Family planning service availability and readiness assessment of primary health care facilities in Delta State, Nigeria: a mixed methods survey

Family planning refers to the use of modern contraception and other methods of birth control to regulate the number, timing and spacing of human births [1]. The implication of this is that parents, particularly mothers, can plan their lives without being overly subject to sexual and social imperatives [1, 2]. It reduces maternal and child mortalities, reduces the number of unsafe abortions, prevents sexually transmitted infections, enhances women empowerment, and helps in population control [3‐5]. However, despite these impressive gains from family planning, most low- and middle-income countries have consistently recorded high fertility rates and low contraceptive prevalence rates (CPR) [6, 7]. Amongst the numerous reasons for these poor indices, is the non-availability of contraceptives in health facilities which limits women’s access to family planning services [8].

Globally, the number of women desiring to use family planning has increased markedly over the past two decades, from 900 million in the year 2000 to nearly 1.1 billion in 2020 [9]. These women would need to have access to contraceptives. Similarly, in developing regions, an estimated 218 million women who want to avoid pregnancy are not using contraceptives for many reasons including contraceptive unavailability [10]. Family planning service availability and readiness is essential to achieving the sustainable development goal (SDG) of universal access to sexual and reproductive health including family planning by 2030 [11]. Therefore, it is important that health facilities have a reliable supply of a broad mix of family planning commodities made accessible to consumers, thereby making it easier for women of reproductive age to choose a method they like and switch methods when they want [12‐15]. Thus, when there are problems with the supply chain, resulting in stockouts or temporary unavailability of contraceptives at a health facility, this may result in women losing faith in the health service and discontinuing use of contraception [12]. Other factors affecting contraceptive availability include poor knowledge of contraceptives among providers, lack of trained staff, lack of equipment and low demand from clients [16, 17]. To ensure universal coverage of family planning services, health facilities should be ready to always provide these services. The current study was conducted with the aim of assessing the family planning service availability and readiness in primary health care facilities in Delta State, Nigeria. Findings from the study will provide evidence to inform policy decision making by the relevant authorities concerned with the provision of family planning services in the study setting and other similar settings in Nigeria.

The analysis of this study revealed that despite renewed efforts to scale up family planning services in Nigeria, the availability of some contraceptives especially the Long-Acting Reversible Contraceptives (IUCD and Implants) was still low in most health facilities. These contraceptives require higher levels of skill and training to be able to administer them. The implication of this is that lower cadre health providers, or those who lack sufficient training and skills needed to administer these commodities, would make no effort to have them in stock. In this study, reproductive health supervisors attributed the low availability of contraceptives to lack of supply from the central stores in the State leading to stock-outs of commodities and thus affecting the contraceptives methods mix in the health facilities. This observation corroborates with findings from a previous study conducted in Nepal [22].

The three most common contraceptives observed in this study were the injectables, condoms and OCP in decreasing order and has been reported by previous similar studies conducted in Ghana and Nigeria [23, 24]. Discussions with the facility managers reveal that contraceptive availability depends on demand by clients hence, contraceptives with a higher demand would be the most available. Thus, from this study, injectable contraceptives had a higher demand than other contraceptives. This is mostly because of its ease of administration.

This study also observed that only one health facility had emergency contraceptives. This is a bit worrisome considering the fact that the need for emergency contraception exists throughout societies where prevalence of unintended pregnancies remains high, especially with widespread incidents of gender-based violence, rape, conflict, humanitarian disasters, refugee and displacement situations, as well as other emergencies as is the case in Nigeria today [21]. For women caught in these situations, emergency contraception represents perhaps the only chance to prevent a pregnancy that is not wanted [25]. Therefore, availability of emergency contraceptives is an indication of health facility readiness to offer family planning services.

The global programme on reproductive health commodity security under the UNFPA recommended availability of at least 5 modern contraceptives in a health facility to allow for a broad method mix and increase the chances of a woman getting her preferred method [22]. The modern methods under consideration were the condoms, OCP, injectables, IUCDs, implants and sterilization. In this study, it was found that a little above one-third of the surveyed health facilities did not offer up to five modern contraceptive methods. A similar study conducted in some PHCs in Nigeria revealed that a quarter of facilities did not have up to three contraceptives available [26]. The proportion of health facilities not offering up to five modern contraceptive methods observed in this study was lower compared to the report from a previous study conducted in Nepal where sixty-five percent of the PHCs did not offer at least five modern contraceptive methods [22].

