The role of traditional contraceptive methods in family planning among women attending primary health care centers in Kano.

Background: Traditional contraceptive methods (TCMs) have been used by our ancestors for a long time in child spacing before the advent of the modern contraceptive methods but even with the introduction of the modern methods some women prefer and are still using TCMs. Aim: The aim of this study was to assess the utilization of traditional contraceptives in child spacing and its association with family size among women of child-bearing age attending primary healthcare centers in Kano. Materials and
Methods: This was a cross-sectional study among 400 women attending primary healthcare centers in Kano. Their sociodemographic characteristics, number of children, knowledge, and use of traditional contraceptives were recorded on a pretested questionnaire.
Results: The mean age ± standard deviation (SD) was 29.1 ± 6.22 years. The mean number of children (±SD) was 3.9 ± 2.27. A total number of 280 (70.0%) participants knew about TCMs, but only 147 (36.8%) used these methods and among those that used TCMs, herbal medicine was the most used method (n = 67, 45.6%). There was no statistically significant difference between the mean number of children of the respondents who used traditional contraceptives and those who did not (t = 0.382, df = 398, P = 0.703, 95% confidence interval:-0.374-0.555). Educational status was significantly associated with the use of traditional contraceptives (χ2 = 8.327, P = 0.005).
Conclusion: There was more knowledge of traditional than modern contraceptive methods. Herbal medicine was the most commonly used method. There was poor utilization of the modern contraceptive methods and fair utilization of the TCMs. The study showed no clear benefit of traditional contraceptive usage over its nonuse in reducing family size.

INTRODUCTION

Nigeria is Africa's most populous country, with a current population of approximately 193 million people which is equivalent to 2.55% of the total world population.[1] The current total fertility rate in Nigeria is estimated to be 5.46 per woman.[2]

Family planning/child spacing is defined as a conscious effort by a couple to limit or space the number of children they want to have through the use of contraceptive methods.[3] It is a way of living that is adopted voluntarily on the basis of knowledge, attitude, and responsible decision-making by individuals or couples to pin the number, timing, and spacing of the children they want, with intention of promoting the health and welfare of the family group, and contribution toward the advancement of the society.[4] Basically, there are two major methods of family planning; the traditional and modern methods.

Attempts to control increase in population started from the early men. Evidence from medical history indicates that our forefathers did space their children through traditional means,[5] and the traditional methods of family planning had been handed down from generation to generation. In developing nations like Nigeria, children are valued as they not only demonstrate the masculinity of the men but equally provide the extra useful hands in communities where agriculture is the major source of income.[6] In addition, aged parents and extended family relations depend on their children for care at old age hence reluctance to limit birth.

Before the introduction of modern methods, Africans had methods of fertility regulation. Nigerian culture includes many myths, rituals, and the use of herbs in attempts to regulate women's fertility. Although many of these traditional methods of family planning have no harmful effects on a woman's health, some however, do have dangerous or counterproductive effects.[7] In addition, the complete effectiveness of many of the traditional methods remains doubtful.[8]

The traditional methods of contraception include the lactational amenorrhea method,[9] coitus interruptus (withdrawal method), calendar method or rhythm method,[10] cervical mucus method and abstinence.[11] Other form of traditional contraceptive methods (TCMs) can be customs or beliefs which include some rituals and use of traditional medicine and herbs.[12]

The overall contraceptive prevalence among women in Nigeria is 16%, with the NorthWest having 4.3%, and the TCM used by women in Nigeria is 5%.[3]

Elsewhere, a demographic health survey data in Ouagadougou showed that traditional methods are not very popular;[13] only 6.1% of women in union are reported to use a traditional method across Sub-Saharan Africa, compared to 15.7% for modern methods.[13] Worldwide, estimates show that 9 out of 10 contraceptive users rely on a modern method.[5] In Sub-Saharan Africa, however, smaller, more localized studies have tended to show a different picture of traditional method use.

The benefits of child spacing are numerous; they include: preventing pregnancy-related health risks in women, reducing infant mortality, helping to prevent HIV/AIDS, empowering people and enhancing education, reducing adolescent pregnancies, slowing population growth, reducing rates of unintended pregnancies, and reducing the need for unsafe abortion.[10]

Promotion of family planning and ensuring access to preferred contraceptive methods for women and couples is essential to securing the well-being and autonomy of women, while supporting the health and development of communities.[10]

Knowledge about modern contraception is getting higher in the North with increased awareness and interventions from various organizations and health workers, but still misconceptions about modern contraceptives are abundant.[14] Examples of modern contraceptive methods commonly used in this community include female and male sterilization, oral hormonal pills, intrauterine device, male condom, injectables, implant, vaginal barrier methods, female condom, and emergency contraception.[14] Although many studies have been conducted on family planning methods, little is known about the utilization and determining factors of TCMs among women of child-bearing age groups in the study area. As women's contraceptive choice and practice are a key element of quality care in family planning service program, knowing utilization status and its determinants is crucial. Findings from this study would aim to contribute to the understanding whether the TCMs have a role in child spacing and why women in this community prefer these methods.

