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Demand and Unmet Needs of Contraception Among Sexually Active In-Union Women in Nigeria: Distribution, Associated Characteristics, Barriers, and Program Implications:

Demand and Unmet Needs of Contraception Among Sexually Active In-Union Women in Nigeria:... It is not clear whether the 16% unmet need for contraceptives in Nigeria indicates a success story. This study assessed the contraceptive prevalence rate (CPR), total contraceptive demand, and unmet needs and determined the distribution, determinants, and barriers to contraceptive demands and unmet needs in Nigeria. The fertility, breastfeeding, and contraceptive use information provided by 27,829 women who were either currently married or in a sexual union in the 2013 Nigeria Demographic and Health Survey (NDHS) were extracted. Associations between having unmet needs and the demographic, socioeconomic, and reproductive profiles of the respondents were assessed using bivariate and multiple logistic regression at 5% significance level. Multiple response data analysis techniques were used to assess barriers to nonuse of contraceptives. Data were weighted to reflect differentials in the population of in-union women in each geographical state. The modern CPR was 9.8% while total demand for contraception was 31.2%, consisting of unmet need at 16.1% and met needs at 15.1%. Unmet need for family planning was higher among rural women compared with urban women (16.8% vs. 14.9%); younger women (adjusted odds ratio [aOR] = 4.29; confidence interval [CI] = [3.03, 6.07]), women belonging to poorer economic status (aOR = 2.27, CI = [1.92, 2.68]), and women with no education (aOR = 3.23, CI = [2.60, 4.02]) had higher odds of unmet needs. The low unmet need should not be mistaken for a good progress in family planning programming in Nigeria; the success is better measured using the level of total demand for contraceptives and CPR. Interventions to improve the socioeconomic status of women, increase the knowledge of modern contraceptives, and improve women’s decision-making power should be prioritized. Keywords unmet needs, in-union women, demand for contraceptives, Nigeria one of the most cost-effective investments a nation can offer Introduction its present and future and that “every $1 spent on FP translate In recent times, campaigns for improved sexual and repro- to $6 savings to be expended on other livelihood services” ductive health of women through the use of contraceptives (The Gates Foundation, 2015). In Nigeria, US$603 million have been one of the world’s major public health interven- has been budgeted to achieve full-scale FP program for tions. It has been advocated by international organizations, 2013–2018 (Federal Government of Nigeria, 2014). governments, and nongovernmental organizations as well as Compared with 3% in 2003, 22% of the 2015 Nigeria gov- charity and community-based organizations. Worldwide, ernment total expenditure went on public health of which several million women who desire contraceptives are not using it despite huge investments in contraceptives. Prior to North West University, Mafikeng, South Africa 2009, it was estimated that about US$3.1 billion was spent University of Ibadan, Nigeria annually on education, promotion, production, and distribu- Corresponding Author: tion of various family planning (FP) methods to about 600 Adeniyi Francis Fagbamigbe, Department of Epidemiology and Medical million people who use modern contraceptives worldwide Statistics, Faculty of Public Health, College of Medicine, University of (Kent, 2010; Singh, Darroch, Ashford, & Vlassoff, 2009). Ibadan, 234OY, Ibadan, Nigeria. The Gates Foundation had stressed that voluntary FP remains Email: fadeniyi@cartafrica.org Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open contraception is a major component (U.S. Agency for billion of women of childbearing ages (15-49) in developing International Development [USAID], 2015). The big ques- countries wanted to avoid pregnancy but are not using an tion is “does the level of unmet need of FP in Nigeria justify effective means of contraception (Kent, 2010; Singh et al., the budget it has attracted in recent time”? 2009). According to World Health Statistics, approximately The worldwide campaign for use of FP is borne out of the one in every eight currently married or in-union women aged fact that adoption of FP can help improve sexual and reproduc- 15 to 49 years across the globe had an unmet need for FP tive health. If used properly and regularly, some FP methods compared with one in four in the WHO African Region such as condoms prevent the transmission of HIV and other (WHO, 2011; United Nations, 2011; WHO, 2012, 2014). sexually transmitted infections (Adebowale, Fagbamigbe, & Unmet need for contraception is a major indicator of FP Bamgboye, 2011). FP also reduces unwanted pregnancy and the among the SDG (United Nations, 2011; WHO, 2012) and demand for unsafe abortion (Martinez, Copen, & Abma, 2011; shows the gap between the reproductive intentions of cur- Martinez, Daniels, & Chandra, 2012). The long-term benefits of rently in-union women and their contraceptive behavior using FP include securing the well-being and autonomy of (Demographic and Health Surveys [DHS], 2015; Measure women, enhancing health and development of communities and Evaluation, Population and Reproductive Health [PRH], nations, reduction of infant and maternal mortality, reduction of 2015; WHO, 2013). Reduction of unmet need would decrease incidence of HIV, empowering people, ensuring better educa- unwanted pregnancies and abortion which is higher among tion, and making population growth slower (Ezire, Oluigbo, poorer women, thereby improving their socioeconomic status Archibong, Ifeanyi, & Anyanti, 2013; Fagbamigbe, Adebowale, (Gelband, 2001). The predominantly high fertility in Nigeria & Olaniyan, 2011; Martinez et al., 2011; Wellings et al., 2006). could be reduced significantly if unmet needs are met. These benefits necessitated the inclusion of contraceptive Although no linear relationship has been established prevalence rate (CPR) as one of the indicators of the between reduction of the unmet need for FP and increasing Sustainable Development Goals (SDG) 5 (Adebowale et al., the CPR, reducing unmet need has been reported to be posi- 2011; Ezire et al., 2013; Fagbamigbe et al., 2011, Federal tively associated with increased contraceptive use and Government of Nigeria-Millennium Development Goals, decreasing total fertility rates (TFRs) (Becker et al., 2006). 2014; PATH, 2008; United Nations, 2011; World Bank, 2013; Unfortunately, the two indicators are both low in Nigeria. World Health Organization [WHO], 2012). Evidence suggests While the 2013 CPR estimate in Nigeria is 15%, the unmet that unwanted pregnancies are common among women at the need for FP is 16% (Federal Ministry of Health Nigeria, beginning and later end of their reproductive age (Becker, 2013; National Population Commission [Nigeria] and ICF Wolf, & Levine, 2006; Kent, 2010; Klima, 1998). Unwanted International, 2014) compared with Indian estimates which pregnancy has also been reported to be strongly associated reduced from 25.4% in 1990 to 20.4% in 2015 in India (New, with maternal mortality through unsafe abortion and preg- Cahill, Stover, Gupta, & Alkema, 2017). nancy complication factors (Klima, 1998; Singh, Darroch, Literature is replete with factors affecting the unmet need Ashford, & Vlassoff, 2009). According to reports from the for FP. Women with little or no educational attainment have Gates Foundation, about a quarter of the 80 million unplanned been reported to have higher odds for unmet needs for FP pregnancies in developing countries were aborted in an unsafe compared with those with higher education (Abdel & Amira, manner in 2012 (The Gates Foundation, 2015). Later in life, 2013; Choudhary, Saluja, Sharma, Gaur, & Pandey, 2009; products of unwanted pregnancies may have higher negative Population Reference Bureau, 2012a). Also, unmet needs outcomes than those who were not and their poverty gap may have been documented to be significantly influenced by place get wider (Gelband, 2001; Marston & Cleland, 2003). of residence, FP knowledge, wealth quintile, partner educa- Although contraceptive use has increased globally, its use tion, religion, number of surviving births, and media expo- has remained very low in sub-Sahara Africa, Nigeria inclu- sure (Bradley, Croft, Fishel, & Westoff, 2012; Choudhary sive (Ashford, 2003; Darroch, Sedgh, & Ball, 2011; World et al., 2009; Rafiqul, Ahmed, & Mosiur, 2013; Widman, Noar, Bank, 2010). The world CPR rose from 54% in 1990 to 57% Choukas-Bradley, & Francis, 2014). Accessibility, affordabil- in 2012 and from 23% to 24% in Africa over the same period ity, adequacy, and proper use of FP methods have been cited (United Nations, 2011; WHO, 2014). National surveys in also as risk factors of unmet need (Assefa & Fikrewold, 2011; 2012 and 2013 have placed CPR in Nigeria at about 15% Saurabh, Prateek, & Jegadeesh, 2013). which was the same with 2007 estimate (Federal Ministry of There are divergent views on the definition and measure- Health Nigeria, 2013; Federal Ministry of Health [FMoH], ments of unmet needs. It has been measured using assump- 2007; National Population Commission [Nigeria] and ICF tions which are often imprecise and controversial (Cleland, International, 2009; National Population Commission Harbison, & Shah, 2014). Until recently, the definition prof- [Nigeria] and ICF International, 2014). fered by Westoff and Ochoa (1991) has been used in deter- Despite high knowledge rate and increasing overall levels mining levels of unmet needs for contraception. The authors of contraceptive use across the globe, existing significant stated that fecund women who want their next child within gaps between the women’s desire to delay or stop childbear- the next 2 years, or currently pregnant or amenorrheic women ing and their actual use of contraception have remained who were using contraception at the time they became preg- unchecked. By the end of 2009, as many as 15% of the 1.4 nant with the current/last or whose pregnancy was reported Fagbamigbe et al. 3 as intentional, are not to be considered as having unmet need. currently has about 180 million inhabitants (Akande, 2014; Critics of the Westoff and Ochoa method identified its four Fagbamigbe et al., 2015; Godswill, 2016; Population major limitations in that allowances were not made for mar- Reference Bureau, 2014). Nigeria is the most populous ried or cohabitating women who abstain from sex. Also, nation in Africa and one of the most populous countries in those never-married or formerly married women were not the world (Gupta et al., 2014; Population Reference Bureau, included in the computation; users of traditional methods are 2012b) with the possibility of becoming fifth largest in 