Reproductive health issues of concern among Nigerians: an online survey

INTRODUCTION

Reproductive health is a key component of public health that is necessary for both the well-being and procreation of any population. Reproductive health indices in Nigeria are poor, with the contraceptive prevalence rate being 17% for all methods and 12% for modern methods and the unmet need for contraception being 19% among married women.¹ The uptake of contraception is higher among unmarried women (37%) as childbearing outside marriage is generally frowned upon by society. The total demand for contraception is 36% and the maternal mortality rate is 512/100,000 livebirths. The low of uptake of contraception and reproductive health services may be as a result of various factors including socio-cultural norms, religious beliefs, low educational status, difficulty in accessing services (due to distance, cost, lack of manpower, equipment or supplies), poor provider attitudes and poor involvement of men.^1-3 In addition to these, some vulnerable groups such as adolescents, people with disabilities, migrants and refugees also face barriers to accessing services that are peculiar to them such as limited opening hours, lack of appropriate communication materials, language barriers, and lack of appropriate equipment to cater to their specific needs.^4,5

Poor involvement of men in reproductive health has resulted in a limited understanding of these issues among men in Nigeria and elsewhere.^2,3,6-9 As a result of their limited understanding of reproductive health, men usually are more concerned with issues that affect their sexual health and tend to view other aspects of reproductive health as women’s issues.^6,8,9 Involvement of men is particularly important as they are the decision makers in these settings and their limited understanding of, and lack of support for reproductive health contributes to the poor reproductive health indices. The use of contraception, in particular, is more likely to occur when there is support from the husband/male partner.^10-12 Other factors that prevent the uptake of contraception include fear of side effects, religious beliefs/misconceptions, lack of access to services, and the belief among older women who are close to menopause, that they are no longer fertile.^10,11,13,14

On the other hand, women are usually concerned about all aspects of reproductive health and have high unmet needs for reproductive health services especially among young people, and those who are of lower educational and socioeconomic status.^2,10,12 This may be due to greater awareness of reproductive health issues that affect women because most interventions focus on these issues, especially those that are associated with mortality.

Improving the reproductive health indices requires improved understanding on reproductive health issues, how to prevent reproductive health challenges, and the available options for addressing reproductive health challenges. This requires interventions to improve access to information and interventions to improve access to services. This study was undertaken to get an understanding of what reproductive health issues are of concern to Nigerians and their suggestions on how to improve services in order to meet their needs. Insights obtained from this study will contribute to designing appropriate interventions to address the reproductive health needs in Nigeria and similar contexts.

METHODS

The study was an anonymous online survey using Google Forms that was circulated to contacts via WhatsApp between April and September 2020. The sample was one of convenience based on the authors’ contacts who were also encouraged to share the survey link to their own contacts who are Nigerians and were based in Nigeria. A structured questionnaire was used to obtain information from the respondents. Data obtained from respondents included information on their general biodata (age, sex, religion, education, marital status, place of residence, number of children). Respondents were asked to list three reproductive health issues that were of greatest concern to them in no particular order, with no options provided to choose from. In terms of suggestions on how to improve reproductive health, some options were provided and respondents were asked to select as many as they felt were relevant in addition to listing other possible ways to improve reproductive health that were not listed in the options provided. Similarly, those who felt there was a need for more information to improve reproductive health were asked to select options for their preferred medium for receiving such information or list their preferred medium if not included in the available options in the drop-down menu. The questionnaire also sought information about their other reproductive health experiences such as knowledge and use of contraceptive methods, previous abortions for non-medical reasons, and experience of sexual challenges. The questionnaire was pre-tested among contacts who were not health professionals and based on their inputs, modifications were made in order to ensure that the desired responses were obtained. The statistical analyses included rates and comparative analyses, and these were carried out using MINITAB statistical software version 19. The rates used in this paper are percentages. Statistical tests of association included chi-squared test, and student’s t-test. The level of significance used for all the tests of association was a p value of less than 0.05.

The limitations of the study include the convenience sampling and the use of an online survey both of which resulted in respondents being only those who are educated and have access to the internet.

RESULTS

There were 106 responses and of these, six respondents were not resident in Nigeria (1 from Canada, 1 from United Kingdom, 1 from Kenya, 1 from Australia, and 2 from United States of America). The non-resident responses were excluded and the analysis carried out on the data obtained from the 100 Nigeria-resident respondents.

