SOCIO-ECONOMIC AND CULTURAL DETERMINANTS OF USE OF FAMILY PLANNING SERVICES IN NKANU AREA OF ENUGU STATE.
CHAPTER ONE
INTRODUCTION
1.1       Background to the study
Family Planning is the purposeful regulation of conception or childbirth or the use of devices, chemicals, abortion or other techniques to prevent or terminate pregnancy or voluntary avoidance or delay of pregnancy (Wikipedia, 2010; Caufield, 1998). Family planning techniques commonly used include sexual education, prevention and management of sexually transmitted infections, pre-conception counseling and management and infertility management (Wikipedia, 2010). These services are defined as “educational, comprehensive medical or social activities which enable couples, individuals including sexually active adolescents and minors, to determine freely the number and spacing of their children, avoid getting pregnant and/or even avoid sexually transmitted diseases, to select the means by which this may be achieved” (Wikipedia, 2010; Plata, 1996). Family planning is sometimes used as a synonym for birth control or child spacing, though it often includes more.
The use of family planning implies that the users make concerted efforts to deal with procreation within the context of a sexual relationship. This covers things as varied as when to get pregnant, the number of children that are wanted, how to deal with fertility issues, how to avoid getting pregnant, whether to consider an abortion if an unwanted pregnancy occurs, or adoption etc. to say nothing of working out parental strategies with one’s partner. Family Planning was listed as one of the twelve pillars of Reproductive Health. Among the objectives of Family Planning is to help women to protect themselves from unwanted pregnancies (FMHN, 2005). In Nigeria, before the introduction of modern family planning by Babangida administration in 1989 there were traditional methods of birth control (Odimegwu, 1999). These traditional methods which still exist and are convenient for users (Encyclopedia Americana, 2001) are natural while the modern types which are new in Nigeria are both natural and artificial. In Nigeria like in most developing countries, the story of family planning services is not successful because of a number of factors, such as culture of the people and low status of women (Coleman, 2004). Other factors include lack of education and understanding about health related issues, the ability of women to command resources and make independent decisions about their fertility, birth control knowledge, (Nwakeze, 2003). Location, religion and social class, lack of cooperation from spouse, cost, perceived difficulty with the method and lack of knowledge about contraceptive methods etc. (World Bank, 2004; IPPF, 1993). Moreover in Nigeria, the provision of health services is more in the urban areas than in the rural areas (Dobie, et al 1998). Where family planning services are located in rural areas, access is low due to lack of proximity, bad road network and the nearest urban center, where such clinic is available, it may not provide adequate care because of lack of proper trained staff and equipment (Wikipedia, 2009; Quedraogo, 2005; NISER, 2001). Other factors include lack of proper family planning function dissemination; inadequate motivation to seek actively, access and regularly use contraceptives (Odimegwu, 1999).
Lack of use of family planning services is enormous as it affects the individual, the family, the community and nation at large. Empirical findings have shown that it leads to increase in maternal illness, such as multiple pregnancies, hemorrhage, etc. (Ikpeze, 2010; Wikipedia, 2009; Wikipedia, 2008). It sometimes leads to social problems in the family and community such as violence, desertion, accusation of infidelity, fear of violence on the part of the woman, mistrust. On the part of the man, it could lead to having multiple sexual partners with its attendant contraction of STIs and HIV/AIDS, affecting sexual and reproductive lives of women (Ezumah, 2003; Pop Report, 1999) and sometimes it leads to maternal death. These have socio- economic consequences on the immediate family as the resources meant for the up- keep of the family are diverted to the health care of the parent(s) as the case may be, time wasted and the future and the life of the children truncated. Family planning services have the function of preventing most maternal illnesses and deaths (Wikipedia, 2008), yet it has been recorded that the rate of maternal morbidity and mortality is high in developing countries compared to developed countries (Ikpeze, 2010; FMHN, 2005). UNICEF (2008) estimate shows that maternal mortality in Nigeria is high about 800/100,000 live births yet attitude of members of the developing countries to family planning services is low and this attitude is attributed to socio-cultural and economic reasons (Engender Health, 2009; Galadanci, 2009; Agujiobi, 2003; Ezumah, 2004; Onyeneho and Okeibunor, 2003; Nwakeze, 2003).With the adverse consequences of non-consent and non-use, and the inappropriate understanding of the importance of family planning services on the reproductive health of women, concerted efforts must be  made economically, socially, politically and otherwise towards  ensuring that the negative consequences of lack of use of family planning services are controlled to the barest minimum. This study therefore will examine the socio-economic and cultural barriers to access and use of family planning services by women of reproductive age in Nkanu area of Enugu State and suggest measures that could enhance effective use of family planning services for both genders in the research area.