2050. treated as nonusers because it is less effective and that male Nigeria has a predominant young population with a high fer- partners were excluded from computations of unmet need tility rate of 5.5% (National Population Commission estimates (Cleland et al., 2006; Cleland et al., 2014). [Nigeria] and ICF International, 2014). Recent nationally According to United Nations, the women with unmet representative surveys have put Nigeria CPR at 15% with needs are (a) in-union pregnant women whose pregnancies unmet need for FP at 16% (Federal Ministry of Health were unwanted or mistimed at the time of conception, (b) Nigeria, 2013; National Population Commission [Nigeria] in-union postpartum amenorrheic women who were not on and ICF International, 2014). Nigeria has 36 states and a contraceptives and whose last birth was unwanted or mis- Federal Capital Territory (political divisions), grouped into timed, and (c) all in-union fecund women who were neither six geopolitical zones. Nigeria has more than 50 ethnic pregnant nor postpartum amenorrheic, and who either want groups among which Yoruba, Hausa/Fulani, and the Igbo are to limit family size or want to space births, but were not on the dominants while Islam and Christianity are the predomi- any contraceptives (United Nations, 2014). Bradley et al. nant religions practiced. (2012) defined unmet need as a proportion of fertile and sex- ually active in-union women who are not using contracep- Study Design and Data Collection tives but would have preferred to limit or space the birth of next child. In this study, we adopted the definition proposed We used the data from 2013 Nigeria Demographic Health by Bradley et al. which has also been reported earlier Survey. This was a cross-sectional analysis of nationally rep- (Measure Evaluation, PRH, 2015). resentative secondary data. The data were collected from women of reproductive age residing in noninstitutional The aim of the current study is to assess and compare the dwelling units in Nigeria. The survey used the sampling prevalence of contraceptive demand and unmet needs across frame to detain the enumeration areas (EAs), local govern- social-demographic characteristics and autonomy of the ment areas (LGAs), states, and zones in Nigeria as prepared women, and determine the distribution and determinants of in the 2006 Population Census of the Federal Republic of unmet needs as well as the barriers to contraceptive demands Nigeria. The sample used for the interview was selected in Nigeria. Women autonomy is particularly important to use using a stratified three-stage cluster design spread over rural of contraceptives as reported in previous studies that deci- and urban areas in Nigeria. Detailed sampling design has sion making is associated with increased likelihood of con- been documented earlier (National Population Commission traceptive use and a decreased likelihood of unmet need [Nigeria] and ICF International, 2014). (Austin, 2015; Letamo & Navaneetham, 2015). Although estimates of unmet need and CPR in Nigeria were published earlier using the same data (National Population Commission Outcome Variable [Nigeria] and ICF International, 2014), our study provides a We extracted fertility, breastfeeding, and contraceptive use reanalysis and additional estimates across the characteristics information provided by 27,829 women who were either cur- of the respondents which were not provided in the earlier rently married or in a sexual union. The contraception includes report. Knowledge of the level of unmet need and its deter- both the traditional and modern methods. The modern methods minants could spark up interventions that could help increase were male and female sterilization, pills, intrauterine device contraceptive use, lower fertility and reduce the likelihood of (IUD), injectables, implants, male condom, female condom, maternal and children deaths (Khalil, Alzahrani, & Siddiqui, and lactational amenorrhea method (LAM). The primary out- 2017). We hypothesized that women background character- comes in this study were demand and unmet need for contra- istics and reproductive behavior would significantly influ- ceptives. We defined demand for contraceptive as the totality of ence the levels of the unmet needs for contraceptives in needs for contraceptive, either met or unmet. Unmet need was Nigeria. The outcomes of this study will assist in strengthen- based on recent definitions by Bradley et al. (2012), as a pro- ing FP programming in Nigeria and other sub-Sahara African portion of fertile and sexually active in-union women who are countries. not using contraceptives but would have preferred to limit or space the space the birth of next child. In this study, we adopted Method the procedure in Figure 1 for computing the number of women of reproductive age, either married or in a union, who have an Study Area unmet need for FP. As shown in Table 1, breastfeeding history This study was carried out among women of reproductive of the previous child was used to determine whether pregnancy age in Nigeria. Nigeria with an annual growth rate of 3.2% occurred during breastfeeding (postpartum amenorrheic). 4 SAGE Open Figure 1. Definition of unmet need among currently married women. Source. Bradley, Croft, Fishel, and Westoff (2012). This model was used in the final computation of unmet decisions, whether a woman has suffered abuse or violence, needs, and our estimates are presented in Table 1. Details and whether a woman can move about freely without being have been reported earlier (Measure Evaluation, PRH, 2015) monitored and can discuss FP. where it was recommended that contraceptive demand and unmet needs are better computed using responses to ques- Data Analysis tions on desire for additional children and desired length of birth interval; current use of contraceptive; current fecundity, We estimated the demand for contraceptives (addition of pregnancy, and amenorrhea status for noncontraceptive number currently using contraceptive and number with users; number and time planning status of the current/last unmet need divided by number of all in-union women), prev- pregnancy for women currently pregnant or amenorrheic; alence of both types of unmet needs: limiting (number with and contraceptive use as at the time of the current/last preg- unmet need for limiting divided by number of all in-union nancy (Measure Evaluation, PRH, 2015). women) and spacing (number with unmet need for spacing divided by number of all in-union women), the total met needs by modern contraception (modern contraceptive users Independent Variables divided by number of all in-union women), and all contra- The independent variables include geographical zones of ception methods (all users divided by number of all in-union residence, wealth quintile, educational attainment, religion, women) by background characteristics using descriptive sta- place of residence, religion, and ethnicity. The factors have tistics. Unmet need for spacing is defined as the noncurrent been identified in the literature to have an influence on use of FP despite the desire of eligible couples’ desire to demand and unmet need for contraceptives (Austin, 2015; delay the next birth by at least 2 years while “unmet need for Horney, 2003; Letamo & Navaneetham, 2015). To determine limiting” occurs when eligible couples are not currently whether autonomy of women can explain differentials in using a method of contraception and want to stop childbear- demands and unmet need for contraceptives, we explored ing. The “total unmet need” is the addition of both the unmet four variables. They are whether a woman is allowed to need for spacing and limiting (Austin, 2015; Bradley et al., decide by herself how she spends her income, whether a 2012; Bradley, Schwandt, & Khan, 2009; Khalil et al., 2017; woman has access to household resources and can make PATH, 2008). Fagbamigbe et al. 5 Table 1. Need and Demand for Family Planning Among Currently Married Women by Their Characteristics. Unmet need Unmet need Unmet Met need Uses MC Total demand Demand Demand Ideal a b c Characteristics n for spacing for limiting need total for FP methods for FP satisfied satisfied by MC family size Age 15-19 2,251 13.0 0.1 13.1 2.1 1.2 15.2 13.9 7.6 7 20-24 4,362 16.1 0.4 16.6 9.6 6.2 26.1 36.6 23.8 7 25-29 5,913 15.7 1.1 16.8 14.1 8.8 30.9 45.6 28.6 7 30-39 9,171 11.4 6.0 17.4 20.0 13.0 37.4 53.5 34.8 7 40-49 6,133 5.6 8.7 14.3 17.7 11.5 32.0 55.2 35.9 8 Residence Urban 10,124 10.3 4.7 14.9 26.8 16.9 41.7 64.2 40.5 6 Rural 17,705 12.8 3.9 16.8 8.5 5.7 25.3 33.6 22.6 8 Zone North Central 3,895 16.9 6.6 23.5 15.6 12.4 39.1 39.9 31.7 6 North East 4,679 14.2 3.3 17.6 3.2 2.7 20.7 15.2 13.1 9 North West 10,034 10.4 1.6 12.0 4.3 3.6 16.3 26.2 22.3 9 South East 2,333 7.4 5.1 12.5 29.3 11.0 41.8 70.0 26.4 6 South South 2,699 14.9 7.3 22.2 28.1 16.4 50.2 55.9 32.6 5 South West 4,189 9.0 6.5 15.5 38.0 24.9 53.5 71.1 46.6 5 Wealth quintile Lowest 12,410 11.9 3.0 14.8 3.3 2.2 18.2 18.3 12.3 9 Middle 4,983 14.8 5.3 20.0 13.3 9.1 33.3 39.8 27.4 7 Highest 10,437 10.6 5.1 15.7 30.1 19.1 45.9 65.7 41.5 6 Education No education 13,470 12.0 2.9 14.9 2.7 1.7 17.5 15.2 9.9 9 Primary/Qur’anic 5,336 12.2 7.1 19.4 20.0 13.6 39.3 50.8 34.7 7 Secondary 6,980 12.7 4.6 17.3 29.2 18.7 46.4 62.8 40.2 5 Higher 2,043 8.0 3.7 11.7 37.0 22.4 48.7 75.9 46.0 5 Religion Catholics 2,396 11.0 6.0 16.9 28.3 15.3 45.2 62.5 33.9 6 Other Christian 8,185 11.5 6.9 18.3 30.0 19.6 48.4 62.1 40.5 5 Islam 16,811 12.3 2.6 14.9 6.2 4.3 21.1 29.4 20.5 8 Others 437 11.0 5.1 16.1 8.3 5.1 24.4 34.0 21.1 7 Tribe Hausa/Fulani 11,485 11.5 1.9 13.4 1.8 1.2 15.2 11.8 7.9 9 Yoruba 3,565 8.4 6.4 14.8 41.6 28.9 56.4 73.8 51.2 5 Igbo/Ibibio 3,055 8.2 4.8 13.0 31.2 13.7 44.2 70.5 31.0 5 Others 9,723 14.8 5.9 20.5 15.5 11.7 36.0 43.1 32.5 6 Autonomy with her income Autonomous 12,911 11.7 4.5 16.2 16.1 10.7 32.3 49.8 33.2 7 Not autonomous 5,501 10.6 5.8 16.4 24.1 15.4 40.5 59.5 38.1 6 Access to household resources Had access 10,463 10.1 5.9 16.0 28.3 18.0 44.3 63.9 40.6 6 No access 17,366 13.0 3.1 16.2 7.2 4.8 23.4 30.8 20.6 8 Abused/suffered violence Abused 5,108 13.1 5.6 18.7 24.0 15.7 42.7 56.2 36.8 6 Not abused 16,511 12.0 3.1 15.1 13.7 8.7 28.8 47.6 30.2 7 Move freely/discuss FP Can move freely 7,829 11.2 4.3 15.6 17.6 11.1 33.2 53.0 33.4 7 Cannot 13,790 12.8 3.4 16.2 15.3 10.0 31.5 48.6 31.7 7 Total 27,829 11.9 4.2 16.1 15.2 9.8 31.2 48.5 31.3 7 Note. Percentages generated using the revised definition of unmet need presented in Bradley, Croft, Fishel, and Westoff (2012). FP = family planning; MC = modern contraceptives. Total demand is the sum of unmet and met need. Percentage of demand satisfied (by any method) is met need divided by total demand. Modern methods include female sterilization, male sterilization, pill, intrauterine device, injectables, implants, male condom, female condom, and lactational amenorrhea method. Source: National Population