contraceptive uptake among women who had exposure to family planning messages from religious leaders relative to those with no exposure (odds ratio=1.70; 95% confidence interval, 1.54 to 1.87; P<.001). This association remained significant after adjustment for background characteristics and other selected variables. CONCLUSION: Interventions that engage clerics of different faiths as change agents for shaping norms and informing behaviors about family planning and contraceptive use are crucial for increasing contraceptive uptake in Nigeria.

Factors affecting the achievement of fertility intentions in urban Nigeria: analysis of longitudinal data.

BACKGROUND: Maternal mortality ratio in Nigeria is among the highest in the world with an estimated 160 women dying every day of complications related to pregnancy and childbirth. In addition to appropriate management of complications related to pregnancy and childbirth, preventing unwanted pregnancies is an effective way to reduce maternal deaths. Identifying potentially modifiable factors associated with the achievement of fertility intentions is critical for developing behavior change interventions that will contribute to reducing maternal mortality. METHODS: The data analyzed came from a longitudinal design with data collected in 2010/2011 and 2014 from the same group of women of reproductive age in six Nigerian cities. The data were collected as part of efforts to evaluate the effects of the Nigerian Urban Reproductive Health Initiative (NURHI). A total of 10,672 women were interviewed at the two points in time but the analyses in this manuscript were limited to 1921 in-union women who reported that they desired no more children at baseline in 2010/2011. The principal analytic method was multivariable regression adjusted for clustering at the enumeration area level. The analysis controlled for socio-demographic and household variables, ideational characteristics, and contraceptive use at baseline. RESULTS: About two thirds of the women who desired no more children at baseline have neither had any children nor were pregnant at endline. The strongest predictors of the achievement of fertility intentions include parity, age, religion, residence, spousal communication about family size, perceived severity of another pregnancy, and spousal agreement about family size. CONCLUSION: A comprehensive strategy to help women avoid unwanted pregnancies should include efforts to increase women's understanding about effective ways to prevent unplanned pregnancies and strengthen self-efficacy for contraceptive use. Promoting spousal communication about reproductive issues, engaging men, promoting smaller family sizes and changing pronatalist attitudes should also be part of such a strategy.

The role of gender empowerment on reproductive health outcomes in urban Nigeria.

To date, limited evidence is available for urban populations in sub-Saharan Africa, specifically research into the association between urban women's empowerment and reproductive health outcomes. The objective of this study is to investigate whether women's empowerment in urban Nigerian settings is associated with family planning use and maternal health behaviors. Moreover, we examine whether different effects of empowerment exist by region of residence. This study uses baseline household survey data from the Measurement, Learning and Evaluation Project for the Nigerian Urban Reproductive Health Initiative being implemented in six major cities. We examine four dimensions of empowerment: economic freedom, attitudes towards domestic violence, partner prohibitions and decision-making. We determine if the empowerment dimensions have different effects on reproductive health outcomes by region of residence using multivariate analyses. Results indicate that more empowered women are more likely to use modern contraception, deliver in a health facility and have a skilled attendant at birth. These trends vary by empowerment dimension and by city/region in Nigeria. We conclude by discussing the implications of these findings on future programs seeking to improve reproductive health outcomes in urban Nigeria and beyond.

Knowledge and practices among medical abortion seekers in southeastern Nigeria.

Nigeria has restrictive abortion laws; unsafe abortion and its complications are major public health challenges. Access to reproductive health services in Nigeria, including medical abortion, is poor. We determined the socio-demographic characteristics, patterns of abortion practices, and experiences of medical abortions among abortion seekers in southeastern Nigeria. We carried out a descriptive, cross sectional survey of 100 consecutive medical abortion seekers in southeastern Nigeria. Subjects had a mean age of 23.5 + 4.4 years. Fifty-five percent of respondents were students. Sixty-four percent had a secondary educational level, 33% had a tertiary education level and 3% had a primary educational level. Fifty-eight percent of subjects were ages 18-20 years at coitarche; 25% had one or more previous deliveries and 49% had a previous termination of pregnancy. Forty-eight percent had used drugs for pregnancy terminations. Drugs used for termination included quinine combined with other drugs in 8%; gynaecosid alone in 6%, gynaecosid combined with other drugs in 6% menstrogen combined with other drugs in 6% and an unclassified drug in 14%. Thirty-three percent of subjects purchased their abortion drugs in a pharmacy. Three percent, 2%, and 0% of subjects had a knowledge of misoprostol, mifepristone and methotrexate, respectively. One percent of respondents had used misoprostol. We detected serious information gaps regarding abortion and poor access to reproductive health services. There is a need for policies and program to bridge this gap, and a need for revision of the present Nigerian abortion law.

Introducing misoprostol for the treatment of incomplete abortion in Nigeria.

Despite legal restriction, induced abortions and resulting complications are common in Nigeria. Misoprostol administration for incomplete abortion was introduced in 3 Nigerian hospitals. The feasibility of the hospitals, patient and provider acceptability were assessed using questionnaire and interview guides administered to 205 women and 17 providers respectively. Amongst the women, 194 (95%) were satisfied and very satisfied with misoprostol, 176 (86%) would choose misoprostol again if another incomplete abortion occurred and 191 (93%) would recommend it to another woman in a similar situation. Providers were highly satisfied with misoprostol. The ease of use and ability to redirect surgical resources to more complicated issues were positive features cited by them. The providers agreed that integration of misoprostol was straightforward and required few resources. Therefore, misoprostol for incomplete abortion is safe, efficacious and acceptable to providers and patients. In remote areas of Nigeria with limited post-abortion care (PAC), misoprostol administration is an important potential PAC treatment modality. Features of misoprostol-low cost, room temperature stability, and ease of introduction-render it an important treatment option, particularly in low resource and rural settings.

An evaluation of a national intervention to improve the postabortion care content of midwifery education in Nigeria.

OBJECTIVE: To examine the impact of a national intervention to improve the postabortion care (PAC) content of midwifery education in Nigeria. METHODS: A 3-part quantitative assessment was carried out during and post-intervention. The first baseline component developed and examined the intervention to improve teaching capacity and improve the PAC curriculum among 6 midwifery schools that were to become regional training centers. The second survey was a pre- and post-assessment conducted among midwifery instructors from all schools of midwifery in the country. In the third component, 149 midwives graduating from the 6 regional midwifery schools were interviewed once 3-9 months after graduation to evaluate whether the intervention had improved their knowledge of PAC and clinical practice, and the likelihood that they would provide PAC after graduation. RESULTS: Data from 6 schools of midwifery in 2003 showed that none offered PAC or had educators trained in PAC prior to the intervention. Incorporation of PAC content and teaching capacity increased in all 6 study schools during the 3 years after a national intervention. Midwifery instructors demonstrated statistically significant improvements in knowledge of and exposure to PAC and manual vacuum aspiration (MVA) after the intervention. A follow-up interview with 149 student midwives post graduation showed increased knowledge, exposure to, and use of MVA in the workplace. CONCLUSION: Significant changes in graduate midwives' exposure, practice, and provision of PAC services resulted from a national intervention to improve the training environment and skills of midwifery instructors and students in the 6 schools of midwifery selected for evaluation.