Nigeria currently has one of the highest fertility rates in the world (World Bank, 2020), with the northwest region experiencing the highest rates within the country (National Population Commission (NPC) [Nigeria] & ICF, 2019). The 2018 Nigeria Demographic and Health Survey (NDHS) indicated that the total fertility rate in the northwest of the country was 6.6 live births per woman, and that women aged 40 to 49 years averaged 8.3 births in their reproductive lifetimes (National Population Commission (NPC) [Nigeria] & ICF, 2019). This high-fertility situation places women at greater risk of birth complications and maternal mortality. Nigeria currently has more maternal deaths annually than any other country in the world (Roser & Ritchie, 2020) and the fourth highest maternal mortality ratio (World Health Organization, 2020).
Contraceptive use to limit or space births is not the norm in this region. In the 2018 NDHS, only 6.2% of married women in the northwest were currently using any form of modern contraception, and the majority of married women - 68.7% - reported no need for family planning for either spacing or limiting (National Population Commission (NPC) [Nigeria] & ICF, 2019). Much of this absence of demand for family planning can be attributed to social norms for high fertility, pro-natal cultural and religious beliefs, misconceptions about contraceptive methods, and gender inequalities.
Role of high parity norms
In this region, the desire for large families is extensive, reflected in a mean ideal number of children of 7.5 (National Population Commission (NPC) [Nigeria] & ICF, 2019). This is nearly three children more than the ideal in the south of the country (Babalola et al., 2017). Even among high parity couples, the desire to continue having children prevails. According to the 2018 NDHS, 61.6% of women with six or more children in this region wanted more children. Among men with six or more children, that percentage was even higher; 89.1% desired more (National Population Commission (NPC) [Nigeria] & ICF, 2019).
Social norms driving high fertility in the northwest are tied in part to perceptions of its social advantages, such as signaling greater wealth and status, ensuring the survival of family names, and broadening social networks and influence. Large family size is believed to both represent and engender wealth, influence, respect, and fame (C. O. Izugbara & Ezeh, 2010). Further, large families are perceived to have economic benefits, such as serving as social insurance for parents as they age and contributing household labor or income from market-based employment (C. O. Izugbara & Ezeh, 2010). Son preference may further drive high fertility (Sinai, Anyanti, Khan, Daroda, & Oguntunde, 2017).
Role of religion
In the north, where the majority of the population is Muslim, religious beliefs drive high fertility (Babalola et al., 2017; Duze & Mohammed, 2006; C. O. Izugbara & Ezeh, 2010; Sinai et al., 2017). Izugbara and Ezeh (2010) note that many women believe that high fertility honors Allah. Specifically, one way “to serve God with fertility is to give birth to several children who will worship Him and secure the future of Islam” (C. O. Izugbara & Ezeh, 2010). Similarly, Obasohan (2015) highlights the cultural belief that God places children in the womb and “until they are given birth to, you do not stop.”
Role of contraceptive myths
Further affecting high fertility rates in northwestern Nigeria are misconceptions and negative perceptions about family planning use, such as beliefs that contraceptives are dangerous to a woman’s health (FP2020, 2019; Gueye, Speizer, Corroon, & Okigbo, 2015; P. Hutchinson et al., 2018), that they can harm a woman’s womb (Ankomah, Oladosun, & Anyanti, 2011; Gueye et al., 2015; Measurement Learning and Evaluation Project, National Population Comission (NPC) Nigeria, & Data Research and Mapping Consult Ltd, 2015), that they can inhibit subsequent fertility (Gueye et al., 2015; P. Hutchinson et al., 2018) or that they can cause cancer (C. O. Izugbara & Ezeh, 2010).