Commission (Nigeria) and ICF International (2014) except the additional characteristics. We examined the associations between having unmet multivariate logistic regression at 5% significance level. needs and the demographic, socioeconomic, and repro- We used multiple response data analysis techniques to ductive profiles of the respondents using bivariate and assess barriers to nonuse of contraceptives among those 6 SAGE Open who had unmet demand. Data were weighted to reflect Table 2. Determinants of Unmet Needs Among Sexually Active Women With Family Planning Needs in Nigeria. differentials in the population of in-union women in each state as recommended by DHS. Characteristics OR (95% CI) aOR (95% CI) Age Ethical Approval 15-19 7.10* [5.18, 9.73] 4.29* [3.03, 6.07] 20-24 2.22* [1.91, 2.58] 2.01* [1.69, 2.40] Ethical approvals for the study were obtained from the 25-29 1.60* [1.41, 1.82] 1.74* [1.50, 2.02] National Health Research Ethics Committee assigned num- 30-39 1.13* [1.01, 1.26] 1.24* [1.09, 1.41] ber NHREC/01/01/2007 as earlier documented (National 40-49 Population Commission [Nigeria] and ICF International, Zone 2014). North Central 2.50* [2.19, 2.86] 0.99 [0.82, 1.19] North East 10.39* [8.7, 12.4] 1.68* [1.31, 2.16] North West 8.20* [6.96, 9.66] 0.69* [0.52, 0.92] Results South East 1.01 [0.86, 1.19] 0.67* [0.52, 0.87] Among the 27,829 in-union women included in the analy- South South 2.04* [1.79, 2.34] 1.06 [0.87, 1.29] sis, total demand for contraception in Nigeria was 31.2%. South West This was made up of unmet need at 16.1% (11.9% for spac- Residence ing and 4.2% for limiting) and met needs at 15.2% as shown Urban in Table 1. The overall CPR was 15.2% while modern CPR Rural 3.12* [2.86, 3.41] 1.35* [1.20, 1.51] was 9.8%. Almost a half (48.5%) of the total contraceptive Education demand was satisfied by any method. The 9.8% modern No education 14.62* [12.2, 17.5] 3.23* [2.60, 4.02] Primary/Qur’anic 3.05* [2.59, 3.58] 1.76* [1.47, 2.11] contraceptive prevalence reduced the total contraceptive Secondary 1.96* [1.68, 2.29] 1.43* [1.21, 1.69] demand satisfied by modern contraceptives to 31.3% com- Higher pared with 48.5% demand satisfied by all methods. Unmet Religion need for FP was higher among rural women compared with Catholics urban residents (16.8% vs. 14.9%) and among women who Other Christian 1.15[0.99, 1.32] 1.24* [1.05, 1.45] cannot move around freely without being monitored by Islam 3.85* [3.33, 4.46] 1.81* [1.48, 2.21] their spouses than those who were freer (16.2% vs. 15.6%). Others 3.42* [2.24, 5.24] 2.11* [1.31, 3.39] The rate of unmet need was higher among women with Tribe either no education (12.0%), primary or Quranic (12.2%), Hausa/Fulani 17.84* [14.9, 21.3] 5.47* [3.61, 8.29] or secondary (12.7%) compared with women with higher Yoruba education at 8.0%. Also, unmet need was higher among Igbo/Ibibio 1.16 [0.99, 1.53] 1.34* [0.95,1.89] respondents who experienced violence than those who did Others 3.47* [3.10, 3.91] 2.04* [1.62, 2.58] not (18.7% vs. 15.1%; Table 1). Wealth quintile Demand for contraceptives increased with age of the Lowest 7.88* [6.97, 8.90 2.27* [1.92, 2.68] women but declined among those aged 40 to 49 years. The Middle 2.62* [2.34, 2.92] 1.51* [1.32, 1.73] total demand in urban areas nearly doubled that of rural areas Highest (41.7% vs. 25.3%). There were variations in zonal demand Autonomy with her income for contraceptives, highest in the South West (53.5%) and Not autonomous 1.52* [1.37, 1.68] 1.43* [1.24, 1.65] least in the North West (16.3%). While 65.7% of the demands Access to household resources No access 3.28* [3.00, 3.59] 1.43* [1.24, 1.65] for FP among women in highest wealth distribution were met Abused/experienced violence by any method of contraceptives, only 18.3% were met Abused 1.18* [1.06, 1.31] 1.17 [0.99, 1.36] among those in the lowest wealth distribution. On the pro- Can move freely/discuss FP portion of total demand satisfied by modern contraceptives, Cannot 1.22* [1.11, 1.35] 1.21* [1.08, 1.19] 41.5% were found among the women in highest wealth dis- tribution compared with 18.3% among those in the lowest Note. OR = odds ratio; aOR = adjusted odds ratio; CI = confidence category. Also, women who had access to their household’s interval; FP = family planning. Reference. resources had a higher rate of FP demand satisfied by mod- *p < .05 ern contraceptives (40.6% vs. 20.6%). The average ideal number of children desired by the women was 7, and it var- ied slightly across women’s characteristics as shown in Table Results of the bivariate logistic regression showing unad- 1. Women in urban areas desired fewer children compared justed odds ratios were presented in the first panel of Table 2. with those in rural areas, five among those with secondary Younger women living in northern parts of Nigeria, practicing education or higher compared with nine among those with no Islam, from rural areas, having little or no education, and from formal education. households in poorer wealth quintile, had higher odds of unmet Fagbamigbe et al. 7 Discussion In this study, we investigated the distribution, associated characteristics, barriers to demand, and unmet needs of con- traception among sexually active in-union women in Nigeria with the aim of providing evidence-based information that will help strengthen contraceptive programming in Nigeria. We analyzed the contraceptive information provided by cur- rently married or in-union women in the 2013 NDHS. We found that total demand for contraceptives in Nigeria is gen- erally low as only a third of the respondents had a demand for contraceptives. Only about a half of the demands were met while the second half was unmet. The unmet needs differed by individual, household, and community characteristics of the women surveyed. While the demands for contraceptives are low, the supply is equally low as evidenced by the level of unmet needs. This is in agreement with earlier reports (Austin, 2015). Also, the major barriers to demand and unmet need of contraceptives were found to be opposition by the women or their spouses, health concerns and side effects, and poor awareness of sources and methods of contraceptive. These findings are similar to the reported distribution of reasons Figure 2. Barriers to contraceptive use among in-union women preventing women from using contraceptives in sub-Sahara with unmet needs. Africa (Darroch et al., 2011). The estimated 16.1% unmet need for contraceptive use needs. In the multiple logistic regression (reported in the second found in our study is higher than the rate of 9% in Botswana panel of Table 2), we controlled for other variables in the model (Letamo & Navaneetham, 2015), at par with the reported and computed the adjusted odds ratios (aOR). We found younger level of 15.5% in Zimbabwe in 2005/2006 but relatively low women had higher odds of having unmet needs than the older compared with 26.6% in Zambia in 2007 (Bradley et al., women (aOR = 4.29; confidence interval [CI] = [3.03, 6.07]). 2012). The low level of unmet need in Nigeria could be Women residing in North East had higher odds of unmet needs ascribed to several factors including the demand and supply compared with South West (aOR = 1.68, CI = [1.31, 2.16]). of contraceptives and also barriers prohibiting individuals Being an Islam faithful (aOR = 1.81, CI = [1.48, 2.21]), belong- from accessing the commodity (Austin, 2015; Ezire et al., ing to lowest wealth distribution (aOR = 2.27, CI = [1.92, 2.68]), 2013; Letamo & Navaneetham, 2015). The low unmet need and having no education (aOR = 3.23, CI = [2.60, 4.02]) in Nigeria is also accompanied by only half of the met needs. increased odds of unmet needs as shown in Table 2. Similarly, Less than one third of the women demanded contraceptives women who had free chance to determine how their income is compared with 80% reported in Botswana (Letamo & spent and those who had unhindered access to family resources Navaneetham, 2015). It is not certain whether the low HIV were 43% times more likely to have unmet needs (aOR = 1.43, prevalence of 3.4% reported in Nigeria (Federal Ministry of CI = [1.24, 1.65]) while those who cannot move freely or Health Nigeria, 2013) compared with over 30% rate in discuss FP were 21% times more likely to have unmet need Botswana (Letamo & Navaneetham, 2015) could possibly (aOR = 1.21, 95% CI = [1.08, 1.19]). explain the differentials in contraceptive demand in the two Using analysis of multiple response techniques in Stata, countries. However, literature is replete on the fact that high version 12, we aggregated all reported barriers to 100% and identified main barriers to contraceptive use to include oppo- prevalence of contraceptives may not affect HIV as most sition by the women or their spouses to use of contraception contraceptives except condoms do not prevent HIV and are (32%), health concerns and side effects (23%), and poor more common among older women than younger women awareness of sources and methods of contraceptive (15%). who actually have a higher contribution to HIV epidemics Other reported barriers to use of contraceptives include (Horney, 2003; Letamo & Navaneetham, 2015). “leaving chances to God” (9%), “religious prohibition” Nevertheless, the high TFR of 5.5 (National Population (7%), and “accessibility and affordability” (6%), whereas Commission [Nigeria] and ICF International, 2014) and the “others” reasons indicated in Table 2 consisted of meno- desire for large family size found in the current study are pausal, hysterectomy, opposition by relatives or other per- fallouts of unmet needs and low demands for contraceptives. sons, preferred/No method not available, perceived This assertion is intuitive because low fertility levels reported subfecundability, and inconvenient to use constituted 8% put in certain countries have been linked to higher demands for together as shown in Figure 2. contraceptives (Letamo & Navaneetham, 2015), although 8 SAGE Open research gap existed as to whether the purpose of the high the low contraceptive demands by these women were rarely contraceptive use was to control births or prevent HIV. We met. As other studies have shown, the involvement of women found that an average sexually active in-union woman in in household decisions and particularly in decisions that Nigeria desired seven children which varied across individ- affect their health can improve contraceptive demands and ual characteristics. However, there were unmet needs for lower unmet needs (Austin, 2015). Women should have demands for contraception to space births (Austin, 2015). autonomy to spend their income and have free access to fam- Austin (2015) affirmed that contraceptive campaigns in ily wealth and also be allowed to move freely and discuss FP Nigeria could only be successful if it is not targeted at limit- unhindered. This is of high importance as male spouses have ing childbearing but rather