Knowledge , attitude and uptake of family planning services among women of reproductive age group attending outpatient clinic at a tertiary health institution in Edo State , Nigeria

Globally, family planning service is an essential element of reproductive health care and contributes immensely to the reduction of the worldwide burden of maternal and child morbidity and mortality. This study was designed to assess the knowledge, attitude and uptake of family planning services, among women of reproductive age group attending outpatient clinic at Irrua Specialist Teaching Hospital, Irrua, Nigeria. A cross-sectional study was carried out among women of reproductive age group attending outpatient clinics from December 2017 to January 2018. Respondents were selected using multi-stage sampling technique. Questionnaires were used for data collection. Data were analyzed using Statistical Package for Social Sciences SPSS version 17. A total of 191 (95.5%) women aged between 15 and 49 years were successfully interviewed during the study. Majority, 174/191 (91.1%) of the respondents had a good knowledge of family planning services; 125/174 (72.0%) had a positive attitude towards the use of various types of contraceptives and 29 (15.0%) were completely against the use of contraceptives. Majority of the respondents, 132 (69.0%) were not using any form of family planning. Condom was the most frequently used contraceptive method; where it accounts for 60.0% while sterilization contributes the least that is 22.0%. Major factors associated with the uptake of contraceptives include marital status (p=0.029) and the occupation of the respondents (p=0.010). Respondent’s knowledge towards family planning was good but this did not translate to use. Also, over half of the respondents had positive attitude towards family planning. The uptake of family planning services was higher than the average for Edo State and for Nigeria. Common barriers to uptake included fear of side effects and for religious reasons. The state and local government should bridge the gap between awareness and uptake of contraception; by providing correct information to women of reproductive age to break down common barriers.


INTRODUCTION
Globally, family planning (FP) is an essential element of reproductive health care and contributes immensely to the reduction of the worldwide burden of maternal and child morbidity and mortality (Cates et al., 2010).Family planning services primarily enable couples and individuals decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choices and make available a full range of safe and effective methods.In almost all the regions of the world, contraceptives are used by majority of women in the reproductive age range (15-49 years) and its goals are commonly defined using the concepts of unmet needs (United Nations, 2017;UNFPA, 2004;Kabir et al., 2017).
It has been estimated that meeting women's need for modern family planning services could prevent about one-quarter to one third of all maternal deaths annually worldwide.It was also found that fulfilling unmet contraceptive need can prevent an additional 150,000 maternal deaths globally annually; and an estimated 40,000 maternal deaths in Nigeria could be averted annually (Singh, 2003;Izugbara, 2017).Unsafe abortion, which is a common consequent of poor family planning and a major contributor to maternal death has been reported to account for up to 56% of unintended pregnancies in Nigeria (Izugbara, 2017).
The uptake of modern contraceptive has been reported to be generally poor in Middle and Western Africa; with values as low as 25% compared to Europe, Latin America and Caribbean with up to 70% uptake (United, 2017).The considerably low contraceptive prevalence rate (CPR) of 15% in Nigeria is very worrisome (Npopc [Nigeria], 2014).
The uptake of contraceptives is often affected by poor access of clients to providers, weak government programmes wealth quintile of clients, educational status, rural/urban influence and marital status.People in the higher socio-economic group; who are almost always educated have higher contraceptive prevalence rate (Army et al., 2010;David, 2011;Aliu, 2009).
The objective of this study was to assess the knowledge, attitude and uptake of family planning services, among women of reproductive age attending outpatient clinic at Irrua Specialist Teaching, Hospital, Irrua, Nigeria.

Study area
The study was carried out in Irrua Specialist Teaching Hospital, Irrua.Irrua is the administrative headquarters of Esan Central Local Government Area (LGAs); which is one of the five LGAs that make up Edo Central Senatorial District.This hospital provides services mainly for people from the Edo Central and Northern Senatorial Districts.The institution also receives patients from the neighboring states of Delta, Kogi and Ondo, especially cases related to reproductive health and viral haemorhagic fevers.Furthermore, it offers clinical care, laboratory services and radiological services as well as preventive services; either on outpatient or inpatient basis.

Study design and duration
A descriptive cross-sectional study was carried out between Januarys and March, 2018.

Study population
This included women of reproductive age groups attending medical and obstetric and gynecology out-patient clinics at Irrua Specialist Teaching Hospital.

Sample size determination
The minimum sample size was determined using Fisher's formula for estimating sample size (Araoye, 2004).
Considering a possible attrition rate of 10%, based on this the minimum sample size, n =200, the respondents were however enrolled in consecutive order until the estimated sample size was reached.

Sampling technique
A multi-stage sampling technique was used to recruit respondents for this study.First, a simple random sampling technique was used to select four outpatient clinics whose clients include women of reproductive age.Those selected included the medical outpatient clinic, the surgical outpatient clinic and antenatal clinic.
In the second stage, the selected departments were stratified and the required number of respondents from each department was estimated through proportional allocation until the sample size was achieved.
Third, the respondents were selected from these departmens in consecutive order until the sample size was reached.

