Summary

Service utilization in the two government-owned family planning clinics in Enugu has been low. It is not known whether this represents a true decline in family planning practice or clients preference for private family planning service providers. A cross-sectional survey of all the 266 registered private hospitals, clinics and maternity centres in Enugu was conducted to determine the availability of privately-owned family planning services as well as the trends of family planning service utilization in such health facilities. 31 out of the 266 private health facilities (i.e. 11.7%) were offering family planning services. 27 (87.1%) facilities reported increasing trends in service utilization while 4 (12.9%) facilities reported no change in trends. No facility reported a falling trend. The major factors reported to be responsible for the rising trends were; increased mass media enlightenment (67.7%), economic realities of large families (58%), and better accessibility to family planning services (54.8%).The rising trend in service utilization in most of the private family planning clinics in Enugu suggests that clients prefer private family planning services which might explains the declining patronage of public FP clinics.

Introduction

Family planning is one reproductive health intervention that promotes the health of the entire family; not just that of the woman alone. Appropriate birth spacing is known to be associated with improvement in child survival whereas too short and too long birth intervals have the opposite effect on child survival^1-8. Abortion and its associated complications of maternal mortality and morbidity ⁹ are consequences of failed or non-practice of contraception. So also are a large proportion of multigravid pregnancies ⁹, especially in the developing countries where women with no access to effective contraction keep having children until they become menopausal. Adolescent sex-related problems including unwanted pregnancies, unsafe abortion and sexually transmitted infections (including HIV) could be significantly reduced or prevented altogether with appropriate contraceptive measures^{10, 11, 12, 13}. The practice of effective contraception enables couples to have healthy sexual relationship without the fear of unwanted pregnancies. Fear of unplanned pregnancies in the absence of effective contraception is known to lead to sexual starvation, frustration, marital friction, extramarital sexual relationships as well as other psycho-social problems including divorce^{14, 15}. Despite these facts as well as the high awareness of family planning among Nigerians¹⁷, the reported contraceptive prevalence rate in Nigeria remains very low¹⁸. Religious, cultural and institutional barriers have been blamed for the low contraceptive prevalence^{19, 20, 21, 22}. Many couples are however, reported to practice contraception in spite of contrary official positions of their religions²³ and some women practice contraception without the knowledge and consent of their husbands or male partners. Such people prefer the confidentiality that is best offered by private family planning service providers. Private family planning service providers may also be preferred for reasons other than the barrier issues. These include customized services, flexible appointments and general client-friendly attitude that are often lacking in public family planning clinics¹. Therefore, it is reasonable to expect that the official contraceptive prevalence rate, based only on data from the government-owned family planning clinics, may represent under-estimation. Indeed, the recent experience with the telecommunication services in Nigeria has revealed that the existence of competitive private sector service providers could lead to a decline in public sector patronage despite sharp increases in total service utilization.

In Enugu Nigeria, there has been low and fluctuating family planning service utilization in government-owned family planning clinics over the past five years. The status (availability and trends) of private sector family planning services in Enugu has not been studied. It is therefore difficult to determine whether the observed trends in family planning service utilization in public family planning clinics represent the true trends in family planning utilization in Enugu or whether it is a result of clients’ preference of private service providers. Knowledge of the available family planning service providers and the trends in service utilization in such facilities are useful for determining the true trends of family planning service utilization in Enugu. This information is necessary for the planning of effective interventions to improve family planning service utilization. The objectives of this study were to identify private family planning service providers in Enugu, to determine the trends in family planning service utilization and the determinants of such trends in the private family planning facilities.

Materials and Method

Research setting and population

Sampling and research method.

