FACTORS INFLUENCING UTILIZATION OF FAMILY PLANNING AMONG WOMEN ATTENDING INFANT WELFARE CLINIC AT THE UNIVERSITY COLLEGE HOSPITAL, IBADAN
1.0Brief introduction
Family planning (FP) is the process or practices that make it possible for people to determine the number of children and regulate intervals between pregnancies. Family planning is defined by World Health Organization as practices that “allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility” (WHO, 2010). Family planning services include counseling, education on sexuality and contraception. There are various methods of family planning available; these can be grouped into three: natural, hormonal and non-hormonal family planning methods (Amu et al., 2017). According to Lule et al, (2007) family planning can lower maternal mortality by reducing the number of unwanted pregnancies, abortions, and the proportion of births at high risk. The Federal Government of Nigeria (2014) in its family planning blueprint stated that family planning continues to offer a host of additional health, social, and economic benefits; as it can help reduce the spread of HIV and poverty, improve gender equality, accelerate socioeconomic development and safeguard the environment.
Knowledge of family planning is very high in Sub Saharan Africa generally; it ranges between 75% and 95% though it differs from country to country and between different geographical locations in the same country (NPC, 2014; Handady et al., 2015). In Nigeria, knowledge of family planning on any contraceptive method is 85.2% with Oyo state having a higher percentage of 90.9% (NPC, 2014). Despite the high level of knowledge and huge gains associated with use of family planning services, the uptake of the service still remains low in Sub-Saharan Africa (Eliason et al., 2013). For example, the national contraceptive prevalence rate (CPR) in Nigeria was 20.4% as at 2016 (KNOEMA, 2018). There are also regional and sociocultural differences within the country (NPC, 2014). A study conducted in Bayelsa, South-South Nigeria, among university undergraduate students and staff reported a CPR of 58.2% while another study conducted among female undergraduates in Benin, South-South Nigeria about a decade earlier, reported a CPR of 39% (Aziken et al., 2003; Eniojukan et al., 2016). In Oyo as at 2013, the contraceptive prevalence for any method was 37.4% while the modern contraceptive prevalence was 24.4% (NPC, 2014).

Problem Statement
Family planning is critical in safeguarding individual health rights but also in improving the quality of life for women. The World Health Organization observes that low contraceptive use coupled with high fertility rates can always contribute to women’s and young children’s ill health and yet family planning can avert up to 25 – 30% of all maternal deaths that occur (WHO, 2015). The International Conference on Family Planning (2013), reported that Nigeria experiences high maternal mortality rates (544/100,000 live births), largely due to short birth spacing and poor health delivery system as the country has a total fertility rate (TFR) of 5.7% (coupled with a contraceptive prevalence rate of 15.1% in 2013). The risk of maternal morbidity and mortality also increases where women have birth spaced closely together, with insufficient time to regain their strength which will affect women’s health and survival, as well as their infants (Oyedokun, 2007). It is estimated that 70,000 women die each year as a result of unsafe abortions and almost all of them occur in developing countries including Nigeria (Eyong and Ivi, 2017).