MATERIALS AND METHODS

It was a cross-sectional study conducted from March 1 to July 31, 2017, at primary health centers (PHC) in Tarauni local government area of Kano State. Ethical approval was obtained from Kano State Primary Health Care Agency, Tarauni Local Government before the study was carried-out. Four PHC were selected by systematic sampling methods of which 100 consenting women of child-bearing age (15–49 years) were also selected randomly using balloting from each of the selected PHC. Women below the age of 15 years and above 49 years were excluded from the study. Questionnaire, containing closed and open ended questions, was structured and pretested before administration. Information obtained on the questionnaire included sociodemographic characteristics of the respondents, current usage and knowledge of both modern and traditional contraceptives, and certain quantitative measures of the characteristics of the respondents on the role and use of TCMs.

Data were entered in to a personal computer and analyzed using Statistical Package for Social Sciences (SPSS) Electronic Software (IBM SPSS Statistics 19, Inc, Chicago, IL, USA). Chi-squared test was used for categorical data. Where the criteria for applying Chi-squared test were not met, Fishers’ exact test was used, and the P < 0.05 was considered to be statistically significant. In this study, TCMs refer to family planning methods that pre date the emergence of modern contraceptive methods such as abstinence, withdrawal methods, cervical mucus, and use of herbal medicine.

Sample size estimation

The sample size was determined using the formula (n = z2pq/d2).[15]

where, n = minimum sample size,

z = normal standard deviate set at 95% confidence limit = 1.96,

q = 1–p (complementary probability),

d = margin of error = 5% =0.05,

p = the least prevalence 0.5 (50%).

Therefore;

P = 0.5

q = 1–0.5

=0.5

n = (1.96)2 × 0.5 × 0.5

0.052

n = 3.8416 × 0.5 × 0.5

0.0025

n = 0.9604

0.0025

n = 384.16

To account for incomplete response, the minimum sample size was approximated to 400.

RESULTS

During the study period (from March 1 to July 31, 2017), 400 consenting participants (women of reproductive age group) were selected for the study. The mean age ± standard deviation (SD) was 29.1 ± 6.22 years. The median age was 28 years.

A large proportion (133, 33.3%) of the respondents were within the age group of 25–29 years while the least number of the respondents 4 (1.0%) were of the age group of 45–49 years [Table 1].

Table 1

Sociodemographic characteristics of the respondents

Variables	Frequency (%)
Age group
15-19	8 (2.0)
20-24	88 (22.0)
25-29	133 (33.3)
30-34	79 (19.8)
35-39	62 (15.5)
40-44	26 (6.5)
45-49	4 (1.0)
Total	400 (100.0)
Marital status
Married	381 (95.3)
Separated	1 (0.3)
Divorced	13 (3.3)
Widowed	5 (1.3)
Total	400 (100.0)
Ethnic group
Hausa	350 (87.5)
Igbo	7 (1.8)
Yoruba	11 (2.8)
Others	32 (8.1)
Total	400 (100.0)
Religion
Islam	388 (97.0)
Christianity	12 (3.0)
Total	400 (100.0)
Educational status
Primary	92 (23.1)
Secondary	196 (49.1)
Tertiary	69 (17.2)
Qur’anic	30 (7.5)
None	13 (3.1)
Total	400 (100.0)
Occupation
Home managers	150 (37.5)
Business	131 (32.8)
Professional/executive	37 (9.3)
Student	8 (2.1)
Artisan	74 (18.5)
Total	400 (100.0)
Husband's occupation
Don’t have husbands (divorced/widowed/separated)	19 (4.8)
Unemployed	20 (5.0)
Self-employed	250 (62.4)
Student	13 (3.3)
Employed	86 (21.5)
Retired	12 (3.0)
Total	400 (100.0)

Majority of the respondents (381, 95.3%) were married. The divorced constituted 13 (3.3%).

Hausa (n = 350, 87.5%) was the largest ethnic group among the respondents. Other tribes, 32 (8.1%) were Bula, Kanuri, Fulani, Idoma, Birom, Igala, Babur, and Ibira.

Most of the respondents (196, 49.1%) attained secondary school level as their highest level of education; tertiary and primary level of education constituted 69 (17.2%) and 92 (23.1%), respectively.