on birth spacing and improve- been found to oppose the use of contraceptives (Adebowale ment of the health of the mother and child as the former & Palamuleni, 2014). might not be culturally acceptable (Austin, 2015). Across the Regarding barriers to contraceptive demands, we found board, unmet need for spacing was higher than the unmet opposition by either the women or their spouses to use of con- need for limiting number of births. traception, health concerns and side effects, and poor aware- We found the age of sexually active in-union women to be ness of sources and different methods of contraceptive to be the associated with levels of unmet need. While the unmet need for commonest reasons why women in Nigeria have unmet limiting increased as women get older, unmet need for spacing demand and in some cases have no demands for contracep- peaked among those aged 20 to 24 years and declined thereaf- tives. Similar reasons have been reported elsewhere (Adebowale ter. This finding corroborated earlier reports (Assefa & & Palamuleni, 2014; Austin, 2015; Bradley et al., 2012; Fikrewold, 2011; Kent, 2010), and it is an indication that FP Bradley et al., 2009; Letamo & Navaneetham, 2015; Sedgh & intervention must be targeted at the girl child as they enter Hussain, 2014) although with different magnitudes. Opposition reproductive age so as to prevent unwanted births. Also, the to the use of contraceptives by women and their spouses consti- unmet need for limiting was higher among urban dwellers than tuted a great challenge to use of contraceptives in Nigeria. This rural dwellers, but the reverse was the case for the unmet need is probably due to the fact that they both wanted large family for spacing. These findings are in consonance with reports else- sizes. This suggests that men are not push-overs in sexual and where (Adebowale & Palamuleni, 2014; Assefa & Fikrewold, reproductive outcomes of their spouses. Sexual and reproduc- 2011; Letamo & Navaneetham, 2015; Saurabh et al., 2013). tive health programming should target both men and women The likelihood of having unmet need also differed across geo- for meaningful changes to be achieved. political zones where the women reside in Nigeria. The reported health concerns and side effects to use of The levels of demand for contraceptives and unmet need contraceptives could lead to eventual discontinuation of by the respondents also differed by their educational attain- methods by users and none uptake of methods by nonusers. ment and wealth status with less educated and poorer women Therefore, there is an urgent need for proper reorientation of been the worst hit. Conversely, those with higher economic women, their spouses, and the community at large through a status had higher contraceptive demand, higher demand sat- functional contraceptive education and promotion, and isfied, and lower family size desire. These findings are simi- behavioral change communication programs as the current lar to other previous documentation (Adebowale & high knowledge of contraceptives in Nigeria did not translate Palamuleni, 2014; Austin, 2015; Letamo & Navaneetham, to usage. The education and promotion will overcome the 2015). The nearly 50% demand for FP satisfied with modern barriers of carefree attitudes, leaving chances, religious pro- methods found in our study is low compared with indices in hibition, myths, misconceptions, and hearsays. We found India which rose from 59% in 1990 to 72% in 2015 (New accessibility and affordability of contraceptives as other et al., 2017). The significance found among education, eco- threats to increased demand and met contraceptive needs in nomic status, demands, and unmet need for contraceptives Nigeria. This is consistent with reports of a Burkina Faso suggested that women should be adequately empowered not study (Adebowale & Palamuleni, 2014) and an earlier study only in terms of finance but also in education so as to improve in Nigeria (Ezire et al., 2013; Fagbamigbe et al., 2011). The knowledge and awareness of methods and sources of contra- Gates Foundation has also identified “insufficient donor and ceptives which has been cited as a major barrier to contra- funding in developing countries, lack of appropriate FP ceptive use (Adebowale & Palamuleni, 2014). methods that meet users’ needs, unreliable distribution sys- We found higher demands for contraceptive among sexu- tems, cultural and knowledge barriers” as hurdles to scale in ally active in-union women practicing Catholic and other eradicating unmet needs (The Gates Foundation, 2015). Christian religions than the Muslims who coincidentally had higher odds of unmet needs compared with other religions. Strengths and Limitations This is consistent with the previous finding that Muslim women, who live mostly in the Northern part of Nigeria, The use of DHS-approved computation of unmet needs has were less likely to have demand for contraceptives as they given credence to our findings compared with other esti- usually desire large families (Austin, 2015; Doctor, Findley, mates before now. However, the exclusion of sexually active Afenyadu, Uzondu, & Ashir, 2013). To worsen the situation, but not in-union women in the computations might have Fagbamigbe et al. 9 strongly underestimated the burden of unmet need for con- discussions. ARF and ESA partook in study design and writing of the introduction and discussions. All authors proofread the final traceptives. All the indicators used in computing the demands version of the manuscript. and unmet needs were self-reported by the respondents which might have suffered recall bias. However, the large- Declaration of Conflicting Interests ness of the data, its national representativeness as well as the high response rates coupled with pretested, consistent, and The author(s) declared no potential conflicts of interest with respect standardized data collection procedures might have elimi- to the research, authorship, and/or publication of this article. nated the potential effect of any recall bias. Funding The author(s) received no financial support for the research, author- Conclusion ship, and/or publication of this article. Although unmet need among the women was low, the met needs and the total demand for contraceptives were also ORCID iD low. The poor, uneducated, and rural women are at greatest Adeniyi Francis Fagbamigbe https://orcid.org/0000-0001-9184-8258 risk of low contraceptive demands and unmet needs. This poses a damaging effect on attainment of good sexual and References reproductive health for women. Despite high knowledge of Abdel, A. A. A., & Amira, O. (2013). Factors affecting unmet need contraceptives in Nigeria and the political will by the for family planning in Eastern Sudan. BMC Public Health, 13, Nigeria government, CPR has remained low at 15%. Article 102. Considering the high fertility desire among the women and Adebowale, S. A., Fagbamigbe, A. F., & Bamgboye, E. A. (2011). the low contraceptive demand, the low unmet need in Contraceptive use: Implication for completed fertility, parity Nigeria should not be mistaken for a good progress in FP. progression and maternal nutritional status in Nigeria. African The success of FP programming in Nigeria is better mea- Journal of Reproductive Health, 15(4), 60-67. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22571107 sured using CPR, level of contraceptive demands, and the Adebowale, S. A., & Palamuleni, M. (2014). Determinants of proportions of demand satisfied. unmet need for modern contraception and reasons for non-use among married women in rural areas of Burkina Faso. African Recommendation Population Studies, 28, 499-514. doi:10.11564/28-1-503 Akande, T. (2014). Youth unemployment in Nigeria: A situa- To achieve a remarkable and desired increase in the CPR, tion analysis. Washington, DC: The Brookings Institution. cost barriers should be removed so that the very poor can Retrieved from https://www.brookings.edu/…/youth-unem- have unlimited access to contraceptives provided all other ployment-in-nigeria-a-situation-analysis barriers have been dealt with effectively. Government and Ashford, L. (2003). Unmet need for family planning: Recent other stakeholders should do more in ensuring accessibility trends and their implications for programs. New York, NY: and affordability as well as ensuring an increased effective- Population Reference Bureau. Assefa, H., & Fikrewold, H. (2011). Factors affecting unmet ness of FP programming in Nigeria. There is need to reverse need for family planning in Southern Nations, Nationalities the unabated population growth in Nigeria through fertility and Peoples Region, Ethiopia. Ethiopian Journal of Health control. This can only be achieved by combined efforts tar- Science, 21(2), 77-89. geted at encouraging households to lower their desired num- Austin, A. (2015). Unmet contraceptive need among married ber of children which would, in turn, improve demands for Nigerian women: An examination of trends and drivers. contraceptives while unmet needs for contraceptives are Contraception, 91, 31-38. been eliminated. For Nigeria to meet the goal of 36% contra- Becker, L., Wolf, J., & Levine, R. (2006). Measuring commitment ceptive prevalence rate by 2018, interventions to enhance to health: Global health indicators working group consultation formal education and improve women’s decision-making report. Washington, DC: Center for Global Development. power should be embraced urgently. Bradley, S., Croft, T. N., Fishel, J. D., & Westoff, C. F. (2012). Revising unmet need for family planning (DHS Analytical Studies No. 25). Calverton, MD: ICF International. Acknowledgments Bradley, S., Schwandt, H., & Khan, S. (2009). Levels, trends, and The authors acknowledge the National Population Commission reasons for contraceptive discontinuation (DHS Analytical (Nigeria) and ICF International for granting them access to the data. Studies No. 20). Calverton, MD: ICF Macro. They also acknowledge the technical support received from the Choudhary, S., Saluja, N., Sharma, N., Gaur, D., & Pandey, S. (2009). Consortium for Advanced Research Training in Africa (CARTA). A study on the extent and reasons of unmet need for family plan- CARTA had trained the first author in research methodologies. ning among women of reproductive age group in rural area of Haryana. 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Unmet need for fam- of North Carolina at Chapel Hill. ily planning. Retrieved from http://www.dhsprogram.com/ Kent, M. M. (2010). What would it cost to meet family planning TOPICS/UNMET-NEED.CFM needs in developing countries? Retrieved from http://www. Doctor, H., Findley, S., Afenyadu, G., Uzondu, C., & Ashir, G. prb.org/Publications/Articles/2010/addingupfpcosts.aspx (2013). Awareness, use, and unmet need for family planning Khalil, S. N., Alzahrani, M. M., & Siddiqui, A. F. (2017). Unmet in rural northern Nigeria. African Journal of Reproductive need and demand for family planning among married women Health, 17(4), 107-117. of Abha, Aseer Region in Saudi Arabia. Middle East Fertility Ezire, O., Oluigbo, O., Archibong, V., Ifeanyi, O., & Anyanti, J. Society Journal. Retrieved from https://ac.els-cdn.com/ (2013). Barriers to repeated use of female condom among S1110569017300596/1-s2.0-S1110569017300596-main.pdf?_ women and men of reproductive age in Nigeria. 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Demand and Unmet Needs of Contraception Among Sexually Active In-Union Women in Nigeria: Distribution, Associated Characteristics, Barriers, and Program Implications:

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Abstract

It is not clear whether the 16% unmet need for contraceptives in Nigeria indicates a success story. This study assessed the contraceptive prevalence rate (CPR), total contraceptive demand, and unmet needs and determined the distribution, determinants, and barriers to contraceptive demands and unmet needs in Nigeria. The fertility, breastfeeding, and contraceptive use information provided by 27,829 women who were either currently married or in a sexual union in the 2013 Nigeria Demographic and Health Survey (NDHS) were extracted. Associations between having unmet needs and the demographic, socioeconomic, and reproductive profiles of the respondents were assessed using bivariate and multiple logistic regression at 5% significance level. Multiple response data analysis techniques were used to assess barriers to nonuse of contraceptives. Data were weighted to reflect differentials in the population of in-union women in each geographical state. The modern CPR was 9.8% while total demand for contraception was 31.2%, consisting of unmet need at 16.1% and met needs at 15.1%. Unmet need for family planning was higher among rural women compared with urban women (16.8% vs. 14.9%); younger women (adjusted odds ratio [aOR] = 4.29; confidence interval [CI] = [3.03, 6.07]), women belonging to poorer economic status (aOR = 2.27, CI = [1.92, 2.68]), and women with no education (aOR = 3.23, CI = [2.60, 4.02]) had higher odds of unmet needs. The low unmet need should not be mistaken for a good progress in family planning programming in Nigeria; the success is better measured using the level of total demand for contraceptives and CPR. Interventions to improve the socioeconomic status of women, increase the knowledge of modern contraceptives, and improve women’s decision-making power should be prioritized. Keywords unmet needs, in-union women, demand for contraceptives, Nigeria one of the most cost-effective investments a nation can offer Introduction its present and future and that “every $1 spent on FP translate In recent times, campaigns for improved sexual and repro- to $6 savings to be expended on other livelihood services” ductive health of women through the use of contraceptives (The Gates Foundation, 2015). In Nigeria, US$603 million have been one of the world’s major public health interven- has been budgeted to achieve full-scale FP program for tions. It has been advocated by international organizations, 2013–2018 (Federal Government of Nigeria, 2014). governments, and nongovernmental organizations as well as Compared with 3% in 2003, 22% of the 2015 Nigeria gov- charity and community-based organizations. Worldwide, ernment total expenditure went on public health of which several million women who desire contraceptives are not using it despite huge investments in contraceptives. Prior to North West University, Mafikeng, South Africa 2009, it was estimated that about US$3.1 billion was spent University of Ibadan, Nigeria annually on education, promotion, production, and distribu- Corresponding Author: tion of various family planning (FP) methods to about 600 Adeniyi Francis Fagbamigbe, Department of Epidemiology and Medical million people who use modern contraceptives worldwide Statistics, Faculty of Public Health, College of Medicine, University of (Kent, 2010; Singh, Darroch, Ashford, & Vlassoff, 2009). Ibadan, 234OY, Ibadan, Nigeria. The Gates Foundation had stressed that voluntary FP remains Email: fadeniyi@cartafrica.org Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open contraception is a major component (U.S. Agency for billion of women of childbearing ages (15-49) in developing International Development [USAID], 2015). The big ques- countries wanted to avoid pregnancy but are not using an tion is “does the level of unmet need of FP in Nigeria justify effective means of contraception (Kent, 2010; Singh et al., the budget it has attracted in recent time”? 2009). According to World Health Statistics, approximately The worldwide campaign for use of FP is borne out of the one in every eight currently married or in-union women aged fact that adoption of FP can help improve sexual and reproduc- 15 to 49 years across the globe had an unmet need for FP tive health. If used properly and regularly, some FP methods compared with one in four in the WHO African Region such as condoms prevent the transmission of HIV and other (WHO, 2011; United Nations, 2011; WHO, 2012, 2014). sexually transmitted infections (Adebowale, Fagbamigbe, & Unmet need for contraception is a major indicator of FP Bamgboye, 2011). FP also reduces unwanted pregnancy and the among the SDG (United Nations, 2011; WHO, 2012) and demand for unsafe abortion (Martinez, Copen, & Abma, 2011; shows the gap between the reproductive intentions of cur- Martinez, Daniels, & Chandra, 2012). The long-term benefits of rently in-union women and their contraceptive behavior using FP include securing the well-being and autonomy of (Demographic and Health Surveys [DHS], 2015; Measure women, enhancing health and development of communities and Evaluation, Population and Reproductive Health [PRH], nations, reduction of infant and maternal mortality, reduction of 2015; WHO, 2013). Reduction of unmet need would decrease incidence of HIV, empowering people, ensuring better educa- unwanted pregnancies and abortion which is higher among tion, and making population growth slower (Ezire, Oluigbo, poorer women, thereby improving their socioeconomic status Archibong, Ifeanyi, & Anyanti, 2013; Fagbamigbe, Adebowale, (Gelband, 2001). The predominantly high fertility in Nigeria & Olaniyan, 2011; Martinez et al., 2011; Wellings et al., 2006). could be reduced significantly if unmet needs are met. These benefits necessitated the inclusion of contraceptive Although no linear relationship has been established prevalence rate (CPR) as one of the indicators of the between reduction of the unmet need for FP and increasing Sustainable Development Goals (SDG) 5 (Adebowale et al., the CPR, reducing unmet need has been reported to be posi- 2011; Ezire et al., 2013; Fagbamigbe et al., 2011, Federal tively associated with increased contraceptive use and Government of Nigeria-Millennium Development Goals, decreasing total fertility rates (TFRs) (Becker et al., 2006). 2014; PATH, 2008; United Nations, 2011; World Bank, 2013; Unfortunately, the two indicators are both low in Nigeria. World Health Organization [WHO], 2012). Evidence suggests While the 2013 CPR estimate in Nigeria is 15%, the unmet that unwanted pregnancies are common among women at the need for FP is 16% (Federal Ministry of Health Nigeria, beginning and later end of their reproductive age (Becker, 2013; National Population Commission [Nigeria] and ICF Wolf, & Levine, 2006; Kent, 2010; Klima, 1998). Unwanted International, 2014) compared with Indian estimates which pregnancy has also been reported to be strongly associated reduced from 25.4% in 1990 to 20.4% in 2015 in India (New, with maternal mortality through unsafe abortion and preg- Cahill, Stover, Gupta, & Alkema, 2017). nancy complication factors (Klima, 1998; Singh, Darroch, Literature is replete with factors affecting the unmet need Ashford, & Vlassoff, 2009). According to reports from the for FP. Women with little or no educational attainment have Gates Foundation, about a quarter of the 80 million unplanned been reported to have higher odds for unmet needs for FP pregnancies in developing countries were aborted in an unsafe compared with those with higher education (Abdel & Amira, manner in 2012 (The Gates Foundation, 2015). Later in life, 2013; Choudhary, Saluja, Sharma, Gaur, & Pandey, 2009; products of unwanted pregnancies may have higher negative Population Reference Bureau, 2012a). Also, unmet needs outcomes than those who were not and their poverty gap may have been documented to be significantly influenced by place get wider (Gelband, 2001; Marston & Cleland, 2003). of residence, FP knowledge, wealth quintile, partner educa- Although contraceptive use has increased globally, its use tion, religion, number of surviving births, and media expo- has remained very low in sub-Sahara Africa, Nigeria inclu- sure (Bradley, Croft, Fishel, & Westoff, 2012; Choudhary sive (Ashford, 2003; Darroch, Sedgh, & Ball, 2011; World et al., 2009; Rafiqul, Ahmed, & Mosiur, 2013; Widman, Noar, Bank, 2010). The world CPR rose from 54% in 1990 to 57% Choukas-Bradley, & Francis, 2014). Accessibility, affordabil- in 2012 and from 23% to 24% in Africa over the same period ity, adequacy, and proper use of FP methods have been cited (United Nations, 2011; WHO, 2014). National surveys in also as risk factors of unmet need (Assefa & Fikrewold, 2011; 2012 and 2013 have placed CPR in Nigeria at about 15% Saurabh, Prateek, & Jegadeesh, 2013). which was the same with 2007 estimate (Federal Ministry of There are divergent views on the definition and measure- Health Nigeria, 2013; Federal Ministry of Health [FMoH], ments of unmet needs. It has been measured using assump- 2007; National Population Commission [Nigeria] and ICF tions which are often imprecise and controversial (Cleland, International, 2009; National Population Commission Harbison, & Shah, 2014). Until recently, the definition prof- [Nigeria] and ICF International, 2014). fered by Westoff and Ochoa (1991) has been used in deter- Despite high knowledge rate and increasing overall levels mining levels of unmet needs for contraception. The authors of contraceptive use across the globe, existing significant stated that fecund women who want their next child within gaps between the women’s desire to delay or stop childbear- the next 2 years, or currently pregnant or amenorrheic women ing and their actual use of contraception have remained who were using contraception at the time they became preg- unchecked. By the end of 2009, as many as 15% of the 1.4 nant with the current/last or whose pregnancy was reported Fagbamigbe et al. 3 as intentional, are not to be considered as having unmet need. currently has about 180 million inhabitants (Akande, 2014; Critics of the Westoff and Ochoa method identified its four Fagbamigbe et al., 2015; Godswill, 2016; Population major limitations in that allowances were not made for