© 2023Conscientia Beam. All Rights Reserved.
Firdausi Umar Sadiq5
1,2,3,6,7,8,9Health Systems Consult Limited, Jabi, Abuja, Nigeria.
1Email: [email protected]
2Email: [email protected]
3Email: [email protected]
6Email: [email protected]
7Email: [email protected]
8Email: [email protected]
9Email: [email protected]
4,5Bill & Melinda Gates Foundation, USA.
4Email: [email protected]
5Email: [email protected]
10Lagos State Health Management Agency
Maternal mortality rates remain unacceptably high, especially in developing countries like Nigeria. Nigeria is responsible for about 20% of all global maternal deaths, with a Nigerian woman having a 1 in 18-lifetime risk of dying because of pregnancy or childbirth. Evidence-based strategies have been proposed, including family planning (FP), to reduce the incidence of maternal mortality, which is the only strategy that reduces the proportion of high-risk pregnancies and births and reduces exposure to the risk of maternal mortality. Despite these benefits, there is still a high unmet need for family planning services. The present study assesses the choices and availability of FP services in Lagos state health facilities, examines the challenges, barriers, andcultural restraints to modern contraception, and proffers solutions that will help increase FP uptake in the state. The study also presented supply-and-demand interventions that are most effective at increasing voluntary contraceptive uptake in Lagos state
Contribution/Originality: There is a gap in studies that assess FP services and commodities availability in Lagos state health facilities. This study fills that gap and contributes the necessary literature to aid health administrators and policymakers in developing policies and interventions most effective at increasing voluntary contraceptive uptake in Lagos state.
In low to middle-income countries, pregnancy,and childbirth-related complications are the leading cause of death among adolescent girls ages 15-19. The adverse incidence is partly due to a lack of accessibility to family planning (FP) services. Thus, expanding the reach of these services, which include contraceptive information and reproductive health education, is one of the most lucrative interventions for preventing maternal, infant, and child deaths worldwide. By supporting the health and well-being of women and children globally, FP underpins other positive outcomes such as poverty reduction, teen pregnancy reduction, gender equity,human immunodeficiency viruses(HIV)and othersexually transmitted infections(STI)prevention, and a reduction in infant mortality rate[1, 2].
Modern reversible contraception has prevented unintended pregnancyand short inter-pregnancy intervals, leading to adverse health consequences for mothers and infants[4-8]. While there are several facilitators of contraceptive use, high-quality interpersonal communication from FP providers,such as counseling on proper use and possible sideeffects[9-14],clarification of misconceptions[15, 16],and addressing spousal dynamics[17-19]are associated with increased contraceptive uptake and continuation among women. Another vital factor in the utilization of FP services is quality, ensured by upholding the principle that "client-provider interactions respect informed choice, privacy and confidentiality, client preferences, and needs".
As a key partner in FP2020, the United States Agency for International Development (USAID), the largest bilateral FP donor in the world, upholds the values of voluntarism and informed decision-making in all of its FP initiatives requiring the provision of information on various FP methods, including the advantages and health risks of specific methods .
Like many countries in sub-Saharan Africa, Nigeria continues to face challenges with meeting the health needs of its population, especially in sexual and reproductive health. Despite dwindling funding from international development partners for Family Planning (FP) services and the revision of the Nigeria Family Planning Blueprint (Scale-Up Plan): 2014-2018 to the currently revised Nigeria Family Planning Blueprint 2020-2024, there is no line item for FP services and commodities in Nigeria's 2022 budget. Given Nigeria's projected annual population growth rate of 2.6% and an estimated population of over 400 million by 2050 , the UN departmentof economic and social affairs questioned the country's continued commitment to closing the enormous FP access gaps throughout the nation. Therefore, it is crucial that family planning services and commodities are both in demand and readily available in medical facilities.
The availability of family planning services is paramount to advancement in health, human rights, economic development, and demographic demonization. Worldwide, about 289,000 maternal deaths were recorded in 2013, of which 99 percent (286,000) of women died in developing nations, with African countries accounting for mostof these deaths. Contraception prevented about 250,000 maternal fatalities worldwide in 2008 by preventing undesired pregnancies, which accounted for 40% of the 355,000 maternal deaths[26, 27]. A recent study on Family planning: the unfinished agenda,predicted that 40% of maternal deaths would be averted if women had used family planning services.