1. 2   Statement of the Problem
 Although the population of Nigeria is very high due to high marital fertility of about 5.6 children per woman and provision of family planning services limited, worst still is that utilization is low as a result of cultural and social pressures. For example, Child-bearing and rearing defines a woman’s value and status in her community, alongside the number and sex of children (NISER, 2001; Onyeneho and Okeibunor, 2003; Agujiobi, 2003; Nnorom, 2003; Ezumah, 2003); therefore deliberate attempt not to access these services by those women may be made (Engender Health, 2009; Galadanci, 2009), this is because of the importance attached to procreation which is emphasized in the extent a barren woman goes to get a wife for her husband to bear children on her behalf, or a wife goes outside her matrimonial home (with or without the consent of her husband in the case of infertility on the man’s side) to get children in order to maintain the family’s existence and value in the community (Ezumah, 2003).. Even though development has increased attitude to use of family planning services especially among the urban middle class in African societies, Bowman and Kuenyehia (2003) empirical findings, show that in urban areas where there are Family planning services information and enlightenment, the rate of access and usage is low as some women shun the use of western methods because it conflicts with indigenous beliefs and practices.Family Planning Services are aimed at benefiting the health and wellbeing of women and families throughout the world, by the provision of contraceptives which help them avoid unwanted pregnancies and space births; provide protection against sexually transmitted infections including HIV/AIDS; and provide other health benefits, in spite of its’ benefits most Nigerian women do not access to it especially those in the rural areas (Wikipedia, 2008), because in relation to contraception, it is a male prerogative (Okeibunor, 2000; Pop. Report, 1999).
 Male control is a major constraint to women’s access and use of family planning services. Also the nature of women’s work in production and reproduction such as household work, (drudge) and child bearing pose great restrictions to accessing and using Family Planning Services, (Barua & Kurz, 2001). Poor financing of health care services (Ikpeze, 2010), lack of focus on curative measures and political will (Quedraogo, 2005) by government serve as barrier to access and use of family planning services in Nigeria (Ikpeze, 2010), disparity in health care services delivery between the remote and non-remote areas (Huang, Yip, Chang and Chou 2006), as in Nigeria, where access and use is limited in rural areas unlike in urban areas (Engender Health 2009). Agujiobi (2003), attributed it to ignorance on the part of the ruralites, and the cause of the ignorance she attributed to lack of presence of Non-Governmental Organisations (NGOS) in the rural areas of Nigeria to educate and enlighten them on the presence and importance of Family Planning Services.  Sometimes the available clinics may not provide decent care because of lack of proper staff and equipment (Engender Health 2009; Wikipedia, 2009). The effects of not planning the family cause a large number of women to continue to experience unplanned pregnancies leading to morbidity, mortality and social distress (Caufeild, 1998). Health of women in developing countries, Nigeria inclusive, is precarious because of high fertility rate; it’s been found that women who have been pregnant six times have twice the risk of experiencing maternal death more than women who have been pregnant only three times (Okeibunor, 2003; Odimegwu, 1999). In sub-Saharan Africa, the life time risk of maternal deaths is 1 in 16 and for developed nations only 1 in 2800 (Wikipedia, 2008). Maternal mortality and morbidity are often much higher in rural areas than in urban areas with up to 1000 per 100,000 reported in rural areas of several countries in Africa. Quedraogo, (2005), noted that 13% of maternal deaths in Africa are due to unplanned pregnancy and risky abortions. These reproductive health problems women experience particularly those that are pregnancy related are preventable; yet they constitute major problems, because women of reproductive ages do not use Family Planning Services (UNICEF, 2008; Bowman & Kuenyehia, 2003:233).