Ethical clearance

Results

Of the 266 privately owned health facilities surveyed, 31(11.65%) were offering family planning services. 17(54.8%) of the facilities offering family planning services were operated by nurses and midwives while 14(45.2%) were operated by doctors. The facilities had offered family planning services for a mean 8.2 ±1.21 years with a range of 5 to 36 years. There was an overall rising trend in family planning service utilization over the preceding 5 years with 27 (87.1%) facilities reporting a rise and 4 (12.%) reporting no change. No facility reported a falling trend. The trends in individual family planning methods are shown in table 1, which reveals that majority of the facilities reported increases in the utilization of condom, Intra-uterine contraceptive device (IUCD) and implants and a fall in bilateral tubal ligation (BTL) and the natural methods. The reasons offered for the observed rising trends were increase in mass media enlightenment (67.7%), economic implications of large families (58.1%), improved accessibility to family planning services (54.8%) and increase in NGO support (48.4%). Other reasons are as shown in table 2. On discontinuation of contraceptive methods, 21(67.8%) reported a falling trend while 10(32.3%) reported no change. No facility reported a rising trend in discontinuation of family planning. The reasons for discontinuation of contraception are shown in table 3 which shows that majority discontinued in order to conceive (reported by 25 out of 31 facilities), because of male partner disapproval (reported by 23 out of 31facilities), and because of religious disapproval (reported by 20 out of 31 facilities). Methods most often discontinued were natural methods (53%), pills (30%), IUCD (10%) and injectable methods (6%) while methods commonly switched over to were the following: IUCD (58%), implants (17%), injectable (13%) and condom (10%).

Figure 1

Table 1: Trends in utilization of individual family planning methods in Enugu, Nigeria (n=31)

Figure 2

Table 2: Reasons for the rising trend in family planning service utilization in Enugu (Number of facilities=31)

Figure 3

Table 3: Reasons for discontinuing family planning practice among the private family planning service users in Enugu (N=31)

NB: The figures represent the number of facilities that gave each reason (out of a total of 31 facilities interviewed) and % represent the percentage of facilities that gave the reasons (out of 31 facilities interviewed).

Discussions

This study revealed strong presence of private sector family planning services in Enugu. Only 2 government-owned facilities offer regular family planning services in Enugu capital city as against the 31 identified in the private sector. The observed rising trends in the private sector family planning service utilization also contrasts with the low and fluctuating trends in the public family planning clinics and suggests that clients have a preference for the private service providers. Any contraceptive prevalence rate calculated from public-sector derived data is obviously an underestimation of the true contraceptive prevalence in Enugu.

The observed rise in condom utilization is probably influenced by the mass media promotion of condom as part of HIV prevention strategies. The implants (Norplant and Implanon) are known to be heavily subsidized and promoted by a major international non-governmental organization (NGO) at the time of the survey. These are consistent with the observed influences of the mass media and NGO support in the rising trends of family planning utilization. Why these factors have not also influenced the public sector family planning service utilization needs to be identified. It could be due to institutional, religious or male-partner barriers^19-23. Apart from the desire to conceive, partner and religious disapproval were the most important identified reasons for discontinuing family planning in this study. This clearly suggests that these disapprovals constitute important barriers and may be the major reasons why women avoid the public family planning clinics. In a socio-cultural milieu where contraception is disapproved by the religious organizations and male partners, many women would not like to be seen at a designated public family planning clinic for fear of stigmatization or sanctions from their religious organizations or partners. Partner counseling on the benefits of family planning as well as targeted advocacy to religious leaders are reported to be effective in overcoming these barriers to family planning²⁴. The health workers at the public family planning clinics may benefit from training and re-training on provision of services that may be viewed as stigmatizing by an influential and domineering segment of the populace (represented by religious leadership and male partners). Relocation of the public family planning clinics in Enugu from their present exposed locations (they are both sited at readily visible sites in front of their respective facilities and identified with prominent labels) to less visible locations might encourage some women to patronize them. Although all the private family planning service providers charge fees for their services, it is noteworthy that cost was not found to influence service utilization or discontinuation of methods.

Only 11.65% of the private health facilities offer family planning services. Since clients prefer the private service providers, an effective way to increase FP service utilization would be to encourage more private facilities to offer FP services. Capacity building and other forms of support could be provided to the prospective private service providers in the context of a Public-Private-Partnership (PPP) arrangement for cost effectiveness.

Conclusions

It is concluded that there are many functional private family planning services in Enugu with rising trends in service utilization, suggesting that women prefer to receive family planning services from the private providers. Male partners and religious disapproval are the major barriers to family planning service utilization in Enugu. Partner counseling and targeted advocacy to religious leaders are recommended to overcome these barriers. A public-private-partnership arrangement is also recommended to increase cost-effective access to Family Planning services in Enugu.

Limitations of the study: Absence of records on the actual number of clients offered services as well as the actual family planning services offered made it impossible to quantify these services. This is a major limitation of the study.