Data collection
Data were collected using an interviewer administered questionnaire.The questionnaire contained questions on respondents' socio-demographic data, knowledge of family planning, attitude towards family planning and uptake of contraceptives.Respondents were categorized as using contraceptives if they or their spouses used any form of modern contraceptive.For cross tabulation respondents who had not head of family planning where considered not to use any form of contraceptive method.Use of FP methods was assessed by asking the respondents about whether or not they were currently using any FP methods.Again, those who had not heard of FP where *Corresponding author.E-mail: alendoc@yahoo.com.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License considered not to use any form of FP.Users of FP methods were asked about the sources of FP supplies.The use of condom included male or female condom by either or both of the partners.Data analysis was carried out with the use of SPSS version 17 statistical software (SPSS Inc.Chicago, Illinois, USA).Chi-square statistical test of significance was used to test for associations between socio demographic variables and factors influencing the uptake of family planning services.

Ethical consideration
Ethical approval for the study was obtained from the Ethics and Research Committee of Ambrose Alli University, Ekpema, Edo State.Permission to carry out the study and informed consent were obtained from management of Irrua Specialist Teaching Hospital, Irrua, Edo State and participants, respectively.

RESULTS
A total of 191 (95.5%) women aged between 15 and 49 years were successfully interviewed during the study.
Table 1 reveals the socio-demographic characteristics of the respondents and the uptake of family planning services.Majority of the respondents (40.3%) were within the ages of 25 to 34 years.This was closely followed by those within the ages of 35 to 44 (37.2%).Most of the respondents were married (75.9%), while 2/191(1%) were widowed.A greater proportion of them (51.8%) were of Esan ethnic group while the Igbos were in the minority 8/191 (4.2%).Christianity was the predominant religion (89.5%) and trading was the major occupation of the respondents (26.2%).A larger proportion (58.6%) of the respondents had tertiary level education.This was closely followed by secondary education (33%).As regards uptake of family planning services, it was the highest between the ages of 25 to 34 (24.6%).It was also higher among married (46.3%).In terms of ethnic group, those from Esan had relatively higher uptake of family planning services 28 (32.6%).Traders, 14 (16.0%) had higher uptake than other professions.In all, there was a statistically significant association between the occupation of the respondents and the uptake of family planning services (P= 0.010).There was also a statistically significant relationship between the marital statuses of the respondents and the uptake of family planning services (P=0.029).
Figure 1 shows the respondents' awareness of family planning and the types of family planning methods they had used.One hundred and seventy three (90.6%) of the respondents were aware of family planning and 16/191 (8.4%) had no idea of family planning.Among those aware of family planning, condom (60.2%) was the most frequently used method of family planning.This was closely followed by the use of pills (51%).However, billings method was the least used method of family planning (20%) among the respondents.
Figure 2 reveals the various sources of information on family planning.Most of the respondents received information on family planning from mass media (25.15%) and from health workers (25.1%).Only 7% of them received information on contraceptives from friends.
In Figure 3, most of the respondents (72%) had positive attitude towards the use of family planning services.Thirteen percent of the respondents were indifferent about the use of these services.
Figure 4 shows the use of contraceptives by the respondents.It also reveals the various reasons for noneuse of family planning services.Among those aware of family planning services, 54/174 (31%) were on one form of contraception or the other.Fear of side effects 73 (61%) was the major reason for non-use of contraception by the respondents who do not use any form of contraceptives.Poor access to health facilities and lack of family planning services was the least reason for nonuse 8 (6%).