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The low utilization of family planning is largely blamed on many factors. It has been observed that the awareness of the availability of family planning services has a great influence on the uptake of family planning services (Lauria et al., 2014). Additionally, even though some women are aware of the availability of family planning services, they are not properly informed about the various forms of family planning methods and how they work (Malini et al., 2014). Additionally, there has been complaint that it is difficult to access family planning services as such services were provided by health facilities that were far from their homes (Gaetano et al., 2014). Also, religious inclination has been noted to be a major constrain to the uptake of family planning services in Africa (Odimegwu, 2005; Gaetano et al., 2014). Some individuals perceived that family planning services were meant for only married couples whilst others fear that they will become sexually promiscuous if they go for family planning services once they cannot become pregnant (Odimegwu, 2005; Gaetano et al., 2014).
In Nigeria, despite the efforts made to increase the ease of access to and use of family planning services through decentralize health care services to ensure that health services are located closer to the people and are also more affordable there are still many impediments. This can be seen as the unmet need for family planning was at 9.9% as at 2013 in Nigeria while that of Oyo state was at 10.2% (NPC, 2014). Furthermore, the use of modern contraceptive method rose from 54% in 1990 to 57.4% in 2014 globally compared to 11.1% In Nigeria and 24.4% in Oyo state (as at 2013) (PRB, 2013; NPC, 2014). Also, findings from various studies revealed even a lower prevalence rate of utilization of long-term reversible methods. For instance, the National Population Commission (NPC) through the Nigeria Demographic and Health Survey (2014) states that all women within age group 15-49 years currently using IUD and implant in Nigeria were 0.8% and 0.3% respectively. In Oyo state, it was 6.1% and 0.5% respectively.
Justification for the study
Reproduction and sexual health care including family planning services and information is recognized not only as a key intervention for improving the health of women and children but also as a human right (Cottingham et al., 2010). Lule et al. (2015) indicates that access to FP services can decrease the number of healthy years of life that are normally lost due to disability and premature deaths among women and their newborn babies by more than 60%. Unplanned and unwanted pregnancies account to a large extent the poor state of health of women and children in most developing nations. All individuals have the right to selection, choice, benefits and to family planning methods. Family planning clients should be provided with correct and adequate information to enable them voluntarily make informed choice of a family planning method (Audu et al., 2006).
Given the significance of family planning services in reducing poverty, promoting gender equality and empowerment, it will be important for the health sector to have policies and programs that will help increase utilization of family planning services in the country. Understanding of the factors that influence decision-making, provision and utilization of family planning services will therefore inform policy makers to develop appropriate interventions to improve the uptake of family planning services. It is therefore necessary to conduct a research to identify and determine the actual factors that hinder women utilizing family planning.

Aims and Objectives
General Objective
The general objective of the study is to assess the factors influencing the effective use of family planning among women attending infant welfare clinic at the university college hospital, Ibadan.

Specific Objectives
The specific objectives of the study are to:
To assess the knowledge of family planning among the women.
To establish the utilization of family planning among the women.

To determine factors that hinders the women’s access to family planning.

To determine the factors influencing utilization or non-utilization of FP among the women.

2.0Brief Methodology
Study Area
Historically, Ibadan started from the interior/core areas of Ibadan such as Mapo, Beere, Oje, Opo-Yiosa, Oranmiyan, Boode, Ita- Merin, Ayeye, Inalande, Yemetu, Oja-Oba and Beyerunka to mention a few. According to Ayeni (1994) what is regarded as Ibadan today is just an extension of aerial differential due to the increase in the population of migrants. Today, while most non-indigenes who are migrants settled down in the modern and satellite areas of Ibadan which has been classified as central business district and highly residential areas, the indigenes of Ibadan settled in the core zone of the metropolis in order to sustain their source of livelihood (Lasisi et al., 2016).

Study Design
The study will employ a cross-sectional descriptive research design using both quantitative and qualitative approach. A structured questionnaire, key informant interviews and focus group discussions will be used to collect data. The study will describe the factors that hinder women’s utilization of family planning among women attending infant welfare clinic at the university college hospital, Ibadan.

Study Population
The study population will comprise of child bearing women aged between 18-49 years old attending the infant welfare clinic at the university college hospital, Ibadan for the questionnaires and FDGs. The study will also target health workers involved in provision of family planning services and also local administration at the infant welfare clinic at the university college hospital, Ibadan for the KIIs. The health workers and admin staff will be targeted due to their involvement in reproductive health and family planning issues in the clinic and therefore will provide significant impetus to the study findings.

Inclusion Criteria
Child bearing women residing in Ibadan. Only those who are between the ages of 18 and 49 years of age will be selected for this study.