 In Nkanu area, people’s main source of livelihood is subsistence farming which makes their condition even worse. Social amenities such as quality health care facilities, government presence, etc, are lacking causing increase in high maternal and infant morbidity and mortality. Also prevailing attitude and cultural practices affect women’s knowledge of their reproductive health needs and their willingness/ability to seek appropriate care (Alumanah, 2003). Nkanu area is culture bound and therefore could be described as traditional society even when some of its communities are close to the city. Little or no academic research on family planning has taken place in this study area, even though pregnancy related problems exist here as in other rural communities in Nigeria. If use of family planning services is not encouraged in this study area, it will become not only a great health problem but also continuous social and economic problems to the community and nation at large. Therefore this study will seek to investigate the socio-cultural and economic barriers to access and use of family planning services among the people of the study area.
1. 3      Research Questions
            This study will seek to provide answers to these questions:
1)         What is the level of people’s awareness of and use of family planning services in the study area?
2)         What types of family planning services are available in the study area?
3)         What are specific constraints militating against people’s use of family planning services?
4)         What problem(s) arise(s) as a result of people not accessing any of these services?
5)         Who decides when and how to access or not to access family planning services?
6)         What are peoples’ preferred methods of family planning?
7)         What efforts are in place to encourage peoples’ use of family planning services in Nkanu Area?
8)         What suggestions can be made on how to improve peoples’ access to and use of family planning services in Nkanu area.
1. 4      Objectives of the Study
The main objective of the study is to investigate socio-cultural and economic factors that determine married women’s access to and use of family planning services in Nkanu Area of Enugu State.
The specific objectives of the study are to;
1)      Ascertain married women’s awareness and knowledge of provision and importance of family planning services;
2)      Ascertain  the type of family planning services  available in the study area;
3)      Identify specific constraints that people experience in access to and use of family planning services;
4)      Identify problems that arise as a result of people not accessing family planning services;
5)      Determine who decides when and how to access or not to access family planning services and consequences of such decisions;
6)      Determine the most desired and accessed family planning methods and reason(s) for their acceptance;
7)      Ascertain the efforts in place (especially stake holders) to encourage target groups’ use of family planning services in Nkanu Area;
8)      Make suggestions on how best to enhance (currently in-union) access to and use of family planning services in Nkanu.
1. 5      Significance of the Study
      This study will be theoretically important. Wikipedia, (2008), noted that the essence of family planning services is to benefit the health and wellbeing of women and families throughout the world. Pooda (2005), noting WHO’s estimate stated that one woman dies every minute due to complications of pregnancy and/or childbirth, about 4 million women suffer disabilities, some of which are serious and lifelong. Family planning therefore is expected to serve the purpose of helping couples to plan to have the number of children they desire and also be able to raise their children with full assurance of available resources, maintain good health and save (Wikipedia, 2010), and unmarried women including adolescents and minors to manage their active sexual lives properly without  regret. It is hoped this study will provide additional insight to the existing literature on family planning services, attitudes and perceptions in Nigeria with particular reference to Nkanu area. It is hoped to form a basis for triggering-off follow-up or new studies on the topic.
The practical significance includes the fact that the findings will be of immense benefit for stakeholders in making policies that will empower women in accessing family planning services, and encourage male and female support of use of family planning services and their health in general.
It is expected that this study will: (a) help raise consciousness of not just the target group but all who have attained adolescence and are sexually active especially in the rural and semi-rural areas of the need for access and use of family planning services, (b) help stake holders co-join in making millennium development goal of attaining good health for all by the year 2020 a reality in Nigeria.
1.6       Definition and Operationalization of Concepts
Socio-economic factors: these refer to the level of education, income, occupation of the people under study and how they affect their knowledge, access, and use of family planning services.
Cultural factors: refer to the institutions, language, symbols, practices, values, beliefs, norms, folklores, etc of the people and how these affect knowledge and access to family planning services.  