Premature birth, low birth weight, and complications during labor are common in babies born to women under 18, resulting in a child or mother's death[28, 29]. Women who use FP can postpone their first pregnancy until they are 18 or older. Health Also, FP can help women wait at least two years before trying to conceive again, drastically lowering the number of newborns, child, and infant deaths. Similarly, according to a recent study, FP can help reduce one in three maternal deaths by helping women postpone childbirth, avoid unexpected pregnancies and miscarriages, and stop reproduction once they attain their desired family size.
In 2015, 64% of European womenused some contraception methods, while contraceptives were not as widespread in Africa (33%).The United Nations Fund for Population Activitiesestimated that globally, 225 million women who want to avoid pregnancy are not using safe and effective family planning methods. Most women with this unmet need for contraceptives live in sixty-nine of the poorest countries. Some studies have also stipulated that this dearth is due to rapidly growing populations with a concurrent shortage of family planning services.
Contrary to popular belief, FP allows women and men to do more than limit the size of their families. It protects people's health and rights while improving the family's quality of life and, in turn,society. The adage that a healthy nation is a wealthy one will hold for a long time. Since FP is one of the best approaches to minimize maternal, newborn, and child mortality,it serves as a legitimate poverty reduction avenue. Similarly, the Federal Government of Nigeria (FGN) proposed that reducing the number of undesired pregnancies,abortions,and the fraction of high-risk deliveries might reduce maternal mortality. Meeting women's modern contraceptive needs is predicted to avoid a quarter to a third of all maternal fatalitiesand save between 140,000 and 150,000 lives per year.
According to the World Health Organization (WHO), FPis the ability of people and couples to foresee and achieve the desired offspring independent of space and time. It is accomplished by using contraceptive techniques and treating unintended infertility. Individuals and couples can obtain the name, location, and time of contraceptive use through FP. In 2017, 63% of married women or those who choose to have children utilized a contraceptive technique. Contraception usage is over 70% in Europe, Latin America, the Caribbean, and North America, but less than 25% in Central and West Africaand Nigeria in particular. Despite women's adequate knowledge and the unmet need for FP, the contraceptive prevalence rate is only 17%;12% use modern methods, and 5% use traditional methods. A greater understanding of the barriers to FPthat informs service utilization and preferences is needed to improve service delivery.
Providing quality, affordable, and appropriate maternal health services in underdeveloped nations improves women's FP experiences,leading to greater uptake. Challenges of demand (such as accessibility) and supply (unqualified or scarce health personnel), compounded by economic, cultural, cognitive, and administrative barriers, influence women's tendency for uptake[38, 39]. Nevertheless, elements of the healthcare setting can be exploited to improve women's use if they are aware of their preferences.
FP can improve partner engagement in decisions about whether and when to have childrenandthe health benefits of mother and child [40, 41]. Couples who can plan their families are less physically, emotionally, and financially stressed, have more time and energy for personal and family growth and have more economic opportunities [28, 38]. As a result, good FPrelieves community resources, including social services and health care.
In order to provide 120 million women and girls with modern contraceptives by 2020, the global family planning initiative FP2020 was launched in 2012 [26, 27, 42-44]. For each of the ten FP dimensions, the FP2020 Rights and Empowerment Working Group established guiding principles to advance this objective. Two of the ten dimensions are service quality and availability . The principles of accessibility state that healthcare facilities, providers, and contraceptive methods must be accessible "to ensure that individuals can exercise full choice from a full range of methods" and that contraceptive methods must also be accessible without informational or other barriers .
The present study aims to assess FP services and commodities availabilityin Lagos state health facilities. Specific objectives of the study are:To assess the choices and availability of contraception in Lagos state health facilities, to examine the challenges, barriers, and cultural restraints to the use of modern contraception, and to proffer solutions that will help increase FP uptake in the state, to examine the impact of making a wide variety of contraceptive options accessible and available to women and couples on contraceptive uptake, unintended pregnancy, and maternal and infant morbidity and mortality, and to examine the supply-and demand-side interventions that are most effective at increasing voluntary contraceptive uptake in Lagos state.
