Introduction
The global population is expected to reach 8.6 billion by 2030 [
1]. Many developing countries are already dealing with the consequences of a large population. Unchecked population growth, in low-resource settings, presents diverse challenges to all and sundry. As a result, many countries put in place a variety of population policies to lower the high fertility rate. A proven strategy for fertility regulation is the effective use of contraceptives [
2,
3]. Contraceptive use benefits individuals, families, and society at large [
4]. It promotes national and global socioeconomic development, and improves women's reproductive health [
3,
5‐
7]. It reduces the number of unintended pregnancies, and unsafe abortions and lowers maternal mortality [
7‐
10]. Conscious efforts are ongoing to encourage women of reproductive age to use contraception. Research supports a rise in the number of women aged 15–49 using contraceptives globally. For instance, there was a nine-point rise in the global contraceptive prevalence rate (CPR) from 55% in 1990 to 64% in 2015 [
7]. A further increase from 663 to 851 million women aged 15–49 who used contraceptives was recorded between 2000 and 2020 [
3]. Many developing countries with high fertility rates appear to miss out on this global uptick because of the low use of modern birth control measures [
10]. For example, sub-Saharan Africa (SSA) has the lowest modern contraceptive prevalence rate (mCPR) and accounts for 21% of the global total [
7,
11].
Similar to SSA, the CPR is low in Nigeria, and efforts to improve it have largely been unsuccessful. In 2012, the Nigerian government, alongside some foreign donors, set an mCPR target of 27% by 2020 [
9]. To meet this goal, there were initiatives to increase the availability of family planning services at all levels of healthcare. The target was also aimed at increasing media campaigns to persuade women to seek and accept free access to modern contraception [
12‐
14]. Despite these efforts, Nigeria's CPR among married women in 2018 was 17% for any method and 12% for mCPR [
9]. Nigeria's rising population, socioeconomic woes, poor health, and maternal mortality indicators may be attributed in part to the country's inability to improve on its low mCPR. As a result, 48% of sexually active women and 19% of married women aged 15–49 who would otherwise like to avoid pregnancy have an unmet need for modern contraception [
9].
In contrast to the low CPR, previous studies in Nigeria [
15‐
18] found high contraceptive knowledge among childbearing women aged 15–49. The low use of contraception in Nigeria can be attributed to individual, family, and community factors. Culture, religion, myths and misconceptions, the number of living children, employment status, lack of a partner's support, and other factors all undermine effective contraceptive use [
19‐
21]. As a result, the low mCPR in Nigeria and other SSA countries may have little to do with a lack of contraceptive knowledge and awareness. Most studies to date have concentrated on the factors that contribute to low contraception use among women aged 15–49 [
4,
8,
14,
22]. The relationship between having a high level of knowledge about contraception and using it is not well understood. As a result, this paper aims to fill that gap and push the boundaries of knowledge about contraceptive use in Nigeria and the South-South geopolitical zone even further.
Nigeria recognizes six geopolitical zones, a concept that allows states with comparable socioeconomic, cultural, religious, historical, and political values to be grouped. They are the geopolitical zones of the North-East, North-West, North-Central, South-West, South-East, and South-South. The contraceptive prevalence rate is higher in Nigeria's southern regions on average but lower in the northern regions [
9,
23,
24]. For example, it ranges from 2% in the northern states of Yobe and Sokoto to 29% in Lagos State in Nigeria's south [
9]. Conservatism, dominant culture, and religion are all documented reasons for the north's low CPR [
8,
25]. Low levels of education, a lack of women's autonomy and empowerment, patriarchy, family, and community factors are also issues [
4,
26]. Southern Nigerian women, particularly those of Yoruba ethnic origin, are more likely to use contraception [
9,
23].