mar- Reference Bureau, 2014). Nigeria is the most populous ried or cohabitating women who abstain from sex. Also, nation in Africa and one of the most populous countries in those never-married or formerly married women were not the world (Gupta et al., 2014; Population Reference Bureau, included in the computation; users of traditional methods are 2012b) with the possibility of becoming fifth largest in 2050. treated as nonusers because it is less effective and that male Nigeria has a predominant young population with a high fer- partners were excluded from computations of unmet need tility rate of 5.5% (National Population Commission estimates (Cleland et al., 2006; Cleland et al., 2014). [Nigeria] and ICF International, 2014). Recent nationally According to United Nations, the women with unmet representative surveys have put Nigeria CPR at 15% with needs are (a) in-union pregnant women whose pregnancies unmet need for FP at 16% (Federal Ministry of Health were unwanted or mistimed at the time of conception, (b) Nigeria, 2013; National Population Commission [Nigeria] in-union postpartum amenorrheic women who were not on and ICF International, 2014). Nigeria has 36 states and a contraceptives and whose last birth was unwanted or mis- Federal Capital Territory (political divisions), grouped into timed, and (c) all in-union fecund women who were neither six geopolitical zones. Nigeria has more than 50 ethnic pregnant nor postpartum amenorrheic, and who either want groups among which Yoruba, Hausa/Fulani, and the Igbo are to limit family size or want to space births, but were not on the dominants while Islam and Christianity are the predomi- any contraceptives (United Nations, 2014). Bradley et al. nant religions practiced. (2012) defined unmet need as a proportion of fertile and sex- ually active in-union women who are not using contracep- Study Design and Data Collection tives but would have preferred to limit or space the birth of next child. In this study, we adopted the definition proposed We used the data from 2013 Nigeria Demographic Health by Bradley et al. which has also been reported earlier Survey. This was a cross-sectional analysis of nationally rep- (Measure Evaluation, PRH, 2015). resentative secondary data. The data were collected from women of reproductive age residing in noninstitutional The aim of the current study is to assess and compare the dwelling units in Nigeria. The survey used the sampling prevalence of contraceptive demand and unmet needs across frame to detain the enumeration areas (EAs), local govern- social-demographic characteristics and autonomy of the ment areas (LGAs), states, and zones in Nigeria as prepared women, and determine the distribution and determinants of in the 2006 Population Census of the Federal Republic of unmet needs as well as the barriers to contraceptive demands Nigeria. The sample used for the interview was selected in Nigeria. Women autonomy is particularly important to use using a stratified three-stage cluster design spread over rural of contraceptives as reported in previous studies that deci- and urban areas in Nigeria. Detailed sampling design has sion making is associated with increased likelihood of con- been documented earlier (National Population Commission traceptive use and a decreased likelihood of unmet need [Nigeria] and ICF International, 2014). (Austin, 2015; Letamo & Navaneetham, 2015). Although estimates of unmet need and CPR in Nigeria were published earlier using the same data (National Population Commission Outcome Variable [Nigeria] and ICF International, 2014), our study provides a We extracted fertility, breastfeeding, and contraceptive use reanalysis and additional estimates across the characteristics information provided by 27,829 women who were either cur- of the respondents which were not provided in the earlier rently married or in a sexual union. The contraception includes report. Knowledge of the level of unmet need and its deter- both the traditional and modern methods. The modern methods minants could spark up interventions that could help increase were male and female sterilization, pills, intrauterine device contraceptive use, lower fertility and reduce the likelihood of (IUD), injectables, implants, male condom, female condom, maternal and children deaths (Khalil, Alzahrani, & Siddiqui, and lactational amenorrhea method (LAM). The primary out- 2017). We hypothesized that women background character- comes in this study were demand and unmet need for contra- istics and reproductive behavior would significantly influ- ceptives. We defined demand for contraceptive as the totality of ence the levels of the unmet needs for contraceptives in needs for contraceptive, either met or unmet. Unmet need was Nigeria. The outcomes of this study will assist in strengthen- based on recent definitions by Bradley et al. (2012), as a pro- ing FP programming in Nigeria and other sub-Sahara African portion of fertile and sexually active in-union women who are countries. not using contraceptives but would have preferred to limit or space the space the birth of next child. In this study, we adopted Method the procedure in Figure 1 for computing the number of women of reproductive age, either married or in a union, who have an Study Area unmet need for FP. As shown in Table 1, breastfeeding history This study was carried out among women of reproductive of the previous child was used to determine whether pregnancy age in Nigeria. Nigeria with an annual growth rate of 3.2% occurred during breastfeeding (postpartum amenorrheic). 4 SAGE Open Figure 1. Definition of unmet need among currently married women. Source. Bradley, Croft, Fishel, and Westoff (2012). This model was used in the final computation of unmet decisions, whether a woman has suffered abuse or violence, needs, and our estimates are presented in Table 1. Details and whether a woman can move about freely without being have been reported earlier (Measure Evaluation, PRH, 2015) monitored and can discuss FP. where it was recommended that contraceptive demand and unmet needs are better computed using responses to ques- Data Analysis tions on desire for additional children and desired length of birth interval; current use of contraceptive; current fecundity, We estimated the demand for contraceptives (addition of pregnancy, and amenorrhea status for noncontraceptive number currently using contraceptive and number with users; number and time planning status of the current/last unmet need divided by number of all in-union women), prev- pregnancy for women currently pregnant or amenorrheic; alence of both types of unmet needs: limiting (number with and contraceptive use as at the time of the current/last preg- unmet need for limiting divided by number of all in-union nancy (Measure Evaluation, PRH, 2015). women) and spacing (number with unmet need for spacing divided by number of all in-union women), the total met needs by modern contraception (modern contraceptive users Independent Variables divided by number of all in-union women), and all contra- The independent variables include geographical zones of ception methods (all users divided by number of all in-union residence, wealth quintile, educational attainment, religion, women) by background characteristics using descriptive sta- place of residence, religion, and ethnicity. The factors have tistics. Unmet need for spacing is defined as the noncurrent been identified in the literature to have an influence on use of FP despite the desire of eligible couples’ desire to demand and unmet need for contraceptives (Austin, 2015; delay the next birth by at least 2 years while “unmet need for Horney, 2003; Letamo & Navaneetham, 2015). To determine limiting” occurs when eligible couples are not currently whether autonomy of women can explain differentials in using a method of contraception and want to stop childbear- demands and unmet need for contraceptives, we explored ing. The “total unmet need” is the addition of both the unmet four variables. They are whether a woman is allowed to need for spacing and limiting (Austin, 2015; Bradley et al., decide by herself how she spends her income, whether a 2012; Bradley, Schwandt, & Khan, 2009; Khalil et al., 2017; woman has access to household resources and can make PATH, 2008). Fagbamigbe et al. 5 Table 1. Need and Demand for Family Planning Among Currently Married Women by Their Characteristics. Unmet need Unmet need Unmet Met need Uses MC Total demand Demand Demand Ideal a b c Characteristics n for spacing for limiting need total for FP methods for FP satisfied satisfied by MC family size Age 15-19 2,251 13.0 0.1 13.1 2.1 1.2 15.2 13.9 7.6 7 20-24 4,362 16.1 0.4 16.6 9.6 6.2 26.1 36.6 23.8 7 25-29 5,913 15.7 1.1 16.8 14.1 8.8 30.9 45.6 28.6 7 30-39 9,171 11.4 6.0 17.4 20.0 13.0 37.4 53.5 34.8 7 40-49 6,133 5.6 8.7 14.3 17.7 11.5 32.0 55.2 35.9 8 Residence Urban 10,124 10.3 4.7 14.9 26.8 16.9 41.7 64.2 40.5 6 Rural 17,705 12.8 3.9 16.8 8.5 5.7 25.3 33.6 22.6 8 Zone North Central 3,895 16.9 6.6 23.5 15.6 12.4 39.1 39.9 31.7 6 North East 4,679 14.2 3.3 17.6 3.2 2.7 20.7 15.2 13.1 9 North West 10,034 10.4 1.6 12.0 4.3 3.6 16.3 26.2 22.3 9 South East 2,333 7.4 5.1 12.5 29.3 11.0 41.8 70.0 26.4 6 South South 2,699 14.9 7.3 22.2 28.1 16.4 50.2 55.9 32.6 5 South West 4,189 9.0 6.5 15.5 38.0 24.9 53.5 71.1 46.6 5 Wealth quintile Lowest 12,410 11.9 3.0 14.8 3.3 2.2 18.2 18.3 12.3 9 Middle 4,983 14.8 5.3 20.0 13.3 9.1 33.3 39.8 27.4 7 Highest 10,437 10.6 5.1 15.7 30.1 19.1 45.9 65.7 41.5 6 Education No education 13,470 12.0 2.9 14.9 2.7 1.7 17.5 15.2 9.9 9 Primary/Qur’anic 5,336 12.2 7.1 19.4 20.0 13.6 39.3 50.8 34.7 7 Secondary 6,980 12.7 4.6 17.3 29.2 18.7 46.4 62.8 40.2 5 Higher 2,043 8.0 3.7 11.7 37.0 22.4 48.7 75.9 46.0 5 Religion Catholics 2,396 11.0 6.0 16.9 28.3 15.3 45.2 62.5 33.9 6 Other Christian 8,185 11.5 6.9 18.3 30.0 19.6 48.4 62.1 40.5 5 Islam 16,811 12.3 2.6 14.9 6.2 4.3 21.1 29.4 20.5 8 Others 437 11.0 5.1 16.1 8.3 5.1 24.4 34.0 21.1 7 Tribe Hausa/Fulani 11,485 11.5 1.9 13.4 1.8 1.2 15.2 11.8 7.9 9 Yoruba 3,565 8.4 6.4 14.8 41.6 28.9 56.4 73.8 51.2 5 Igbo/Ibibio 3,055 8.2 4.8 13.0 31.2 13.7 44.2 70.5 31.0 5 Others 9,723 14.8 5.9 20.5 15.5 11.7 36.0 43.1 32.5 6 Autonomy with her income Autonomous 12,911 11.7 4.5 16.2 16.1 10.7 32.3 49.8 33.2 7 Not autonomous 5,501 10.6 5.8 16.4 24.1 15.4 40.5 59.5 38.1 6 Access to household resources Had access 10,463 10.1 5.9 16.0 28.3 18.0 44.3 63.9 40.6 6 No access 17,366 13.0 3.1 16.2 7.2 4.8 23.4 30.8 20.6 8 Abused/suffered violence Abused 5,108 13.1 5.6 18.7 24.0 15.7 42.7 56.2 36.8 6 Not abused 16,511 12.0 3.1 15.1 13.7 8.7 28.8 47.6 30.2 7 Move freely/discuss FP Can move freely 7,829 11.2 4.3 15.6 17.6 11.1 33.2 53.0 33.4 7 Cannot 13,790 12.8 3.4 16.2 15.3 10.0 31.5 48.6 31.7 7 Total 27,829 11.9 4.2 16.1 15.2 9.8 31.2 48.5 31.3 7 Note. Percentages generated using the revised definition of unmet need presented in Bradley, Croft, Fishel, and