Understanding Family Planning Outcomes in Northwestern Nigeria: Analysis and Modeling of Social and Behavior Change Factors

"...well-designed social and behavior change programs that target...drivers [of family planning behaviours] can have large potential benefits."

High fertility and low contraceptive use are common in northwestern Nigeria, with decisions about family planning linked to a complex interaction of high parity norms (desire for large families), pro-natal cultural and religious beliefs, contraceptive myths, gender inequalities, and economic factors. This work examines several family planning outcomes and their relationships with theorised determinants of contraceptive use. Social and behaviour change (SBC) programmes often try to shift drivers of high fertility through multiple channels, including interpersonal interventions, community-level group activities, and mass and social media. The goal is to assist SBC programmes in tailoring these efforts by focusing not just on contraceptive use/uptake but on intermediate determinants, including contraceptive intentions, interpersonal communication, social influences, and contraceptive approval.

Data for this study come from a cross-sectional household survey conducted in the states of Kebbi, Sokoto, and Zamfara in northwestern Nigeria in September 2019, involving 3,000 women aged 15 to 49 years with a child under 2 years. The data were collected as part of a baseline survey conducted by the United States Agency for International Development (USAID)-funded Breakthrough RESEARCH project as part of a 3-year evaluation of the Breakthrough ACTION / Nigeria (B-A/N) project. B-A/N is an integrated SBC programme focusing on family planning, malaria, and maternal, newborn, and child health and nutrition (MNCHN), with activities including: (i) advocacy outreach to opinion leaders and community influencers; (ii) direct engagement of community members through household visits and community dialogues; and (iii) complementary integrated SBC messaging through mass and mid-media and mobile phones. Because this survey was intended as a baseline, no project activities had commenced; hence, no attempt is made here to link programme interventions to health behaviours.

The SBC interventions of the B-A/N project are guided by the Ideational Theory of Behavior Change, which combines components of multiple behaviour change theories and traces the elements of SBC interventions (e.g., mass media, social media, interpersonal communication) through a set of psychosocial influences that affect contraceptive behaviors and intentions. The ideational theory groups these factors into three domains: cognitive (knowledge, beliefs, values, perceived risks, and norms), emotional (self-efficacy), and social influences. Using this framework (see Table 1 in the paper), the researchers carried out mixed-effects logistic regression analyses to assess associations between ideational factors and family planning outcomes, as well as post-estimation simulations with regression coefficients to model the magnitude of effects for these intermediate determinants.

Of the 3,000 women, 13.3% (n = 393) were currently using modern contraception, while an additional 14.7% (n = 333) intended to begin using in the next six months. Only 7.4% had ever discussed with their husbands the number of children to have, and only 22.5% had ever discussed contraception. Only 43% of women reported they approved of family planning for spacing births, with 10.2% using it to limit the number of births. Knowledge of specific benefits of contraception varied by benefit; for example, only 15.5% of women agreed that contraception reduces unwanted pregnancies. Nearly half of women believed contraceptive myths (e.g., that its use can leave a woman permanently infertile). However, nearly 6 out of 10 women believed that couples who use family planning have a better quality of life, and almost half believed that most couples in their community use modern contraception for spacing births. Approximately half of women said religious leaders should speak publicly about family planning.

There was modest evidence for women's autonomy and self-efficacy in decision-making. Nearly 60% of women strongly agreed that a woman should play a role in household decision-making, and nearly 70% agreed that it is important that couples discuss contraception. That being said, less than one-quarter of women said decisions about family planning were solely theirs. Only 37.5% of women said they were confident they could use modern contraception even if their husband disapproved, even though 49.1% felt confident they could convince their husbands about using contraception. In terms of influencers, 30.7% of women reported that their partner influences the contraceptive use decision, while only 3.4%, 3.8%, and 4.7% reported that their decision was influenced by their mother-in-law, a health provider, or their mother, respectively.

The regression analysis supported previous studies indicating that ideational factors - across cognitive, emotional, and social ideational domains - are associated with better family planning outcomes in northwestern Nigeria (see Tables 5-9 in the paper for the data). Several factors - knowledge, contraceptive discussions with husband, and approval of family planning - showed the strongest associations across all of the outcomes. For example, women who personally approve of family planning were nearly 3 times more likely to be currently using modern contraception and nearly 6 times more likely to intend to start use in the next 6 months. The husband's influence was also critical: Women who had ever talked about family planning with their husbands were 3 times more likely both to be currently using modern contraception and to intend to start in the next 6 months. Regression results further indicate that it is not simply the involvement of the husband that matters but rather that the husband needs to be involved in a joint decision-making process with his wife. That is, couples who make family planning choices together (vs. the husband making a unilateral decision) tended to have better family planning outcomes.

Next, the researchers used the post-estimation marginal effects from the regression analysis results to simulate the magnitude of improvements in family planning outcomes that could be achieved in a world with improved ideation (thanks to SBC intervention). They look at these impacts across the different domains of the ideational model: knowledge and risk perceptions, beliefs, values, norms, and emotional (self-efficacy) and social influences. For instance, the simulation shows that improving contraceptive knowledge and risk perceptions alone could increase modern contraceptive use by approximately 8.8 percentage points and approval of modern contraception by 17.5 percentage points. In a world of perfect ideation (e.g., if everyone had correct knowledge and held no contraceptive myths), modern contraceptive use might reach as high as 63.6% of married women, intentions to use might reach 81.6% of non-users, discussions with husbands about the number of children to have and family planning might reach 32.3% and 69.2%, respectively, and approval of family planning for spacing births could reach as high as 95% of women. "Therefore, SBC programs that are able to shift these ideational factors may substantially improve a cascade of family planning outcomes."

SBC programmes interested in improving family planning outcomes could potentially use this study's findings as a guide. For example:

• The data show that approval of family planning represents an important barrier to use: Even though only 43.2% of women approve of contraceptive use for spacing births, approval was associated with a nearly three-fold greater likelihood of contraceptive use. Approval itself could be significantly influenced by SBC programmes geared towards improving family planning knowledge and dispelling contraceptive myths, thereby achieving gains in contraceptive use.
• This work highlights that husbands are critical to family planning behaviours; SBC programmes could maximise effectiveness by specifically engaging spouses in family planning promotion activities.
• The study provides support for SBC programmes working to support the engagement of other stakeholders in the family planning process. For instance, the influence of health providers, while cited by only a few women, was associated with a greater likelihood of using family planning.

The researchers recommend that future studies more fully explore the experimental designs used herein to control for unobservable factors that may simultaneously influence ideational factors and the outcomes they are hypothesised to affect. They also surmise that panel data collection may better tease out the time-order of events (e.g., when was knowledge attained - before, during, or after uptake of modern contraception?). Ideational factors that are measured at one wave of data collection could then be linked to changes in family planning outcomes - use of modern contraception and intentions to use - in subsequent waves, lending greater credence to causal pathways.

In conclusion: "SBC programs interested in improving family planning outcomes could potentially achieve large gains in contraceptive use - even without large-scale changes in socio-economic and health services factors - by designing and implementing effective SBC interventions that improve knowledge, encourage spousal/partner communication, and work towards increasing personal approval of family planning."