Lagos is one of Nigeria's 36 plus 1 states, with 14,368,000 people in 2020. Lagos is Nigeria's most densely populated state, accounting for roughly 7% of the country's population[42, 46-48]. It divides into five administrative divisions: Ikeja, Badagry, Ikorodu, Lagos Island, and Epe (LGAs), into 20 Local Government Areas and 37 Local Council Development Areas. Lagos State is the smallest state in Nigeria and covers 358,862 hectares, or 3,577 square kilometers, or about 0.4 percent of Nigeria's total land area. The state spans 356,861 hectares, with 75,755 hectares of wetlands. The state is in Nigeria's southwestern region[49-52]. Lagos state economy, infrastructure, and healthcaresystems have improved significantly in the last decade. The State Government has made significant progress in its quest to improve health systems through family planning programs, according to the Health Facility Monitoring and Accreditation Agency (HEFAMAA). Lagos has over 10,000 skilled healthcare workers spread across 20 local governments, according to HEFAMAA.Lagos State has 2,333 hospital/clinic beds, with 458 public and 1875 private accredited facilities, 1574 primary, 756 Secondary, and 3 tertiary facilities. Primary Health Centers, Maternal/Child Health Clinics, Specialist Clinics, and Diagnostic Centers are among the over 2,500 accredited healthcare facilities (private and public) in the state that provide healthcare services. While these facilities provide health education, the high rate of preventable deaths in Lagos, especially maternal and child mortality, is profoundly concerning[49, 50].
Table 1 shows that 58% representing 729 facilities in Lagos state offer family planning services to clients, while 42% representing 527 facilities do not. By facility's locality, we observed that 55.4% of the health facilities in the state's urban areas provide family planning services, and 66.9% (192) of the rural facilities also offer the same services. 93.8% of government/public health facilities in Lagos state offer family planning services; this is significantly higher when compared to private for-profit (51.8%) and faith-based institutions (38.1%). Also, primary healthcare facilities engage more in family planning services (71%) than secondary healthcare facilities (18.4%).
Table 2 represents an assessment of facilities offering family planning services by the local government area. Ibeju/Lekki local government area has the highest percentage of facilities in the state offering family planning services; the LGA has83.9% of its healthcare facilities, i.e., 26 in 31 facilities offering family planning services to the residents. Epe local government area has the second-highest statistics of healthcare facilities by LGA offering FP services in the state, with 83.3% of its healthcare facilities, i.e., 10 in 12 facilities offering family planning services. However, Epe LGA has the least number of healthcare facilities in Lagos state, followed by Apapa,with 16 facilities, of which 81.3% offer family planning services. In Mushin LGA, 39.6% of healthcare facilities offer FP services, i.e., 19 in 48 facilities. Alimosho is the local government with the highest number of facilities (221); only 58.9% of these facilities (i.e., 132) offer family planning services. We also examined the different family planning services provided by healthcare facilities by local government areas in Lagos state and presented our findings in Table 2. The result shows that all the facilities in the local governments except Ikeja, Mushin, and Ikorodu, with 96.6%, 94.7%, and 98.5%, respectively, provide family planning counseling services. More than 50% of the facilities in each local government area provide the listed family planning services except for sterilization, which is below 50% except for Ifako-Ijaye, Ikorodu, Oshodi-isolo, and Surulere LGA.
We presented the different family planning services provided in Lagos State healthcare facilities by facility type and ownership, level of care, and locality in Table 3. Family planning counseling is readily available and provided by 99.6% of the facilities offering FP services in the state. Contraceptive injectables were the next most common FP service provided by the facilities in the state; this commodity was available in 94.9% of the FP services facilities in Lagos State. Only 42.2% of the facilities providing FP services in the state provide sterilization as a family planning method. The sterilization method is not widely practiced by residents in the state, as shown by the few healthcare facilities that provide the service. 99.6% and 99.5% of the facilities in the urban and rural areas, respectively, offer family planning counseling services. Health facilities in the urban areas providing sterilization services are 42.1% and 42.7% for rural areas. More facilities in rural areas (96.4%) than urban ones (94.4%) provide conceptive injectables. The result shows that all the government/public facilities offer counseling services, likewise faith-based and secondary healthcare facilities. 99.4% of the private-for-profit and 99.6% of the facilities in the rural areas also offer counseling services.