In Nigeria, there is evidence of inter-regional disparities in contraceptive use [
7,
27]. However, there have been insufficient attempts to illustrate the intra-regional dynamics of contraceptive knowledge and actual use among specific regions. The various factors at work in the South-South region's low contraceptive uptake are not fully understood. Women in the South-South have more freedom, empowerment, and autonomy than many of their counterparts in the North. The zone also has a high level of knowledge about contraception [
23], but the CPR remains inconsistent with these existing realities. Furthermore, despite sharing similar historical, political, social, economic, cultural, and religious contexts, the CPR varies across South-South states. The South-East and South-West zones, which are also located in southern Nigeria, share many socioeconomic similarities with the South-South. The South-South geopolitical zone has the lowest proportion of all women using contraception (20.6%), followed by the South-East (21.0%) and the South-West (26.2%) [
9]. However, it differs significantly from the other northern zones, North-Central (13.3%), North-East (8.4%), and North-West (5.7%) [
9]. Despite the overlapping circumstances among South-South states, some previous studies on knowledge and use of contraceptives in the region [
28‐
30] and the country at large [
31,
32] have failed to examine the relationship between contraceptive knowledge and actual use in South-South Nigeria. As a result, this study looked at the relationship between contraceptive knowledge and actual use among childbearing women in Nigeria's South-South geopolitical region. As a result, policies and programmes may be encouraged to help the South-South region transition from high contraceptive knowledge to actual contraceptive use.
Data analysis
The dataset was weighted with the appropriate sampling weights as per the Demographic and Health Survey (DHS) sampling scheme to adjust for under- and over-reporting. It was also carefully checked for missing values that were excluded using Stata software (version 15.0). The svyset command was used to describe the data sets as products of the survey. The analyses were conducted at three levels, including univariate, bivariate, and multivariate. The baseline descriptive analysis using summarised percentages to describe the study population was used at the univariate level. The Pearson chi-square test was adopted at the bivariate level to examine the association between the outcome variable (use of any contraceptive) and the explanatory variables. At the multivariate level, two different models were fitted to measure the odds ratio (OR) of the association between the use of any contraceptive method and the main explanatory variable (knowledge of contraceptives), as well as the covariates. Model 1 presented the unadjusted logistic regression results, while Model 2 adjusted for all the explanatory variables. In Model 2, all the explanatory variables were fitted because of their significant relationships with the outcome variable. However, marital status was omitted during the analysis because of collinearity. The results of the explanatory variables were expressed as OR with 95% confidence intervals (CI), and the possible association between each of the explanatory variables and the outcome variable was assessed by observing the p-values.
Bivariate association of contraceptive use with all the explanatory variables
Table
3 shows the results of the bivariate analysis of the test of associations between the outcome variable (use of any contraceptive methods) and the explanatory variables. Data show a significant association between all explanatory variables, except marital status (X
2 = 12.8297;
p = 0.002), type of place of residence (X
2 = 5.6025;
p = 0.018), and use of any contraceptive method. The Chi-square statistics show that the use of any contraceptive method was significantly associated with women’s knowledge of contraceptive methods (X
2 = 95.0778;
p = 0.000). Here, knowing about contraceptives was related to the use of any contraceptive methods. A similar result was found for age, as a woman's age and use of a contraceptive method were found to be significantly related (X
2 = 62.5074;
p = 0.000). Likewise, education was significantly related to the use of any contraceptive method (X
2 = 51.9577;
p = 0.000). In this case, higher education was more related to the use of any contraceptive methods than lower education, which is significantly related to the non-use of contraceptives. The link between women's education and contraceptive use extended to their husbands’/partners' education (X
2 = 32.5770;
p = 0.000). In this case, women with more educated husbands/partners were more likely to use any contraceptive method than their counterparts with less educated husbands/partners. Work status (X
2 = 34.4654;
p = 0.000), wealth index (X
2 = 29.2398;
p = 0.000), religion (X
2 = 34.3295;
p = 0.000), and use of any contraceptive methods all had significant associations. Similar findings were found for the number of children ever born (X
2 = 27.7415;
p = 0.000), the number of children alive (X
2 = 30.8104;
p = 0.000), and the use of any contraceptive methods. While working women were more likely to use any form of contraception, those who did not work were more likely to ignore the use of contraception. Similarly, women with a higher wealth index were more likely to use any form of contraception than women with a lower wealth index. Regarding religion, we found that Christians were more likely to use any form of contraception than Muslims. Women who birthed five or more children were also more likely to adopt any contraceptive method than those with fewer children. The same applied to women with a higher number of children alive than those with a lower number of children alive.
