Knowledge, attitude and practice of modern contraception among single women in a rural and urban community in Southeast Nigeria

Summary
The contraceptive information and services offered to single women in most developing countries is compromised by
stigma attached to premarital sex. This study was to ascertain the knowledge, attitude and practice of contraception among
single women in a rural and urban community in southeast Nigeria, using a cross-sectional survey of 279 and 295 single
women in Ngwo (rural) and Enugu (urban) community. The mean age of the population was 21.3 years. Contraceptive
awareness was more among the urban than rural respondents (90.2% vs 34.1%). The major sources of contraceptive
knowledge were mass media (68%) and peer groups (86.3%) for the urban and rural respondents, respectively. Most
respondents in both groups had positive attitude towards contraception. More urban than rural respondents (68.3% vs
12.5%) began sexual activity during adolescence and the level of contraceptive use during first coitus were 48.4% and
13.7%, respectively. Of the currently sexually active respondents, 32.5% (rural) and 59.7% (urban) were using a form of
modern contraception. Condoms, followed by oral pills were the most popular contraceptive method because they can
easily procure them over the counter. Poor contraceptive information, highly critical behavior of family planning providers
towards unmarried women seeking contraception and attitude of male partners militate against contraceptive practice.
There is need to promote information and education on contraception among single women, their male partners and
family planning providers.
Introduction
The society today is more permissive to sex, with the
effect that more and more single women are engaging in
pre-marital relationship and sex. This results in a high
incidence of unwanted pregnancies and abortion among
these sexually active single Nigerians due to limited
access to family planning services (Feyisetan and Pebley
1989). These single women face special circumstances,
which make it difficult for them to obtain the reproductive
health they need even when it is seemingly available.
Such problems include the psychology of being seen
among married women in the family planning clinics. By
lowering the probability of unwanted pregnancy, contraceptives
can decrease the need for abortion, but as in
most African countries contraceptive use in Nigeria is
low (Fakeye and Babaniyi 1989; Nigeria Demographic
and Health survey 1991). Government and donor
agencies are committed to an active family planning
policy and have taken measures to make available a
broad range of contraceptive methods as well as
informing the general public of its availability (Mamadani
et al. 1993).
In this article, we report on in-depth interview exploring
knowledge, attitude and practice of various forms of
modern contraception among single women living in urban
and rural areas of southeast Nigeria.
Materials and methods
The study was conducted in Enugu metropolis and a rural
Ngwo community both in Enugu state in southeast
Nigeria. Enugu is the capital of Enugu state of Nigeria
and is located east of the river Niger. It has a projected
population of one million persons and is divided into nine
zones based on respective residential areas. The major
occupations range from trading to civil service. The
metropolis has a teaching hospital (University of Nigeria
Teaching Hospital), a general hospital (Park Lane Hospital),
12 government health centers, 142 private hospitals
and clinics and 800-registered patent medicine dealers and
pharmaceutical stores. Ngwo on the other hand, is a rural
community in Udi local government area of Enugu state
and is situated to the west of Enugu town. It has an
estimated population of 160,000 and is made up of 10
villages. Ngwo has 20 health facilities: 4 government health
centers and 16 private clinics and maternity homes. Ngwo
by proximity shares cultural norms with Enugu town and
they are predominantly farmers with few civil servants. The
inhabitants of both communities are predominantly Ibos
with pockets of other tribes.
Multistage sampling technique and cross sectional
sample survey were done between January and April
2004. Uwani, one of the nine districts in Enugu metropolis
was selected by simple random sampling from a list of all
the districts after which 11 streets were purposely selected
from it. Two hundred and ninety-five unmarried females
aged between 15 and 49 years (reproductive age group)
were selected by systematic random sampling technique. In
Ngwo, two (Uboji and Ameke) out of the 10 villages were
selected by simple random sampling and 279 unmarried
females of reproductive ages selected by systematic random
sampling technique.
Using pre-tested interviewer-administered questionnaires
information were sought on age, educational
status, religion, income of respondents or their guardians,
knowledge, attitude and practice of modern contraception.
Female nurses who were trained in interviewing technique
conducted the interviews. The entire 574 questionnaires
were completed and analysed, giving a response rate of 100
percent. The data analysis was done by simple percentages
and mean using Graph pad software.
Results
Of the 574 respondents, 279 (48.6%) were living in the
rural area while 295 (51.4%) reside in the urban area. Their
age ranges from 15 to 49 years with a mean age of 21.3
years (Table I). The rural and urban respondents were
mainly Christians of Roman catholic (53.4% vs 63%) and
Anglican (41.9% vs 33.9%) denominations, respectively.
They were of mixed socioeconomic status with almost 50%
of those in the rural area and 21.6% of the urban
respondents earning less than one hundred dollars
monthly. More than 50% of the respondents in both urban
and rural communities had attained menarche by 14 years.
While most respondent attained secondary education,
there were more respondents with tertiary education
among the urban than rural single women (36.9% vs
11.8%). Twelve percent (n = 35) of urban and 5.4%
(n = 15) of rural respondents gave a history of previous
pregnancy.
Table II shows that more respondents in the urban area
(57.6%) had good knowledge of their period than the
respondents in the rural area (37.3%). Also 90.2% of the
urban respondents knew about contraceptives as against
34.1% of the rural respondents. Mass media and information
from peer group were major sources of knowledge of
contraception for urban and rural respondents, respectively.