Role of gender inequalities
Fertility in northwestern Nigeria is also driven by gender power imbalances, fostered by patriarchal social structures in which women have limited autonomy over most decisions, including those affecting marriage, health and fertility (Adanikin, McGrath, & Padmadas, 2019; Sinai et al., 2017). Men are often the final decision-makers on important household matters, including those related to “household purchases, health of family members, timing of pregnancies, family size, and education of children” (Babalola, Kusemiju, Calhoun, Corroon, & Ajao, 2015). As the decision-makers on family size, men ultimately determine contraceptive use through their fertility desires and approval or disapproval of contraception (Schwandt, 2011; Sinai et al., 2017).
Exacerbating power differentials are the low levels of female education and patterns of early marriage. In the northwest, nearly two thirds of adult women have no formal education, and only 29% are considered literate (National Population Commission (NPC) [Nigeria] & ICF, 2019). Forced and early child marriage is common (Wolf, Abubakar, Tsui, & Williamson, 2008), and many girls are married as young as 12. The median age at first marriage is approximately 15.9 years. The median age for men, in contrast, is 25.3 years, revealing considerable age differences, and hence power differentials (National Population Commission (NPC) [Nigeria] & ICF, 2019). In this context, women are valued largely for their reproductive functions (Sinai et al., 2017; Wolf et al., 2008).
From a woman’s perspective, “fertility is one mechanism by which women can impart some control over marital situations that are largely beyond their control” (C. O. Izugbara & Ezeh, 2010). High parity is perceived as a mechanism to ensure marital stability, and protection and financial support from their spouse (Obasohan, 2015; Wolf et al., 2008). Wives often see having many children as a way to discourage husbands from taking on other wives (C. O. Izugbara & Ezeh, 2010), which can affect a wife’s standing within the polygynous familial structure (C. Izugbara, Ibisomi, Ezeh, & Mandara, 2010). In polygynous marriages, resources and wealth are generally distributed to wives based on the number of children they have, both on a daily basis and at the husband’s death, thereby limiting incentives to use contraception (C. O. Izugbara & Ezeh, 2010). Researchers have identified conjugal relationship dynamics as explaining 11% of the variation in contraceptive use between northern Nigerian states and southern Nigerian states (Babalola & Oyenubi, 2018). Further, low fertility can have dire consequences for women as husbands “may cite limited childbearing as an excuse to marry additional women and to divorce their existing wives” (C. O. Izugbara & Ezeh, 2010).
Family Planning Demand
In northwestern Nigeria, decisions about contraceptive use are inextricably linked to this complex interaction of high fertility desires, social norms, and contraceptive myths, as well as economic factors such as financial security, income streams, and the costs of health services (Ankomah et al., 2011; Babalola & Oyenubi, 2018; Okigbo, Speizer, Domino, & Curtis, 2017; Speizer & Lance, 2015).
This work examines several family planning outcomes and their relationships with theorized determinants of contraceptive use. It builds upon an ideational model of contraceptive use (Babalola, John, Ajao, & Speizer, 2015; Kincaid, 2000; Kincaid & Do, 2006; Krenn, Cobb, Babalola, Odeku, & Kusemiju, 2014), which in turn builds upon other behavior change theories, including the diffusion of innovations (Rogers, 2003), the theory of planned behavior (Ajzen, 1991), social cognitive theory (Bandura, 1986, 1994), and the transtheoretical model (Prochaska & DiClemente, 1994). These behavioral models highlight the roles of multiple direct and indirect influencers of behaviors, including intentions, environmental constraints, skills, attitudes, norms, identity, emotion and self-efficacy, with the first three factors believed to be necessary and sufficient for a behavior to occur while the latter five factors influence the strength and direction of intentions (Fishbein et al., 2001).
This study focuses in particular on several key components of these theories that may be of particular relevance for the design and implementation of behavior change programs in northwestern Nigeria that seek to influence contraceptive use, including interpersonal discussions between couples, approval of family planning, and contraceptive knowledge.