Child bearing women who will give consent to participate in the study
Sample Size
Sampling Procedure
In this study, a simple random sampling method will be selected to collect the sample. Purposive sampling will be used to sample health workers and admin staff involved in provision of family planning services. FGD participants will also be recruited based on their accessibility and willingness to participate in the discussions.
Methods of Data Collection
Questionnaire
The main method for primary data collection will be structured interviews using a questionnaire. The questionnaire will be constructed to contain structured open and closed-ended questions and will be used to gather both qualitative and quantitative data.
Key Informants Interviews
Key Informants will be chosen because of their extensive knowledge, experience, expertise, and involvement with FP issues in the study area. The information collected from KIIs will be used to supplement that collected from questionnaire interviews. Such information will be important in supporting or disapproving certain key assertions made during the interviews. A KII Guide will be developed to assist in such interviews.

Focus Group Discussion
This will be done by the help of an FGD guide. The FGD will aid in getting any additional and specific information regarding the topic under study as respondents will be probed further for any further clarifications. The information from FGDs will be used to enrich the data from the questionnaires.

Data Processing and Analysis
The quantitative data obtained from the questionnaires will be entered, cleaned and analyzed using the Statistical Package for Social Sciences (SPSS). Descriptive statistics such as frequency and percentages will be used to present quantitative findings using tables and charts. Qualitative data from KIIs and FDGs will be subjected to content and thematic analysis where the responses will be transcribed and themes developed with these themes presented together with verbatim. Emerging patterns and themes will be compared against the survey data and the study objectives and will be used to complete and supplement quantitative data.

3.0Expected contributions to knowledge
The findings from this study will be useful and of interest especially to researchers and reproductive health stakeholders. It will also be of importance to policy makers in the reproductive health sector and to other interested parties on how to enhance access to FP services to ensure that many women are able to benefit from the services. The findings are hopefully going to benefit policy makers, planners and FP service providers in designing appropriate strategies to enhance access to FP services for women and especially those attending the infant welfare clinic at the university college hospital, Ibadan.

Novelty
Studies on FP have been conducted in Nigeria. Most of these studies have tended to focus on issues such as utilization pattern of FP services, types of services available, unmet needs for family planning as well the effects of FP on development. The current study therefore will attempt to fill in the gaps in the understanding and in the literature about this important topic.

5.0References
Amu, E. O., Odu, O. O., ; Solomon, O. O. (2017). Family Planning Utilization Pattern in Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria: a Six-Year Review.

Ayeni, B. (1994). The metropolitan area of Ibadan: its growth and structure. Ibadan region, 72-84.Aziken, M. E., Okonta, P. I., ; Ande, A. B. (2003). Knowledge and perception of emergency contraception among female Nigerian undergraduates. International family planning perspectives, 84-87.Bhattathiry, M. M., ; Ethirajan, N. (2014). Unmet need for family planning among married women of reproductive age group in urban Tamil Nadu. Journal of family ; community medicine, 21(1), 53.Cottingham, J., Kismodi, E., Hilber, A. M., Lincetto, O., Stahlhofer, M., ; Gruskin, S. (2010). Using human rights for sexual and reproductive health: improving legal and regulatory frameworks. Bulletin of the World Health Organization, 88, 551-555.

Eliason, S., Baiden, F., Quansah-Asare, G., Graham-Hayfron, Y., Bonsu, D., Phillips, J., ; Awusabo-Asare, K. (2013). Factors influencing the intention of women in rural Ghana to adopt postpartum family planning. Reproductive health, 10(1), 34.Eniojukan, J. F., Ofulue, I., ; Okinedo, P. O. (2016). Knowledge, perception and practice of contraception among staff and students in a University Community in Delta State, Nigeria. UK J Pharm Biosci, 4(1), 71-81.