57.3% of the rural respondents and 63.1% of urban
respondents have been exposed to sexual intercourse and
more of the urban than rural respondents (68.3% vs
12.5%) had this experience as adolescent. While 48.4% of
the urban respondents practised contraception during their
first coitus, only 13.7% of rural respondents did the same.
Sixty percent and 32.5% of the sexually active urban and
rural respondents, respectively are currently using one form
of contraception or the other. Condoms, followed by oral
pills were the most popular contraceptive method in the
two groups of respondents. Seventy-six percent of the rural
and 71.4% of the urban respondents who knew about
contraception favored its use by single women. They were
also willing to recommend the use of contraception to their
friends. Majority of the male sexual partners of the urban
respondents had a more positive attitude towards their use
of contraception than those of rural respondents (64.5% vs
40.6%). For male partners of rural respondents contraception
will encourage promiscuity while condom
diminishes sexual pleasure. The partners of urban respondents
on the other hand, view condom as a way of
minimising risk of sexually transmitted diseases as well as
avoiding pregnancy.
Of the respondents using contraceptives, the greatest
obstacle to its use is the embarrassment of going to procure
it especially from the family planning clinic (Table III).
Discussion
In this study, a higher percentage of urban respondents
knew about the fertile period and contraception than those
in the rural area. This level of contraceptive knowledge
among these urban respondents agrees with studies in
other urban sub-Saharan Africans (Bisrat and Pickering
1994). Despite campaign on information dissemination in
family planning in developing countries (Piotrow et al.
1990; Valente et al. 1994), the level of contraceptive
awareness we have documented among rural single women
indicate that changes are rather slow. Most of the rural
single women lacked basic information about reproduction
and contraception and often did not know where or how to
obtain contraceptive information. Furthermore, there were
social, psychological and economic barriers to accessing
these services. The mass media was an important source of
information for most urban women in this study and this
was in agreement with previous studies in Nigeria (Konje et
al. 1998; Adinma and Nwosu 1995). However, the same
cannot be said for the rural women who depended more on
friends and peer group for contraceptive information, some
of which is false. This lack of adequate information and
ignorance has been shown to be key factors militating
against family planning practice in Nigeria (Adinma and
Nwosu 1995). There is therefore a need to bridge the gap
in contraceptive information by redirecting information
dissemination, counselling strategies and restructuring
family planning programmes to facilitate grass root coverage.
Most of the respondents in both rural and urban areas
were sexually experienced with 12.5% of rural and 68.3
percent of urban respondents beginning sexual activity
during adolescence. The first sexual encounter of these
adolescents, as in previous studies (Izugbara 2001) was
promoted by pressure, curiosity and for economic purposes.
These adolescent women face unique problems in
practicing birth control and in doing so effectively. They do
not have accurate or adequate information about effective
contraceptive method and far too often those who have the
knowledge cannot obtain the services and supplies they
need because they may be confronted with social ostracism
for their acknowledgement of sexual activity outside
marriage. It was therefore not surprising that 13.7% of
rural respondents and 48.4 percent of urban respondents
used some form of contraception at first coitus. Greater
availability and access to contraception together with
relaxation of norms governing pre-marital sexual relationships
in the urban areas may account for the differences in
contraceptive usage of the two groups at first coitus.
The level of contraceptive use among currently sexually
active respondents in the urban area is higher than those in
the rural area. This urban-rural difference in contraceptive
practice may be a function of contraceptive awareness,
educational level, previous pregnancy experiences and life
style (Fantahun et al. 1995; Versnel et al. 2002; Spinelli et
al. 2000; Hartlage et al. 2001). It is instructive to note that
all the urban respondents with previous history of
unwanted pregnancy were currently using a method of
contraception. However, this was not the case for those in
the rural area because of non-availability of contraception
or lack of information about its existence. Furthermore, the
highly critical behavior of family planning providers
towards unmarried women who sought contraception tend
to compromise the quality of services offered to these
women (Anate et al. 1997). Since abortion is still restrictive
in Nigeria (Solanke 1977), these unmarried women tend to
resort to clandestine abortion practices after an unwanted
pregnancy.
Condom was the most popular method of contraception
employed by both respondents, followed by oral contraceptive
pills. The reasons for this is obvious, as they can
easily procure them over the counter without the embarrassment
associated with going to the family planning
clinic. Also, most of the single women only have occasional
sex and felt emergency contraceptive pills situated their
situation.
Majority of both rural and urban respondents that knew
about contraception had favorable attitude toward it and
were willing to recommend it to others. However, the
support of the male partners of the rural respondents for
the use of contraception was poor. Ignorance, fear of
promiscuity and diminished sexual pleasure with condoms
were part of the reasons given. On the other hand, majority
(64.5%) of the male partners of the urban respondents
were supportive on the need for family planning and were
willing to promote the use of condom. They believed that
using condom is the best way to minimise the risk of
sexually transmitted diseases as well as preventing pregnancy.
In addition to place of residence, the socioeconomic
and educational status of the male partner of the single
women influenced their attitude towards contraception.
In conclusion, it has become obvious that there is an
urgent need to promote information, education and
communication programmes on contraceptives among
our rural dwellers. Also more effort should be made to
integrate men into the various aspects of reproductive
health programmes. And finally the communication barrier
between the family planning provider and single women
seeking contraceptive advice should be bridged.