A large proportion of the respondents were home managers (150, 37.5%); students constituted 8 (2.1%) [Table 1]. A large number of the respondents’ husbands (258, 64.5%) were self-employed; the unemployed constituted 20 (5.0%).

The mean age (at marriage) ±SD was 17.7 ± 3.00 years. The mean number of children (±SD) was 3.9 ± 2.27. The mean age (±SD) at first child was 18.9 ± 3.90 years.

More than a half of the respondents (214, 53.5%) knew about modern contraceptive methods, but only 83 (20.7%) ever used them [Table 2].

Table 2

Usage of modern and traditional contraceptive methods

Variables	Frequency (%)
Do you know about the MCM?
Yes	214 (53.5)
No	186 (46.5)
Total	400 (100.0)
Do you use the MCM?
Yes	83 (20.7)
No	317 (79.3)
Total	400 (100.0)
Have you ever heard of TCM?
Yes	280 (70.0)
No	120 (30.0)
Total	400 (100.0)
Do you use TCM?
Yes	147 (36.8)
No	253 (63.2)
Total	400 (100.0)

TCM=Traditional contraceptive methods, MCM=Modern contraceptive method

An alarming figure of 280 (70.0%) had heard about TCMs, but only 147 (36.8%) used them. Out of these 147, 47 (32.0%) used withdrawal method, 24 (16.3%) used abstinence, and 67 (45.6%) used herbal medicines Figure 1.

Figure 1

Types of traditional contraceptives used by the respondents

Table 3 depicted the types of TCMs used by the respondents, the frequency of which these methods were used was also shown. Other forms of traditional contraceptives used by the respondents were charms, beads, religious prayers, and other household products such as salt and potash.

Table 3

Utilization of traditional contraceptives

Variables	Frequency (%)
For how long have you been using TCM (years)?
1-2	58 (39.4)
3-4	29 (19.7)
5-6	31 (21.2)
7-8	14 (9.6)
9-10	15 (10.1)
Total	147 (100.0)
How often do you use TCM?
Sometimes	71 (48.4)
Frequently	55 (37.9)
Always	21 (13.7)
Total	147 (100.0)
*What are the types of TCM you used?
Abstinence	24 (16.3)
prolonged breast feeding	4 (2.7)
Withdrawal method	46 (31.4)
Calendar method	3 (2.0)
Cervical mucus method	3 (2.0)
Herbal medicine	67 (45.6)
Total	147 (100.0)
Do you think the TCM are effective for you?
Yes	121 (82.3)
No	26 (17.7)
Total	147 (100.0)
Do you think there are advantages with the use of TCM?
Yes	134 (91.2)
No	13 (8.8)
Total	147 (100.0)
Do you think of any disadvantages with the use of TCM?
Yes	46 (31.3)
No	101 (68.7)
Total	147 (100.0)
Will you continue to use TCM?
Yes	118 (80.3)
No	29 (19.7)
Total	147 (100.0)

*Responses are mutually exclusive. TCM=Traditional contraceptive methods, MCM=Modern contraceptive method

The mean number of children (±SD) of the respondents who used the TCMs was 4.0 ± 2.03. The mean number of children (±SD) of the respondents who never used the traditional methods of contraceptives was 3.9 ± 2.41. There was no statistically significant difference between the two means (t = 0.382, df = 398, P = 0.703, 95% confidence interval [CI]: −0.374–0.555).

Up to 121 (82.3%) thought the traditional method of contraceptives was effective for them while 134 (91.2%) believed there were advantages with the use of TCMs [Table 3].

Table 4 depicted association between the use of TCMs and some sociodemographic characteristics. There was no statistically significant association between the respondents’ age group ([χ2 = 2.221, P = 0.528], ethnicity (χ2 = 0.014, P = 0.906), and religion (P [Fischers’] =0.766) and the use of traditional contraceptives. However, educational status was statistically associated with the use of traditional contraceptives (χ2 = 8.327, P = 0.005).

Table 4

Cross tabulation between variables and use of traditional contraceptives

Variable	Yes	No	χ2, P
Age group and the use of traditional contraceptives
10-19	4 (2.7)	4 (1.6)	2.221, 0.528
20-29	77 (52.4)	144 (56.9)
30-39	52 (35.4)	89 (35.2)
40-49	14 (9.5)	16 (6.3)
Total	147 (100.0)	253 (100.0)
Ethnicity and the use of traditional contraceptives
Hausa	129 (87.8)	221 (87.4)	0.014, 0.906
Others (%)	18 (12.2)	32 (12.6)
Total	147 (100.0)	253 (100.0)
Religion and the use of traditional contraceptives
Islam	142 (96.6)	246 (97.2)	P=0.766*
Christianity	5 (3.4)	7 (2.8)
Total	147 (100.0)	253 (100.0)
Educational status and the use of traditional contraceptives
Formal	142 (96.6)	223 (88.1)	8.327, 0.005
Informal	5 (3.4)	30 (11.9)
Total	147 (100.0)	253 (100.0)