Table 3
Unadjusted bivariate analysis of contraceptive use in South-South Nigeria
Knows contraceptive methods |
No | 766 (20.59%) | 52 (6.24%) | 95.0778 (0.000) |
Yes | 2,954 (79.41%) | 781 (93.76%) |
Marital status |
Never in union | 1,433 (38.52%) | 270 (32.41%) | 12.8297 (0.002) |
Married | 1,973 (53.04%) | 498 (59.78%) |
Widowed/divorced | 314 (8.44%) | 65 (7.81%) |
Age |
15–24 | 1,379 (37.07%) | 201 (24.13%) | 62.5074 (0.000) |
25–34 | 1,101 (29.60%) | 344 (41.30%) |
35 and above | 1,240 (33.33%) | 288 (34.57%) |
Highest education |
No education | 215 (5.78%) | 14 (1.68%) | 51.9577 (0.000) |
Primary | 640 (17.20%) | 119 (14.29%) |
Secondary | 2,366 (63.60%) | 526 (63.14%) |
Higher | 499 (13.41%) | 174 (20.89%) |
Husband/partner’s educational level |
No education | 79 (4.00%) | 1 (0.20%) | 32.5770 (0.000) |
Primary | 342 (17.33%) | 55 (11.05%) |
Secondary | 1,156 (58.59%) | 329 (66.06%) |
Higher | 396 (20.07%) | 113 (22.69%) |
Currently working |
No | 1,108 (29.78%) | 164 (19.69%) | 34.4654 (0.000) |
Yes | 2,612 (70.22%) | 669 (80.31%) |
Wealth index combined |
Poor | 588 (15.81%) | 87 (10.44%) | 29.2398 (0.000) |
Middle | 954 (25.65%) | 177 (21.25%) |
Rich | 2,178 (58.55%) | 569 (68.31%) |
Religion |
Catholic | 362 (9.73%) | 94 (11.28%) | 34.3295 (0.000) |
Other Christians | 3,085 (82.93%) | 723 (86.79%) |
Islam and others | 273 (7.34%) | 723 (1.93%) |
Place of residence |
Urban | 1,316 (35.38%) | 331 (39.74%) | 5.6025 (0.018) |
Rural | 2,404 (64.62%) | 502 (60.26%) |
Children ever born |
0 | 1,310 (35.22%) | 216 (25.93%) | 27.7415 (0.000) |
1–4 | 1,705 (45.83%) | 422 (50.66%) |
5 and above | 705 (18.95%) | 195 (23.41%) |
Number of living children |
0 | 1,336 (35.91%) | 218 (26.17%) | 30.8104 (0.000) |
1–4 | 1,786 (48.01%) | 444 (53.30%) |
5 and above | 598 (16.08%) | 171 (20.53%) |
Multivariate analysis of the association between explanatory and contraceptive use
Table
4 shows the results of the multivariate analysis. The unadjusted logistic regression results in Model 1 showed that women who knew about contraceptives were significantly more likely to use contraceptives (OR: 3.90; CI: 2.91–5.21) compared to those who reported no knowledge of the contraceptive methods. Also, the likelihood of using any contraceptive method significantly increased among married women or those living with their partners (OR: 1.34; CI: 1.14–1.58. Older women aged 25–34 years and 35 years and older were respectively 2.14 times and 1.59 times more likely to use any contraceptive method than their counterparts aged 15–24. Concerning education, the results showed that the likelihood of using any contraceptive method was significantly higher among women (OR: 1.57; CI: 1.29–1.92) and their partners (OR: 2.14; CI: 1.59–2.88) with post-primary education compared with those in the reference categories. The likelihood of women using any form of contraception increased significantly as the number of children born increased. Women with 1–4 children and those with five or more children, for instance, were 1.50 and 1.68 times more likely to use any contraceptive method than those without children.