Westoff (2012). FP = family planning; MC = modern contraceptives. Total demand is the sum of unmet and met need. Percentage of demand satisfied (by any method) is met need divided by total demand. Modern methods include female sterilization, male sterilization, pill, intrauterine device, injectables, implants, male condom, female condom, and lactational amenorrhea method. Source: National Population Commission (Nigeria) and ICF International (2014) except the additional characteristics. We examined the associations between having unmet multivariate logistic regression at 5% significance level. needs and the demographic, socioeconomic, and repro- We used multiple response data analysis techniques to ductive profiles of the respondents using bivariate and assess barriers to nonuse of contraceptives among those 6 SAGE Open who had unmet demand. Data were weighted to reflect Table 2. Determinants of Unmet Needs Among Sexually Active Women With Family Planning Needs in Nigeria. differentials in the population of in-union women in each state as recommended by DHS. Characteristics OR (95% CI) aOR (95% CI) Age Ethical Approval 15-19 7.10* [5.18, 9.73] 4.29* [3.03, 6.07] 20-24 2.22* [1.91, 2.58] 2.01* [1.69, 2.40] Ethical approvals for the study were obtained from the 25-29 1.60* [1.41, 1.82] 1.74* [1.50, 2.02] National Health Research Ethics Committee assigned num- 30-39 1.13* [1.01, 1.26] 1.24* [1.09, 1.41] ber NHREC/01/01/2007 as earlier documented (National 40-49 Population Commission [Nigeria] and ICF International, Zone 2014). North Central 2.50* [2.19, 2.86] 0.99 [0.82, 1.19] North East 10.39* [8.7, 12.4] 1.68* [1.31, 2.16] North West 8.20* [6.96, 9.66] 0.69* [0.52, 0.92] Results South East 1.01 [0.86, 1.19] 0.67* [0.52, 0.87] Among the 27,829 in-union women included in the analy- South South 2.04* [1.79, 2.34] 1.06 [0.87, 1.29] sis, total demand for contraception in Nigeria was 31.2%. South West This was made up of unmet need at 16.1% (11.9% for spac- Residence ing and 4.2% for limiting) and met needs at 15.2% as shown Urban in Table 1. The overall CPR was 15.2% while modern CPR Rural 3.12* [2.86, 3.41] 1.35* [1.20, 1.51] was 9.8%. Almost a half (48.5%) of the total contraceptive Education demand was satisfied by any method. The 9.8% modern No education 14.62* [12.2, 17.5] 3.23* [2.60, 4.02] Primary/Qur’anic 3.05* [2.59, 3.58] 1.76* [1.47, 2.11] contraceptive prevalence reduced the total contraceptive Secondary 1.96* [1.68, 2.29] 1.43* [1.21, 1.69] demand satisfied by modern contraceptives to 31.3% com- Higher pared with 48.5% demand satisfied by all methods. Unmet Religion need for FP was higher among rural women compared with Catholics urban residents (16.8% vs. 14.9%) and among women who Other Christian 1.15[0.99, 1.32] 1.24* [1.05, 1.45] cannot move around freely without being monitored by Islam 3.85* [3.33, 4.46] 1.81* [1.48, 2.21] their spouses than those who were freer (16.2% vs. 15.6%). Others 3.42* [2.24, 5.24] 2.11* [1.31, 3.39] The rate of unmet need was higher among women with Tribe either no education (12.0%), primary or Quranic (12.2%), Hausa/Fulani 17.84* [14.9, 21.3] 5.47* [3.61, 8.29] or secondary (12.7%) compared with women with higher Yoruba education at 8.0%. Also, unmet need was higher among Igbo/Ibibio 1.16 [0.99, 1.53] 1.34* [0.95,1.89] respondents who experienced violence than those who did Others 3.47* [3.10, 3.91] 2.04* [1.62, 2.58] not (18.7% vs. 15.1%; Table 1). Wealth quintile Demand for contraceptives increased with age of the Lowest 7.88* [6.97, 8.90 2.27* [1.92, 2.68] women but declined among those aged 40 to 49 years. The Middle 2.62* [2.34, 2.92] 1.51* [1.32, 1.73] total demand in urban areas nearly doubled that of rural areas Highest (41.7% vs. 25.3%). There were variations in zonal demand Autonomy with her income for contraceptives, highest in the South West (53.5%) and Not autonomous 1.52* [1.37, 1.68] 1.43* [1.24, 1.65] least in the North West (16.3%). While 65.7% of the demands Access to household resources No access 3.28* [3.00, 3.59] 1.43* [1.24, 1.65] for FP among women in highest wealth distribution were met Abused/experienced violence by any method of contraceptives, only 18.3% were met Abused 1.18* [1.06, 1.31] 1.17 [0.99, 1.36] among those in the lowest wealth distribution. On the pro- Can move freely/discuss FP portion of total demand satisfied by modern contraceptives, Cannot 1.22* [1.11, 1.35] 1.21* [1.08, 1.19] 41.5% were found among the women in highest wealth dis- tribution compared with 18.3% among those in the lowest Note. OR = odds ratio; aOR = adjusted odds ratio; CI = confidence category. Also, women who had access to their household’s interval; FP = family planning. Reference. resources had a higher rate of FP demand satisfied by mod- *p < .05 ern contraceptives (40.6% vs. 20.6%). The average ideal number of children desired by the women was 7, and it var- ied slightly across women’s characteristics as shown in Table Results of the bivariate logistic regression showing unad- 1. Women in urban areas desired fewer children compared justed odds ratios were presented in the first panel of Table 2. with those in rural areas, five among those with secondary Younger women living in northern parts of Nigeria, practicing education or higher compared with nine among those with no Islam, from rural areas, having little or no education, and from formal education. households in poorer wealth quintile, had higher odds of unmet Fagbamigbe et al. 7 Discussion In this study, we investigated the distribution, associated characteristics, barriers to demand, and unmet needs of con- traception among sexually active in-union women in Nigeria with the aim of providing evidence-based information that will help strengthen contraceptive programming in Nigeria. We analyzed the contraceptive information provided by cur- rently married or in-union women in the 2013 NDHS. We found that total demand for contraceptives in Nigeria is gen- erally low as only a third of the respondents had a demand for contraceptives. Only about a half of the demands were met while the second half was unmet. The unmet needs differed by individual, household, and community characteristics of the women surveyed. While the demands for contraceptives are low, the supply is equally low as evidenced by the level of unmet needs. This is in agreement with earlier reports (Austin, 2015). Also, the major barriers to demand and unmet need of contraceptives were found to be opposition by the women or their spouses, health concerns and side effects, and poor awareness of sources and methods of contraceptive. These findings are similar to the reported distribution of reasons Figure 2. Barriers to contraceptive use among in-union women preventing women from using contraceptives in sub-Sahara with unmet needs. Africa (Darroch et al., 2011). The estimated 16.1% unmet need for contraceptive use needs. In the multiple logistic regression (reported in the second found in our study is higher than the rate of 9% in Botswana panel of Table 2), we controlled for other variables in the model (Letamo & Navaneetham, 2015), at par with the reported and computed the adjusted odds ratios (aOR). We found younger level of 15.5% in Zimbabwe in 2005/2006 but relatively low women had higher odds of having unmet needs than the older compared with 26.6% in Zambia in 2007 (Bradley et al., women (aOR = 4.29; confidence interval [CI] = [3.03, 6.07]). 2012). The low level of unmet need in Nigeria could be Women residing in North East had higher odds of unmet needs ascribed to several factors including the demand and supply compared with South West (aOR = 1.68, CI = [1.31, 2.16]). of contraceptives and also barriers prohibiting individuals Being an Islam faithful (aOR = 1.81, CI = [1.48, 2.21]), belong- from accessing the commodity (Austin, 2015; Ezire et al., ing to lowest wealth distribution (aOR = 2.27, CI = [1.92, 2.68]), 2013; Letamo & Navaneetham, 2015). The low unmet need and having no education (aOR = 3.23, CI = [2.60, 4.02]) in Nigeria is also accompanied by only half of the met needs. increased odds of unmet needs as shown in Table 2. Similarly, Less than one third of the women demanded contraceptives women who had free chance to determine how their income is compared with 80% reported in Botswana (Letamo & spent and those who had unhindered access to family resources Navaneetham, 2015). It is not certain whether the low HIV were 43% times more likely to have unmet needs (aOR = 1.43, prevalence of 3.4% reported in Nigeria (Federal Ministry of CI = [1.24, 1.65]) while those who cannot move freely or Health Nigeria, 2013) compared with over 30% rate in discuss FP were 21% times more likely to have unmet need Botswana (Letamo & Navaneetham, 2015) could possibly (aOR = 1.21, 95% CI = [1.08, 1.19]). explain the differentials in contraceptive demand in the two Using analysis of multiple response techniques in Stata, countries. However, literature is replete on the fact that high version 12, we aggregated all reported barriers to 100% and identified main barriers to contraceptive use to include oppo- prevalence of contraceptives may not affect HIV as most sition by the women or their spouses to use of contraception contraceptives except condoms do not prevent HIV and are (32%), health concerns and side effects (23%), and poor more common among older women than younger women awareness of sources and methods of contraceptive (15%). who actually have a higher contribution to HIV epidemics Other reported barriers to use of contraceptives include (Horney, 2003; Letamo & Navaneetham, 2015). “leaving chances to God” (9%), “religious prohibition” Nevertheless, the high TFR of 5.5 (National Population (7%), and “accessibility and affordability” (6%), whereas Commission [Nigeria] and ICF International, 2014) and the “others” reasons indicated in Table 2 consisted of meno- desire for large family size found in the current study are pausal, hysterectomy, opposition by relatives or other per- fallouts of unmet needs and low demands for contraceptives. sons, preferred/No method not available, perceived This assertion is intuitive because low fertility levels reported subfecundability, and inconvenient to use constituted 8% put in certain countries have been linked to higher demands for together as shown in Figure 2. contraceptives (Letamo & Navaneetham, 2015), although 8 SAGE Open research gap existed as to whether the purpose of the high the low contraceptive demands by these women were rarely contraceptive use was to control births or prevent HIV. We met. As other studies have shown, the involvement of women found that an average sexually active in-union woman in in household decisions and particularly in decisions that Nigeria desired seven children which varied across individ- affect their health can improve contraceptive demands and ual characteristics. However, there were unmet needs for lower unmet needs (Austin, 