Interpersonal communication among couples
We focus on the role of communication among couples about family planning because of its established association with a greater likelihood of contraceptive use in certain contexts (Ankomah et al., 2011; Okigbo et al., 2017; Shattuck et al., 2011). Nonetheless, contraceptive discussions are not the norm in this region (C. Izugbara et al., 2010), and discussions about family planning with young or unmarried persons are often considered inappropriate (Adebayo et al., 2011). The Nigerian Urban Reproductive Health Initiative (NURHI) reported that less than a third of married women in northern Nigeria discussed family planning with spouses at least once within the past six months (Measurement Learning and Evaluation Project et al., 2015).
While husbands influence fertility decisions, most issues of reproductive health are considered a woman’s domain (Schwandt, 2011; Sinai et al., 2017). Hence, a woman is expected to be the one to initiate conversations about family planning (Kibira et al., 2020; Schwandt, 2011), even though these conversations come with risk for her. Trepidation about discussing family planning inhibits many couples from discussing family planning and introducing the topic with a husband ((Sinai et al., 2017).
Approval of family planning
We focus as well on approval of contraception – or its absence – as a facilitator of contraceptive use, as shown in previous studies (Bongaarts, Cleland, Townsend, Bertrand, & Das Gupta, 2012; Okigbo, McCarraher, Gwarzo, Vance, & Chabikuli, 2014). In northern Nigeria, strong cultural and religious forces limit the acceptability of modern contraception among large swaths of the population. A 2003 study of married men in northern Nigeria found that nearly two thirds of men disapproved of the concept of contraception (Kabir, Iliyasu, Abubakar, & Maje, 2003), a finding mirrored by others (Duze & Mohammed, 2006).
While many studies have looked at the role of contraceptive approval in affecting contraceptive decisions, particularly by partners (Etukudo, 2015; Okigbo et al., 2014), few studies have looked specifically at the determinants of approval itself. Because contraceptive use must fit within a person’s values, approval is a necessary (but not sufficient) condition for use. Its examination in the context of decisions about contraceptive use is therefore critical. Stages of change theories, such as the transtheoretical model, consistently highlight the process of developing a positive attitude toward an intended behavior as a prerequisite to engaging in the behavior (Kincaid, 2000; Lesthaeghe & Vanderhoeft, 2001; Prochaska & DiClemente, 1994). For actions with significant negative associations, behavior change programs necessarily must work to improve attitudes towards the behavior. Achieving improved acceptance of contraception remains an important intermediate goal of those programs.
Contraceptive Intentions
We also focus on contraceptive intentions as an outcome because of the strong role that they play in major behavioral theories, although measurement of intentions often conflates the time order between intentions and contraceptive use. As with approval, we treat intentions as a necessary but not sufficient condition for contraceptive use; women are unlikely to inadvertently begin using contraception and hence intent is a necessary condition. Understanding the factors associated with this necessary step are critical for understanding contraceptive uptake.
Northern Nigeria has persistently low contraceptive intentions because the majority of fertility-aged women desire to become pregnant (Avidime et al., 2010; National Population Commission (NPC) [Nigeria] & ICF, 2019). Even though intentions to use are low, previous analyses have shown that they are malleable and can be influenced by greater self-efficacy, reductions in contraceptive myths, and social influences (Babalola, John, et al., 2015). In other contexts, intentions to use postpartum family planning (PPFP) have been shown to be associated with past use, acceptability of use, and of partner acceptability of contraception (Eliason et al., 2013).
Objective
This paper contributes to the extant literature on contraceptive use in a high-fertility environment by quantifying the importance of the myriad factors highlighted in behavior change theories, not just on contraceptive use but also on intermediate determinants of contraceptive use, including contraceptive intentions, interpersonal communication, social influences, and approval. This paper recognizes the importance of these intermediate determinants in previous reviews of contraceptive use in Nigeria but notes that they have seldom been studied as outcomes themselves, a key aim of this paper. Further extending previous analyses, this paper models how social and behavior change programs may effectively change contraceptive behaviors by targeting these myriad influences.