Table 4
Unadjusted and adjusted logistic regression analysis of contraceptive use by knowledge of contraceptive and covariates, NDHS 2018
Knowledge of contraceptives |
No (Ref.) | 1.00 | 1.00 |
Yes | 3.90 (2.91–5.21)*** | 1.40 (0.93–2.11) |
Marital status |
Never in union (Ref.) | 1.00 | - |
Married/living with a partner | 1.34 (1.14–1.58)*** | - |
Widowed/divorced/separated | 1.10 (0.82–1.48) | - |
Age |
15—24 (Ref.) | 1.00 | 1.00 |
25 – 34 | 2.14 (1.77–2.60)*** | 1.05 (0.72–1.53) |
35 and above | 1.59 (1.31–1.94)*** | 0.87 (0.58–1.30) |
Educational attainment |
No education/primary (Ref.) | 1.00 | 1.00 |
Secondary/tertiary | 1.57 (1.29–1.92)*** | 1.34 (1.00–1.78)* |
Partner's educational attainment |
No education/primary (Ref.) | 1.00 | 1.00 |
Secondary/tertiary | 2.14 (1.59–2.88)*** | 1.74 (1.25–2.43)** |
Children ever born |
0 (Ref.) | 1.00 | 1.00 |
1—4 Children | 1.50 (1.25–1.80)*** | 0.47 (0.11–1.99) |
5 children and above | 1.68 (1.35–2.07)*** | 0.42 (0.09–1.91) |
Number of living children |
0 (Ref.) | 1.00 | 1.00 |
1—4 Children | 1.52 (1.28–1.82)*** | 3.24 (0.77–13.70) |
5 children and above | 1.75 (1.40–2.19)*** | 4.10 (0.90–18.65) |
Currently working |
No (Ref.) | 1.00 | 1.00 |
Yes | 1.73 (1.44–2.08)*** | 1.16 (0.85–1.59) |
Wealth index |
Poor (Ref.) | 1.00 | 1.00 |
Middle | 1.25 (0.95–1.65) | 1.55 (1.04–2.32)* |
Rich | 1.77 (1.38–2.25)*** | 1.87 (1.28–2.73)** |
Religion |
Catholic (Ref.) | 1.00 | 1.00 |
Other Christians | 0.90 (0.71–1.15) | 0.92 (0.66–1.27) |
Islam & others | 0.23 (0.13–0.39)*** | 0.54 (0.27–1.06) |
Place of residence |
Urban (Ref.) | 1.00 | 1.00 |
Rural | 0.83 (0.71–0.97)* | 0.94 (0.74–1.19) |
State of origin |
Edo (Ref.) | 1.00 | 1.00 |
Cross River | 1.05 (0.78–1.41) | 1.05 (0.72–1.54) |
Akwa Ibom | 1.05 (0.79–1.39) | 1.04 (0.71–1.52) |
Rivers | 2.59 (2.02–3.32)*** | 1.63 (1.18–2.24)** |
Bayelsa | 0.18 (0.12–0.29)*** | 0.17 (0.10–0.29)*** |
Delta | 0.72 0.53–0.97) | 0.68 (0.47–1.00) |
Similarly, the likelihood of using any contraceptive method significantly increased among women who had 1–4 and 5 or more living children (OR: 1.52; CI: 1.28–1.82 and OR: 1.75; CI: 1.40–2.19, respectively). Women who reportedly have a current job had higher odds of using any contraceptive method (OR: 1.73; CI: 1.44–2.08) than those who were unemployed. An increase in household wealth status positively influenced the use of any contraceptive method among women. Women from middle- and rich household wealth statuses were 1.25 times and 1.77 times more likely to use any contraceptive method compared with their counterparts from poor households. Concerning religion, the results showed that the likelihood of using any contraceptive method significantly reduced among women of Islam and traditional religious backgrounds (OR: 0.23; CI: 0.13–0.39). Also, the likelihood of using any contraceptive method was significantly reduced among women who were found in rural areas (OR: 0.83; CI: 0.71–0.97) compared to urban residents. The results further showed that the likelihood of using any contraceptive methods significantly increased among women who reported to have come from Rivers State (OR: 2.59; CI: 2.02–3.32) but reduced among their counterparts from Bayelsa State (OR: 0.18; CI: 0.12–0.29) compared to those from Edo State.