None of the health facilities surveyed in this study offered sterilization as a contraceptive option. This is because sterilization requires a higher level of skill and a more developed infrastructure for its provision which is not available in primary health facilities. Apart from this, evidence has revealed that women hardly request for sterilization because they generally perceive sterilization as a method that one would select only out of necessity such as in situations where another pregnancy could threaten their lives or when other methods had failed. Many believe that if a couple has no medical issues, they should not consider sterilization until they have had many children, the woman is nearing menopause, or the man is very old [27]. To meet the varying needs and demands for contraception, sterilization for both males and females should be promoted for couples who have achieved their desired family size. Clearly, this will involve making these methods more accessible and ensuring that qualified personnel are available to provide them [28].

In this study, stock-outs of contraceptives varied by method type with Long-Acting Reversible Contraceptives (IUCD and Implants) being more stocked out. Similar findings from previous studies conducted in Nigeria [26] and Nepal [29] revealed that about half of PHC facilities recorded ‘stock-out’ of contraceptives. The observation from this study is most worrisome because many women now prefer to use these Long-Acting Reversible Contraceptives (IUCD and Implants) due to its effectiveness and longer protection. These could have implications for clients’ satisfaction and continuation of family planning use. Thus, methods offered at health facilities must be consistently available to ensure that there are no gaps in supply of desired contraceptives and to achieve a CPR of 68 percent by the year 2030 [30]. One factor identified in this study as causing stock-outs is poor documentation. Less than half of the surveyed health facilities had complete records of contraceptive supplies making it difficult to know when there are actual stock-outs of commodities. Accurate reporting helps family planning providers and logistic system managers to keep track of commodities used and helps to determine when to make requisitions [12]. It also serves as a monitoring and evaluation tool for the programme [31]. Forgetfulness on the part of health providers, lack of time, work overload and non-availability of documentation materials can result in poor documentation [32]. Discussions with the facility managers revealed that regular training for health providers has been deficient. This therefore calls for urgent steps by relevant stakeholders to train health providers regularly.

To ensure health facilities’ readiness for family planning services, it is important to consider contraceptive validity (expiration). Contraceptives should not only be available but should be valid such that a client can walk into a health facility requesting for her method of choice and get it delivered to her. This study showed that about a fifth of the surveyed health facilities had invalid (expired) contraceptives. This means that a substantial number of contraceptives would be unavailable for use by clients. This observation contrast with findings from a previous study conducted in Ghana and Armenia which reported that all the contraceptives studied were available and valid in all the public health facilities surveyed [33, 34]. This therefore calls for urgent action on the part of relevant stakeholders to ensure that contraceptives are not only available but valid.

Regarding the availability of family planning guidelines and other materials, a substantial number of the facilities recorded few or non-availability of these essential materials. This observation was similar to what was obtained in Edo State, Southern Nigeria, where contraceptive commodities and materials were available in three-quarters of the Primary health centres assessed [35] but differed from that of a study conducted in Lesotho where flip charts or posters were available in 84 percent of facilities, while brochures, pamphlets and other IEC materials were available in 65 percent of the facilities [36]. IEC materials are visual aids which if conspicuously displayed within the health facility contributes to the effectiveness of communicating family planning messages to clients. It also helps providers improve on their knowledge and quality of services rendered thus contributing to the overall uptake of family planning services [37].

A limitation of this study was the small sample size which may affect generalizability of findings from this study. Subsequent studies on this will endeavor to improve on this.

In conclusion, this study showed that the most available contraceptives were the injectables, condom and OCP in decreasing order with majority of the health facilities having up to 5 commodities. This study also revealed that stock-outs of IUCD and implants were observed in a quarter and less than a third of the facilities respectively. Over half of the facilities had no complete records of contraceptive activities while IEC materials and checklists were available in a quarter of the facilities. We recommend increased commitment by the relevant stake holders saddled with the responsibility of providing family planning commodities in all health care facilities. There should be training of family planning for doctors, nurses, community health extension workers. This will ensure that all health workers graduate with adequate skill in counselling and provision of common methods of contraception. In-service training for implants and IUCD insertion should be encouraged for every staff working in a PHC facility. There should be adequate budgetary allocation for family planning as well as timely release of funds to ensure procurement of commodities and improve logistics services.