Eyong, C., Ivi, E.E. (2017). Utilization of family planning services among women of childbearing age (15-45 years) from 2011 to 2013 in Calabar South local Government area of Cross river state-Nigeria. International Journal of Public Heath, Pharmacy and Pharmacology, 2(1), 13 -23.Handady, S. O., Naseralla, K., Sakin, H. H., ; Alawad, A. A. M. (2015). Knowledge, attitude and practice of family planning among married women attending primary health center in Sudan. Int J Public Health Res, 3(5), 243-7.Herman, L., Isaac, E., Mary, N., ; Richard, M. (2015). Determinants of contraceptive utilisationamongst teenagemothers: a case-control study in kyangwali refugee settlement (Uganda). International Journal of Current Advanced Research, 4(8), 243-257.

International Conference on Family Planning (ICFP) (2013). Collaborative approach to implement an effective family planning programme in Resource poor setting. Available at http://fpconference.org/2018/wp-content/uploads/2017/04/ICFP-Evaluation-report_final.pdfKNOEMA (2018). Nigeria – Gender Statistics. Available at HYPERLINK “https://knoema.com/WBGS2018Apr/gender-statistics?tsId=1627240” https://knoema.com/WBGS2018Apr/gender-statistics?tsId=1627240
Lasisi, C. J., ; Bassey, T. I. (2016). Awareness and utilization of family planning among married women in the traditional core areas of Ibadan, Oyo State. Nova Journal of Humanities and Social Sciences, 3(2).Lauria, L., Donati, S., Spinelli, A., Bonciani, M., ; Grandolfo, M. E. (2014). The effect of contraceptive counselling in the pre and post-natal period on contraceptive use at three months after delivery among Italian and immigrant women. Annali dell’Istituto superiore di sanita, 50, 54-61.
Lule, E., Hasan, R., & Yamashita-Allen, K. (2007). Global trends in fertility, contraceptive use and unintended pregnancies. Fertility Regulation Behaviors and Their Costs: Contraception and Unintended Pregnancies in Africa and Eastern Europe & Central Asia. Health, Nutrition & Population Discussion Paper. Washington, DC: World Bank, 8-39.

Lule, H., Echoru, I., Nnabagulanyi, M., & Mulumba, R. (2015). Determinants of contraceptive utilization amongst teenage mothers: A case-control study in Kyangwali refugee settlement (Uganda). International Journal of Current Advanced Research, 4(8), 243-257.

Marrone, G., Abdul-Rahman, L., De Coninck, Z., & Johansson, A. (2014). Predictors of contraceptive use among female adolescents in Ghana. African Journal of Reproductive Health, 18(1), 102-109.

National Population Commission (NPC) & ICF International (2014). Nigeria Demographic and Health Survey (2013). Available at https://dhsprogram.com/publications/publication-fr293-dhs-final-reports.cfm.Odimegwu, C. (2005). Influence of religion on adolescent sexual attitudes and behaviour among Nigerian university students: affiliation or commitment?. African journal of reproductive health, 125-140.Oyedokun, A. O. (2007). Determinants of contraceptive usage: lessons from women in Osun State, Nigeria. Journal of Humanities and Social Science, 1(2), 1-14.

Population Reference Bureau (PRB), 2013. World Population Data Sheet. Available at: https://assets.prb.org/pdf13/2013-population-data-sheet_eng.pdfWorld Health Organization (WHO). (2015). Medical eligibility criteria for contraceptive use. Available at http://apps.who.int/iris/bitstream/handle/10665/181468/9789241549158_eng.pdf;jsessionid=718A7468CDC586345A820A64126101D9?sequence=1World Health Organization (WHO). (2010). The ABC’s of family planning. Available at http://www.who.int/pmnch/media/news/2010/20100322_d_shaw_oped/en/Audu, B. M., Yahya, S. J., ; Bassi, A. (2006). Knowledge, attitude and practice of natural family planning methods in a population with poor utilisation of modern contraceptives. Journal of obstetrics and gynaecology, 26(6), 555-560.

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