The adjusted logistic regression results are presented in Table
4, Model 2. Although not significant, the results showed that the likelihood of using any contraceptive method was higher among women who knew about contraceptives (aOR: 1.40; CI: 0.93–2.11), compared with those in the reference category. The likelihood of using any contraceptive method was significantly higher among women and their partners with post-primary education (aOR: 1.38; CI: 1.00–1.78; and aOR: 1.74; CI: 1.25–2.43, respectively) than those in the reference category. The results further showed that an increase in the household wealth index positively influenced the likelihood of using any form of contraception among women. For instance, women from middle- and high-wealth indexes were (1.55 times and 1.87 times, respectively, more likely to use any contraceptive method than those in poor households. The use of any contraceptive method significantly increased among women from Rivers State (aOR: 1.63; CI: 1.18–2.24) and decreased among women from Bayelsa (aOR: 0.17; CI: 0.10–0.29) compared to those in the reference category.
Discussion of findings
Using data from the 2018 NDHS, this study examined contraceptive knowledge and the actual use among childbearing women aged 15–49 in Nigeria's South-South geopolitical zone. The women in the sample were those whose birth histories had been documented in the five years preceding the survey (i.e. 2013–2018). They responded to questions about the 2018 NDHS family planning services awareness and use module. In all, findings showed that most childbearing women in Nigeria's South-South region had high knowledge about contraception. There are several possible explanations for this high level of contraceptive knowledge in the South-South. Government and other non-governmental organisations fund many local radio and television programmes promoting family planning services. They are also advertised in newspapers, magazines, and at prenatal and postnatal clinics in hospitals [
24]. Furthermore, women in Nigeria's south are well-informed and exposed [
37], and thus open to using contraception. Previous research has found that childbearing women in southern Nigeria [
17,
18,
27], North-West Nigeria [
16], and Uganda [
38] have comparable or even higher knowledge of contraceptives.
The level of contraceptive knowledge influences increased contraception demand and adoption [
18,
31]. Our findings showed that, despite widespread contraceptive knowledge among childbearing women, actual contraceptive use was lacking in our study population. Given that women in the South-South have a medium to a high level of education [
18], this finding is somewhat surprising. Women with higher levels of education are more likely than their counterparts with lower levels of education to use contraception [
24,
39,
40]. The fact that few respondents have ever used any form of contraception emphasizes the gap between respondents' knowledge and actual contraception use. It underscores that, in addition to individual-level factors, family- and community-level factors are critical to contraceptive use [
24,
41]. For example, a woman who is aware of the benefits of contraception may not use it due to the influence of an unwilling partner, religious dogma, or other social circumstances. Regardless of the disparity between widespread contraceptive knowledge and low contraceptive use, the bivariate results showed that women with more contraceptive knowledge were more likely to use any contraception methods. Furthermore, the unadjusted multivariate analysis in Model 1, Table
4 suggested that childbearing women with contraceptive knowledge had a higher probability of using any contraceptive method than those with no contraceptive knowledge. In line with our findings, there are additional reports of discrepancies in Nigeria between high contraceptive knowledge and low contraceptive use [
17,
27,
37,
42]. Aside from the low contraceptive use, a study [
43] found a decrease in contraceptive use, which has implications for maternal and child health. The low CPR implies Nigeria has missed the 27% CPR target set for 2020. Hence, it appears Nigeria is trapped in the knowledge stage rather than the practice stage. A cocktail of social, economic, cultural, and religious issues may contribute to the failure. Additional research is needed to determine how these elements interact to stall the transition from high-level contraceptive knowledge to high CPR in South-South Nigeria.
Rivers State was far ahead of the other South-South states, ranking nearly twice as high as Akwa Ibom. Rivers State reported a significantly higher figure than Bayelsa and Delta States. Contraceptive prevalence rate disparities in the South-South could be explained by differences in education, urbanisation, and income levels within these states. Rivers State, for example, is the most populous and urbanised state in the South-South geopolitical zone. Its citizens are also more likely to be educated and have more control over reproductive decisions. This may play a role in Rivers State’s comparatively high contraceptive prevalence rate. Furthermore, multivariate results revealed that women in Rivers State were more likely than women from other states in the zone to use any form of contraception. Previous research has shown that women in southern Nigeria, including Rivers State, use more contraception [
23,
36]. The prevalence of contraceptive use in the South-South reflects that of the national level. Previous studies [
9,
44] confirmed Nigeria's low national and subnational contraceptive prevalence rates.