2015). Women should have demands for contraception to space births (Austin, 2015). autonomy to spend their income and have free access to fam- Austin (2015) affirmed that contraceptive campaigns in ily wealth and also be allowed to move freely and discuss FP Nigeria could only be successful if it is not targeted at limit- unhindered. This is of high importance as male spouses have ing childbearing but rather on birth spacing and improve- been found to oppose the use of contraceptives (Adebowale ment of the health of the mother and child as the former & Palamuleni, 2014). might not be culturally acceptable (Austin, 2015). Across the Regarding barriers to contraceptive demands, we found board, unmet need for spacing was higher than the unmet opposition by either the women or their spouses to use of con- need for limiting number of births. traception, health concerns and side effects, and poor aware- We found the age of sexually active in-union women to be ness of sources and different methods of contraceptive to be the associated with levels of unmet need. While the unmet need for commonest reasons why women in Nigeria have unmet limiting increased as women get older, unmet need for spacing demand and in some cases have no demands for contracep- peaked among those aged 20 to 24 years and declined thereaf- tives. Similar reasons have been reported elsewhere (Adebowale ter. This finding corroborated earlier reports (Assefa & & Palamuleni, 2014; Austin, 2015; Bradley et al., 2012; Fikrewold, 2011; Kent, 2010), and it is an indication that FP Bradley et al., 2009; Letamo & Navaneetham, 2015; Sedgh & intervention must be targeted at the girl child as they enter Hussain, 2014) although with different magnitudes. Opposition reproductive age so as to prevent unwanted births. Also, the to the use of contraceptives by women and their spouses consti- unmet need for limiting was higher among urban dwellers than tuted a great challenge to use of contraceptives in Nigeria. This rural dwellers, but the reverse was the case for the unmet need is probably due to the fact that they both wanted large family for spacing. These findings are in consonance with reports else- sizes. This suggests that men are not push-overs in sexual and where (Adebowale & Palamuleni, 2014; Assefa & Fikrewold, reproductive outcomes of their spouses. Sexual and reproduc- 2011; Letamo & Navaneetham, 2015; Saurabh et al., 2013). tive health programming should target both men and women The likelihood of having unmet need also differed across geo- for meaningful changes to be achieved. political zones where the women reside in Nigeria. The reported health concerns and side effects to use of The levels of demand for contraceptives and unmet need contraceptives could lead to eventual discontinuation of by the respondents also differed by their educational attain- methods by users and none uptake of methods by nonusers. ment and wealth status with less educated and poorer women Therefore, there is an urgent need for proper reorientation of been the worst hit. Conversely, those with higher economic women, their spouses, and the community at large through a status had higher contraceptive demand, higher demand sat- functional contraceptive education and promotion, and isfied, and lower family size desire. These findings are simi- behavioral change communication programs as the current lar to other previous documentation (Adebowale & high knowledge of contraceptives in Nigeria did not translate Palamuleni, 2014; Austin, 2015; Letamo & Navaneetham, to usage. The education and promotion will overcome the 2015). The nearly 50% demand for FP satisfied with modern barriers of carefree attitudes, leaving chances, religious pro- methods found in our study is low compared with indices in hibition, myths, misconceptions, and hearsays. We found India which rose from 59% in 1990 to 72% in 2015 (New accessibility and affordability of contraceptives as other et al., 2017). The significance found among education, eco- threats to increased demand and met contraceptive needs in nomic status, demands, and unmet need for contraceptives Nigeria. This is consistent with reports of a Burkina Faso suggested that women should be adequately empowered not study (Adebowale & Palamuleni, 2014) and an earlier study only in terms of finance but also in education so as to improve in Nigeria (Ezire et al., 2013; Fagbamigbe et al., 2011). The knowledge and awareness of methods and sources of contra- Gates Foundation has also identified “insufficient donor and ceptives which has been cited as a major barrier to contra- funding in developing countries, lack of appropriate FP ceptive use (Adebowale & Palamuleni, 2014). methods that meet users’ needs, unreliable distribution sys- We found higher demands for contraceptive among sexu- tems, cultural and knowledge barriers” as hurdles to scale in ally active in-union women practicing Catholic and other eradicating unmet needs (The Gates Foundation, 2015). Christian religions than the Muslims who coincidentally had higher odds of unmet needs compared with other religions. Strengths and Limitations This is consistent with the previous finding that Muslim women, who live mostly in the Northern part of Nigeria, The use of DHS-approved computation of unmet needs has were less likely to have demand for contraceptives as they given credence to our findings compared with other esti- usually desire large families (Austin, 2015; Doctor, Findley, mates before now. However, the exclusion of sexually active Afenyadu, Uzondu, & Ashir, 2013). To worsen the situation, but not in-union women in the computations might have Fagbamigbe et al. 9 strongly underestimated the burden of unmet need for con- discussions. ARF and ESA partook in study design and writing of the introduction and discussions. All authors proofread the final traceptives. All the indicators used in computing the demands version of the manuscript. and unmet needs were self-reported by the respondents which might have suffered recall bias. However, the large- Declaration of Conflicting Interests ness of the data, its national representativeness as well as the high response rates coupled with pretested, consistent, and The author(s) declared no potential conflicts of interest with respect standardized data collection procedures might have elimi- to the research, authorship, and/or publication of this article. nated the potential effect of any recall bias. Funding The author(s) received no financial support for the research, author- Conclusion ship, and/or publication of this article. Although unmet need among the women was low, the met needs and the total demand for contraceptives were also ORCID iD low. The poor, uneducated, and rural women are at greatest Adeniyi Francis Fagbamigbe https://orcid.org/0000-0001-9184-8258 risk of low contraceptive demands and unmet needs. This poses a damaging effect on attainment of good sexual and References reproductive health for women. Despite high knowledge of Abdel, A. A. A., & Amira, O. (2013). Factors affecting unmet need contraceptives in Nigeria and the political will by the for family planning in Eastern Sudan. BMC Public Health, 13, Nigeria government, CPR has remained low at 15%. Article 102. Considering the high fertility desire among the women and Adebowale, S. A., Fagbamigbe, A. F., & Bamgboye, E. A. (2011). the low contraceptive demand, the low unmet need in Contraceptive use: Implication for completed fertility, parity Nigeria should not be mistaken for a good progress in FP. progression and maternal nutritional status in Nigeria. African The success of FP programming in Nigeria is better mea- Journal of Reproductive Health, 15(4), 60-67. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22571107 sured using CPR, level of contraceptive demands, and the Adebowale, S. A., & Palamuleni, M. (2014). Determinants of proportions of demand satisfied. unmet need for modern contraception and reasons for non-use among married women in rural areas of Burkina Faso. African Recommendation Population Studies, 28, 499-514. doi:10.11564/28-1-503 Akande, T. (2014). Youth unemployment in Nigeria: A situa- To achieve a remarkable and desired increase in the CPR, tion analysis. Washington, DC: The Brookings Institution. cost barriers should be removed so that the very poor can Retrieved from https://www.brookings.edu/…/youth-unem- have unlimited access to contraceptives provided all other ployment-in-nigeria-a-situation-analysis barriers have been dealt with effectively. Government and Ashford, L. (2003). Unmet need for family planning: Recent other stakeholders should do more in ensuring accessibility trends and their implications for programs. New York, NY: and affordability as well as ensuring an increased effective- Population Reference Bureau. Assefa, H., & Fikrewold, H. (2011). Factors affecting unmet ness of FP programming in Nigeria. There is need to reverse need for family planning in Southern Nations, Nationalities the unabated population growth in Nigeria through fertility and Peoples Region, Ethiopia. Ethiopian Journal of Health control. This can only be achieved by combined efforts tar- Science, 21(2), 77-89. geted at encouraging households to lower their desired num- Austin, A. (2015). Unmet contraceptive need among married ber of children which would, in turn, improve demands for Nigerian women: An examination of trends and drivers. contraceptives while unmet needs for contraceptives are Contraception, 91, 31-38. been eliminated. For Nigeria to meet the goal of 36% contra- Becker, L., Wolf, J., & Levine, R. (2006). Measuring commitment ceptive prevalence rate by 2018, interventions to enhance to health: Global health indicators working group consultation formal education and improve women’s decision-making report. Washington, DC: Center for Global Development. power should be embraced urgently. Bradley, S., Croft, T. N., Fishel, J. D., & Westoff, C. F. (2012). Revising unmet need for family planning (DHS Analytical Studies No. 25). Calverton, MD: ICF International. Acknowledgments Bradley, S., Schwandt, H., & Khan, S. (2009). Levels, trends, and The authors acknowledge the National Population Commission reasons for contraceptive discontinuation (DHS Analytical (Nigeria) and ICF International for granting them access to the data. Studies No. 20). Calverton, MD: ICF Macro. They also acknowledge the technical support received from the Choudhary, S., Saluja, N., Sharma, N., Gaur, D., & Pandey, S. (2009). Consortium for Advanced Research Training in Africa (CARTA). A study on the extent and reasons of unmet need for family plan- CARTA had trained the first author in research methodologies. ning among women of reproductive age group in rural area of Haryana. 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Journal

SAGE OpenSAGE

Published: Feb 7, 2018

Keywords: unmet needs; in-union women; demand for contraceptives; Nigeria

References