*Fishers’ exact test

DISCUSSION

Findings from this study showed that the mean age at marriage ± SD was 17.7 ± 3.00 years. Results from the Nigerian Health and Demographic Survey (2013) also showed half of the women age 25–49 were married by 18 years, and their median age at first marriage was 18.1 years.[16] The mean number of children (±SD) was 3.9 ± 2.27. This is lower than the average national figure of 5.5 children per woman.[16] The mean age (±SD) at first child, which is regarded as a useful indicator for gauging the success of family planning programs aiming to reduce maternal mortality, increase contraceptive use, delay age at first marriage, and improve the health of newborns was 18.9 ± 3.90 years. This is slightly lower than the 20.90 years national estimate.[17] This suggests that there was low success or nonusage of both modern and TCMs within the 1st year of marriage among the respondents. This is not surprising since every couple is expected to have their first child within the 1st year of marriage at least to confirm their fertility. It has been discovered that in developing nations like Nigeria, children are valued as they not only demonstrate the masculinity of the men but equally provide the extra useful hands in communities where agriculture is the major source of income.[6] In addition, the earlier the first child is conceived and delivered after marriage, the more the happiness and anticipation that an heir to the family who will shoulder their responsibility in the near feature has arrived.[18]

Knowledge of modern contraceptive methods was above average (53.5%) in this study, but the utilization was low (20.7%). This was lower than the 99.7% knowledge of modern contraceptive methods among married women in Zaria, Northwestern Nigeria, reported by Aliyu et al.[19] The utilization was also lower than the 51.9% reported by Envuladu et al.[20] in Jos, Plateau State, Nigeria. This poor utilization may not be unconnected to the fear of side effects such as spotting, dizziness, mood changes, headache, and weight gain which are associated with hormonal contraceptives.[21]

While 280 (70.0%) of the respondents demonstrated knowledge of TCMs, utilization was also low 147 (36.8%), though the figure was still better than that of modern contraceptives. This might suggest that the respondents preferred the TCMs perhaps because they believed traditional contraceptives are safer, easy to use, with no known side effects.[22] Ram et al.[23] reported that the side effects of modern contraceptives such as health concerns, opposition from self, husband, and others were the main reasons why women preferred TCMs in India.

The main disadvantages of traditional contraceptives are the lack of scientific proof and evidence of their efficacy. Trussell and Kost[24] reported that traditional medicine lacked precise dosage; its unhygienic method of preparation predisposed to spread of infections. Therefore, health awareness about the benefits of modern contraceptive methods, recommendation of specific types of method over others, and awareness of health risks and uncertainty of the efficacy of TCMs should be uncovered to facilitate the acceptance of modern contraceptive methods.

The mean number of children (±SD) for the respondents who used the TCMs (4.0 ± 2.03) was similar to the mean number of children (±SD) for those who never used the traditional methods of contraceptives (3.9 ± 2.41). (t = 0.382, df = 398, P = 0.703, 95% CI: −0.374–0.555), and they were both lower than the current total fertility rate in the country (5.46)[2]. From the results of this study, it would appear therefore that the use of TCMs has no significant effect on family size compared to its none use in family planning.

A few number of the respondent 46 (31.3%) thought there were disadvantages associated with the use of TCM, and few respondents 29 (19.7%) considered discontinuation of the method. As such, there is a need to do more research on the harmful effect of some of the traditional methods of contraceptives, their contraceptive effect and recommended dosages. To our surprise, 118 (80.3%) acknowledged the side effects of traditional contraceptives; however, they failed to consider discontinuation of the methods. Whether lack of availability of the modern contraceptives, improper counseling about the choices of modern contraceptive methods, pressure from spouse, in-laws or parent are the compelling reasons for the usage are what were not explored in this survey. A study conducted by Apanga and Adam[25] in the Talensi District of Ghana on the factors influencing the uptake of family planning services; showed that misconceptions about family planning methods and husbands’ refusal to allow their wives to access family planning services were the major reasons against usage of family planning services.

CONCLUSION

There was knowledge of TCMs. Herbal medicine was the most commonly used method. There was also no clear role for traditional contraceptive usage in determining family size.

The study also revealed the poor utilization of the modern contraceptive methods and a fair level of utilization of the TCMs.

It is recommended that;

The TCMs should be studied more to know its benefits and health implications

Awareness should be raised about modern methods of family planning

More counseling on the use of contraceptives should be done in clinics as it contributes in allaying fear and anxiety toward the side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.