As previously stated, the male condom was the most popular method of contraception among women in the South-South. Women were also big on implants, injections, and pills, in addition to male condoms. The IUD and the standard-days method, on the other hand, were among the least popular approaches. Given its low cost and ease of use, it is unsurprising that the male condom has become so popular. This differs from other techniques, which may necessitate invasive surgical procedures or a certain level of proficiency. The finding on the male condom being the most widely available type of contraception is supported by previous research that found similar results [
16,
45,
46].
Further, bivariate and multivariate analyses revealed significant influences on contraceptive use. The bivariate results suggest that knowing about contraception, age, education (both women and their husbands/partners), employment, wealth index, and religion were all associated with the use of any contraceptive methods. Marital status and rural/urban residence were unimportant factors influencing contraceptive use. However, the adjusted logistic regression results (Model 2, Table
4) indicated a significant influence on marital status and rural/urban residence. In essence, multivariate results revealed that women who had contraceptive knowledge, were married/and living with partners, were older, had post-primary education, or whose partners had post-primary education were more likely to use any contraceptive methods. Other factors that influenced contraceptive use include having more living children, being currently employed, having a higher wealth index, being non-Muslim, and living in cities. Age has a significant impact on contraceptive use. In essence, older women are more likely to use modern contraception than younger women. This pattern is possible because older women may have reached their desired family size and may turn to contraception to avoid further pregnancies [
21,
47,
48]. Overall, increased education empowers women to work, earn an income, take control of their lives, and make informed decisions about whether and how to use contraception. Previous research from Nigeria [
37,
46] and Senegal [
49] supports our findings. However, one Indonesian study [
50] contradicted our finding on the role of a higher level of education in the use of contraception.
According to previous research, women from the wealthiest households were more likely to use contraception than those from the poorest households [
38,
51,
52]. The affordability of contraception and the decision-making autonomy of wealthier women easily explain why they use contraception more than their poorer counterparts [
53]. Working women, on the other hand, are more likely to use contraception than the unemployed. A plausible explanation is that women who prioritise career growth and professional development may prefer to avoid any pregnancy-related interferences with their career development. Previous research has also confirmed the impact of religion on contraceptive use. In line with previous findings [
23,
35,
53], Christians were more likely to use contraception than Muslims. While modern Christianity frowns at multiple partners, Islam and traditional religions accommodate such. In this case, Christians are likely to use contraception to limit their number of children, especially since there is no competition for children among co-wives. By contrast, there may be a desire for many children among Muslim co-wives, as Islam views multiple births as a blessing from God.
Conclusions
The study examined contraceptive knowledge and use among childbearing women in South-South Nigeria. The most common types of contraceptives, women's knowledge of various contraceptives, and the relationship between the key explanatory factors and contraceptive use were all considered. The government and other non-governmental organisations run programmes that promote family planning services through the use of contraception. Doubtless, the result is that childbearing women throughout Nigeria, including the South-South geopolitical zone, are well aware of contraception. This study shows that, despite widespread knowledge generated by the ongoing effort to use contraception, actual practice has yet to follow. Except for Rivers State, states in the South-South had low contraceptive use during the survey years. Furthermore, the study found that contraceptive use is associated with education level, age, wealth quintile, being married and living with a partner, number of children alive, and number of children ever born, among other factors. As a result, if the South-South's low CPR is to improve, the issues that impede translating high contraceptive knowledge into actual use must be addressed head-on. This could reduce Nigeria's high fertility rate and improve the country's public health and socioeconomic challenges. It may also aid in meeting the SDG target of improving maternal and child health. Hence, more strategies and initiatives should be developed to encourage childbearing women in Nigeria's South-South to use contraception. These strategies should be developed in light of the factors at the family, community, and societal levels that discourage childbearing women from moving from high contraceptive knowledge to actual use.
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