Table 1. The percentage of facilities providing FP services by ownership type, level of care, and locality.
|Ownership type||Facility's level of care||Facility's locality|
|Private-for-profit||Others (Non-Government Organizations (NGOs), mission/Faith-based)||Secondary Health Care (SHC) facility||Primary Health Care (PHC) facility||Urban||
Table 2. Percentage of facilities providing FP services and the various FP services offered across the local government area (LGA).
|% of Facilities offering FP services||% Of available FP services|
|Agege||Yes||No||FP counseling||Contraceptive injectables||Oral contraceptive pills||Intra Uterine contraceptive devices IUCD||Provision of implants||Provision of condoms (Male)||Provision of condoms (Female)||Sterilization|
Table 3. Percentage of FP services provided in the state healthcare facilities; classification by ownership type, level of care, and locality.
|Services||Total||Facility's level of care||Facility ownership type||Facility locality|
|SHC facility||PHC facility||Government/
|Private-for-profit||Others (NGOs, mission/Faith-based)||Rural||Urban|
|Oral contraceptive pills||92.5||86.o||93.0||98.4||90.7||75.0||92.2||93.2|
|Intra Uterine contraceptive devices IUCD||88.3||93.0||87.9||83.5||90.4||62.5||89.9||83.9|
|Provision of implants||85.6||89.5||85.3||90.1||84.6||50.0||86.2||83.9|
|Provision of condoms (Male)||82.9||80.7||83.0||99.5||77.6||62.5||83.1||82.3|
|Provision of condom (Female)||71.1||63.2||71.7||98.4||62.2||50.0||69.6||75|
As observed in this study, one of the most recommended FP services is the contraceptive injectables provided by 94.9% of the studied facilities, followed by oral contraceptive pills (92.9%). These two services were also highly recommended at the rural facilities 96.4% and 93.2%, respectively, than the urban facilities 94.9% and 92.5%. Onoja, et al. ;Tessema, et al. obtained a similar result in a study titled "Comparative Analysis of Family Planning Services in Urban and Rural Health Facilities in Nigeria."Interestingly, government-owned facilities provide more implants and male and female condoms than other facilities in the state. Also, private for-profit provides intrauterine contraceptive devices (IUCDs) family planning services more than other facilities in the state. Secondary facilities (75.4%) and private for-profit facilities (51%) provide sterilization services more than other facilities in the state.
Modern contraception positively impactswomen's health in Lagos State, outweighing any risks (real or imagined), obstacles, and difficulties. One of the major problems is the lack of access to and variety in contraceptive methods. The most vulnerable groups, such as the poor and young, continueto have high unmet needs. In Lagos state, the obstacles to serving the most vulnerable have not been clearly defined. Potential obstacles include those resulting from the culture and health systems, provider beliefs, negative user attitudes toward contraception, and others. Users who only occasionally engage in sexual activity might not think they need contraceptives. In addition, many people are only familiar with a small number of methods or may hold traditional or religious beliefs that forbid the use of contraceptives .Results from a systematic literature review of 12 studies assessing the barriers tocontraceptives in Lagos State indicate a limitation in the hormonal method used due to ignorance, access barriers, and concern over side effects, particularly fear of infertility . Althoughcondoms were frequently more readily available, their use as a method of contraception was constrained by their associations with disease and promiscuity,andgreater male control. The review concludedthat promoting the use of modern contraceptive methods calls for a comprehensive, multifaceted intervention, as well as the simultaneous distribution of knowledge, support, life skills, and access to services geared toward young people. The dual function of condoms as a contraceptive and a tool for STI/HIV prevention should be continuously emphasized, as should interventions aimed at combating misperceptions of modern contraceptive methods.An analysis of the needs, obstacles, and strategies for access and use of contraception by adolescents in low-and middle-income countries, as well as programmatic experience, led to the conclusion that all adolescents, particularly those who are not married, face numerous obstacles to obtaining and using contraception . The authors advocated for enacting and putting into practice laws and policies that would promote sex education, teen-friendly medical care, and contraception through variouschannels and community support for adolescent services. According to a study of Nigerian women, the top perceived barriers that account for low contraceptive use are cultural (20.3%), ignorance (44%), misinformation (32.6%), superstition (22.0%), and perceived side effects (44%) .
- Consistent, sustainable supply and distribution of FP commodities: In Lagos State, a significant challengeoften encountered is the insufficient stock with the untimely and inadequate distribution of FP commodities to the last mile, reaching from the warehouse to the LGA andthen the health facilities.