DISCUSSION
Women of reproductive age group attending the outpatient clinics at Irrua Specialist Teaching Hospital, Edo State, Nigeria were assessed on their knowledge, attitude and uptake of family planning.
The respondents were mostly Christians (89.5%), from Esan (51.8%) and with a mean age of 31 years.Threequarters of them were married and more than half had tertiary education (58.6%).The literacy level may not be unrelated to the long term influence of the existing tertiary institution within the vicinity of the study area, Ambrose University, Ekpoma; which was established in 1981 (Wikipedia, 2018).This is further buttered by the leading role of Edo State in school enrolment (Adedigba, 2018).However, the respondents' impressive educational status is at variance with a previous study carried out in Delta State, in which less than a third of the participants had tertiary education (Aninyei et al., 2008).
More than four fifth of the respondents knew about family planning.This almost universal awareness is similar to what was reported by Obiesan et al. (1998) among women attending antenatal clinic in Ibadan (Obiesan et al., 1998) in which 89% were aware of family planning and contraceptives.This finding also corroborates previous observations in Bagal, Pakistan (Sharma, 2012) and Jos (Utoo, 2010).This observation may also be linked with the educational status of most of the respondents.Education tends to create more avenues for individuals to interact and possibly receive information on several issues (Ejembi et al., 2004;Babalola and Fatusi, 2009).The respondents knowledge of family planning may have also have been enhanced by the current widespread use of social media among the literate group in our society (Ewhrudjakpor, 2009).Mass media, internet and personal interaction with health workers were the respondents' major sources of information concerning family planning.Information received through the mass media included the radio, television, and other related materials.The internet source included information received via e-mail and social media.These major sources of information are in keeping with findings from a previous study by Planned Parenthood Federation of America; in which mass media was observed to be the major source of information on family planning (America, 2010).Majority of the respondents had a positive attitude towards family planning.This is consistent with a previous observation from a national survey carried out in Nigeria; in which over half of the respondents had positive attitudes towards the use of contraceptives (Odimegwu, 1999) and the result of another study in Kenya (Juma et al., 2015) but at variance with another report by Pamela et al. (2015), in which only one third of the respondents showed approval for use of contraceptives   (Juma, 2015).
In terms of uptake of contraceptive, one third of the respondents used at least one form of modern contraceptive.This was indeed higher than the general uptake for Edo State and much higher than the national average uptake of 15% (FGON, 2014;Alenoghena et al., 2015).Furthermore, it is also at variance with a previous observation concerning the uptake of contraceptives in relation to persistently high unmet needs in developing countries (United Nations, 2013).Interestingly, this uptake may not be unrelated to an increase in the number of  In terms of constraints to the use of contraception, about two third of the respondents were deterred from using any form of modern contraceptives for fear of side effects.This was considerably higher than was reported in a previous study carried out in South West Nigeria (Kabir et al., 2017) in which 14.6% of the respondents did not use any form of contraceptives for fear of side effects.This was closely followed by religion.About a third of the respondents abstained from contraception for religious reasons.This may not be unrelated to the fact that majority of the respondents in this study were Christians; and the use of modern contraceptives as birth control measure is not acceptable in the Catholic Church (Kabir et al., 2017;Wikipedia, 2017).About a quarter of the respondents had not used any form of contraception because of perceived high cost of the commodities.This may not be unrelated to their socioeconomic status.Those in the lower socioeconomic groups may have been deterred by cost.Poor access to facilities providing family planning services was stated by less than a tenth of the respondents as reasons for non uptake of contraceptives.Access remains a common denominator in the uptake of health services in developing countries (Babalola and Fatusi, 2009).
Socio-demographic factors associated with the uptake of the family planning services included marital status and occupation of the respondents.There was indeed a statistically significant relationship between marital status and the uptake of modern contraceptives (p=0.029).There was apparently a higher uptake among those married.This is in keeping with a previous observations on factors associated with uptake of contraceptives (Kabir et al., 2017).The relatively increased uptake among the married respondents may possibly be related to the effect of cultural values on the willingness of only married women within the traditional African setting to access family planning services because of the respect towards preservation of virginity before marriage (Alenoghena et al., 2015).This observation is corroborated by the report of a previous study carried out in Edo State (Alenoghena et al., 2015).There was also a statistically significant relationship between the occupation of the respondents and the uptake of any form of modern contraceptives (p=0.010).The influence of occupation on the uptake of family planning services may be related to the affordability and the resultant effect of occupation on socio-economic status of individuals.Similar findings have been reported in previous studies (Babalola and Fatusi, 2009;Alenoghena et al., 2015).
Two thirds of the respondents who had used any form of contraceptives used condom.It was indeed the most frequently used form of contraceptive among the respondents.The use of condom included the use by either the male or female condom or both.This observation was not surprising because of the availability and affordability of condom.Its usage is further enhanced by its simplicity (Alenoghena et al., 2015).Condom use was closely followed by the pills; which was used by half of the respondents.Furthermore, the higher uptake of these contraceptive commodities may be related to their characteristic non-invasiveness (Alenoghena et al., 2015).This is in line with previous reports (Mustafa et al., 2008;Alenoghena et al., 2015).

Conclusion
Respondent's knowledge towards family planning was good but this did not translate to uptake of contraceptives.Their main sources of information on family planning included mass media and health workers.And over half of the respondents had positive attitude towards family planning.There was a relatively higher uptake of family planning services than the average figure in Edo State and the average national value for Nigeria.Common barriers to uptake included fear of side effects and religious inclination.

RECOMMENDATION
Efforts should be made by state government at to break down common barriers to uptake of family planning services like fear of side effects and religious inclinations.

Figure 1 .
Figure 1.Awareness of family planning and various types used by respondents.

Figure 2 .
Figure 2. Respondents' sources of information on family planning.

Figure 3 .
Figure 3. Attitude of respondents towards family planning.

Figure 4 .
Figure 4. Use of contraceptives by respondents and reasons for non-use.

Table 1 .
Socio-demographic characteristics of the respondents.