Postpartum: refers to the period from delivery of a baby to the period when the woman’s body is said to return to normal. This may last up to three to four years; that is when the child is weaned depending on the sex and society.
The woman after postpartum period is compensated by her husband through showering her with gifts of cloths, jewelleries and merry making before normal sexual relation is resumed.
Education: is a social institution, which enables and promotes the acquisition of skills, knowledge and the broadening of personal horizon (Giddens, 2010). It also refers to formal training and instruction that create awareness, knowledge and give empowerment to the educated. For this work levels of formal education will be taken thus: low educational attainment = no formal education, middle educational attainment = elementary one (1) to six (6) and high formal attainment = from class one and above.
Empowerment: Batliwala, (1994) defined empowerment as control over material assets, intellectual resources and ideology. Empowerment is also seen as a process involving not just women, but men, society and the state, and requires a change of attitudes and behaviour of both men and women. It is a process of creating conditions under which women can meet their daily needs and become actively involved in defining and promoting their own social, political and economic projects (IPPFAR 1996). It is the ability to act on knowledge acquired through family planning programmes without restriction, and is encouraged through improvement in literacy level, finance and political policies and programmes, which should insist on family planning services as a basic right.  
Maternal Mortality Ratio: is the rate of the number of maternal deaths per 100,000. Maternal mortality ratio in sub-Saharan Africa rose by 15% from an average of 870/100,000 live births in 1990 to 1000/100,000 live births in 2000 (Pooda, 2005). In Nigeria the ratio is 800 maternal deaths to 100,000 live births.   
Maternal mortality: Also known as maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and size of the pregnancy, from any cause related to or aggravated by the pregnancy or its management including incidental causes but not accidental causes (WHO, 2005).                                             
Incidental causes of maternal mortality: include deaths due to violence against women that may be related to the pregnancy and be affected by the socio-economic and cultural environment, such as wife beating, rape, STDs, other harmful traditional practices such as food allocation, widowhood practices, adult circumcision, etc which are legitimized and perpetuated by beliefs, norms and other social institutions.
Polygyny: is the marriage of one man to more than one wife at the same time. This occurs sometimes through outright marriage of more than one wife, widow inheritance, or levirate marriage . Though no more strictly institutionalized in the study area, its effects still linger such as the issue of concubineship which is not really frowned at.
Contraceptives: devices used to prevent fertilization of an egg such as barriers (e.g condom, etc.) hormonal (such as removable implants, etc.), intrauterine devices, chemical barriers (such as spermicides) vaccines, etc.
Population policy: this refers to a programme or a set of programmes of action that seeks to contribute to national development and welfare goals through measures that are directly or indirectly aimed to influence fertility control and well being of women.
Reproductive Health: it is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes (IPPF, 1996). The reproductive health status of the study area will help explain the health status of Enugu state especially its rural areas and inform current decision making and planning strategies for the health sector.
Reproductive Health Care: a group of methods, techniques, and services that contribute to solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations and not merely counseling and care related to reproductive and sexually transmitted diseases (IPPF, 1996).
Sexuality Communication: refers to the discussions on sex issues such as on menstruation, free period, child spacing, initiating sex, number of children to have, use of contraception such as condom, sterilization, etc infections, etc by couples. Sexuality communication is high when partners discuss freely on sex, sexual activities, etc, it is middle when one of the partners can freely initiate the discussion and the other will not feel offended but finds it difficult to contribute to the discussion, while it is low when it is not allowed at all.
Suppository: also known as spermicidal vaginal tablets, is a small dissolvable medicated solid: a medicated mass that melts at body temperature, designed to be inserted into the rectum, vagina or urethra 10 to 15 minutes before intercourse in order to melt and disperse the spermicide (Birth Control, Microsoft 2009).
Life time risk: it is the rate at which a female dies as a result of unintended pregnancy, unsafe abortion, complications from childbirth. The lifetime risk of a woman in a developing country dying in pregnancy related illness is 1 in 25 to 1 in 40 compared to 1 in 1000 or several thousand risks for women in developed world (Symke, 1991).
A Nigerian woman’s lifetime risk of dying from pregnancy or childbirth is 1 in 13 (FMHN, 2005).