- These challenges often lead to the unavailability of contraceptive commodities at facilities, especially in rural areas. Therefore, a consistent and sustainable channel for procuring, supplying, and distributing contraceptive commodities isessential to increase voluntary contraceptive uptake in the state. There will be constant availability of commodities for intending users at every point, including facilitiesin hard-to-reach rural areas of the state. The state should also explore a sustainable financing mechanism for state-level procurement of contraceptive commodities to buffer supplies from the federal and prevent stock-outs at health facilities in the state.
Increasing range of available methods: Ensuring the availability of contraceptive method mix can increase Lagos state's voluntary uptake of contraceptive services. We expect that clients are counseled on all family planning methods and supported by the provider to choose their preferred method. Clients may refuse to take up contraceptive services if their preferred method is unavailable. However, with various methods available, they are more likely to take up the service by choosing from the range of available methods.
Quality service provision: One factorinfluencing the client's uptake of contraceptives is the client's satisfaction with provider interaction during counseling. Therefore, having well-trained providers capable of providing counseling, sustaining quality provider-client interactions, dispelling myths and misconceptions, and providing quality services is an intervention capable of increasing voluntary uptake of FP services in Lagos state.
Public-private partnership: Privatefacilitiesprovide most Lagos State residents health care services. However, these facilities do not view offering FP services, especially long-acting methods[72, 73],and, as such, do not have readily trained FP service providers nor stock FP commodities. The non-offering of FP services in these facilities has led to many missed opportunities, as potential FP acceptors may walk in and out of the facility without hearing about FP or accessingFP services. Having well-trained FP providers and supplying FP commodities tothe private facilitiesby engaging with the private sector in Lagos State to align service delivery and commodity distribution goals will drive voluntary uptake of FP services.
Inclusion of contraceptive services into the Benefits package of the Lagos State Health Scheme: while contraceptive commodities are provided free of charge to clients at publicfacilities, hidden charges billed as cost of consumables still exists, which often deter clients from taking up contraceptive services. At private facilities, on the other hand, clients are requiredto pay out of pocket for both costs of commodities and consumables. The current benefit package of the LSHSdoes not cover the provision of FP services except counseling. As a result, enrolled clients must pay for the services (either consumable alone or with commodities) at public and private facilities. Including a full range of contraceptive services into the benefits package of the LSHS will make contraceptive services available to enrolled clients at no costin both public and private facilities, which has the potential to increase voluntary uptake of the services.
5.4.2. Demand Side Interventions
- Community outreaches: Involves community health officers (CHOs) and community health extension workers (CHEWs) going into communities to give health talks onfamily planning and inform community members on the range of methods available foruptake. They can alsoprovide contraceptivesduring the outreaches, such ascondoms, pills, and injectables,and refer community members to PHCsfor long-acting methods.
- Engaging Religious and community leaders as FP advocates: influential religious and community leaders can be engaged to discuss and educate them on the benefits and potential impacts of family planning. After that, they will be encouraged to promotefamily planning within their respective spheres of influence.
- Using traditional media and social media to promote FP: scalingup information, education, and communication efforts through appropriately tailoredmessages on various media platforms can improve knowledge about FPand increase voluntary uptake. The use of social media can be beneficial for reaching adolescents. In addition, having confidential, dedicated phone lines that intending users can call to address their concerns may increase voluntary uptake.
- Male involvement in family planning: Identifying male advocates and engaging them to promotefamily planning, especially among other men in their communities. In addition, men should be encouraged to accompany their spouses to health facilities on various clinic days to learn about family planning and support their spouses in deciding to take up contraceptive services and choice of method.
- MNCH/FP integration: integrating FP counseling and services into other maternal and child health services can increase FP services. FP counseling during Antenatal care (ANC)clinics can help women prepare to take up FP services following delivery. In contrast, women who otherwise would not go to the facility solely for FP servicesmay be more likely to take up the services if made available during child immunization clinics.
Other challenges include but are not limited to negative user attitudes towards contraception, provider beliefs, and those arising from the culture and health systems. We further recommended somesupply-and-demand-side interventions that will be most effective at increasing voluntary contraceptive uptake in Lagos state.
Funding: This research is supported by the Bill and Melinda Gates Foundation through the Nigerian-led Strategic Purchasing for Family Planning grant assigned to HSCL (Grant number: INV-007359).Competing Interests: The authors declare that they have no competing interests.Authors’ Contributions: All authors contributed equally to the conception and design of the study.
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