The respondents were made up of 62 women (62%) and 38 men (38%) and majority had a Master’s degree (51%) while the rest had a first degree (32%), PhD (7%) and professional fellowship (5%). Majority were Christians (62%) while the rest were Muslims (38%) and most of them were married (76%) while the rest were single (17%), divorced (4%), widowed (2%) or separated (1%). The age of the respondents ranged from 22 to 60 years with a mean of 41.2 years and a median of 41 years (standard deviation=7.41).

The number of children that respondents had ranged from 0 to 10 with a median of 2 and a mean of 2.22 (standard deviation=1.83). Those who did not have any children were 18% while those who had between 1 and 4 children comprised 75% and the rest (7%) had 5 or more children.

Reproductive health issues of concern

As shown in Figure 1, the most common reproductive health issues of concern to respondents were sexual health, contraception, infections, fertility issues, and female reproductive tract cancer.

Sexual health issues that were mentioned included how to ensure the well-being of the sex organs, penile size, how to have a satisfying sex life/sexual pleasure/orgasm, sex education for adolescents and adults, and information about sexual challenges like erectile dysfunction/weak erection, impotence, quick ejaculation, low libido, selfishness by men during intercourse, and vaginal dryness.

Issues about contraception that were mentioned by respondents included side effects of contraceptives, effects of hormones, effectiveness of natural methods, ease and flexibility of use of contraceptives, freedom to decide when to have children, how to address lack of cooperation by men, and concerns about marketing of artificial methods.

Infections of concern to respondents included fungal infections, sexually transmitted infections (STI), vaginal infections, cervicitis, HIV/AIDS, hepatitis, and pelvic inflammatory disease (PID).

Concerns about fertility included infertility, low sperm count, low sperm quality, sterile sperm, blocked fallopian tubes, and assisted reproduction.

Cancer issues of concern included cancer of the cervix, breast, uterus, and ovary, as well as cervical cancer screening. Prostate cancer was mostly included as part of prostate issues and the data for this is separated from the other reproductive cancers as shown in Figure 1.

Maternal health issues that were mentioned included safe delivery, vaginal birth after cesarean section, pre- and post-natal trauma, excessive bleeding after delivery, and maternal death.

A few respondents were also concerned about access to reproductive health information and services including awareness and education of men and young people (5.10%), availability and affordability (2.04%), getting the right information (1.02%), and ability to discuss reproductive health issues (1.02%). Other concerns mentioned included encouraging the use of traditional medicine for reproductive health issues (1.02%), community attitudes towards reproductive health especially for adolescents (1.02%), poor attitudes of health personnel in public health facilities (1.02%), and the small number of female gynaecologists available (1.02%).

Reproductive health improvements desired

As shown in Figure 2, the most common improvements respondents would like to see in reproductive health included having more information, greater involvement of men, improved access to services, and greater involvement of young people.

Among those who wanted more information, the most common preferred media of information included social media (20.00%), email (20.00%), and health workers including door-to-door services and seminars in schools (13.85%). Other preferred media of information included radio (4.62%), print media (3.08%), parents/family (1.54%), and SMS messages (1.54%).

Respondents who identified sexual challenges as a reproductive health issue of concern were significantly older (mean age=44.17 years) compared to those who did not identify this as an issue of concern (39.96 years) based on the t-test (p=0.006). Age was not significantly associated with any other reproductive health issue of concern. Age was also not significantly associated with the desired reproductive health improvements or the preferred medium for receiving information. Similarly, religion (Islam or Christianity), marital status (married or unmarried), the number of children the respondent had (0, 1–4, 5 or more) and current use of contraceptives (use or non-use), were not significantly associated with any reproductive health issue of concern, any desired reproductive health improvements or the preferred medium for receiving information.

Gender

More women were concerned about the various reproductive health issues especially family planning (significant difference) and fertility (not significant), except for sexual challenges that were reported to be of concern by a larger proportion of men than women. More women indicated that greater involvement of men for improvement of reproductive health while more men than women indicated a need for improved access to services for improvement of reproductive health. Details are in the Table 1.

*More balanced narrative explained as more balanced narrative about reproductive health especially with regards to the use of natural methods and traditional medicine

The proportion of respondents that reported they or their partner had a previous abortion for non-medical reasons was 21%. Majority of respondents (80.95%) who had such history of previous abortion desired greater involvement of men in reproductive health issues compared to those who did not have such previous abortion (56.96%) and the difference was statistically significant based on the chi-squared test (p=0.044). Previous non-medically indicated abortion was not significantly associated with any other desired improvements in reproductive health, any reproductive issues of concern, or the preferred medium for receiving information.

Sexual challenges

Sexual challenges were present among 24% of the respondents. A significantly higher proportion of those who had sexual challenges (75.00%) mentioned the need for improved access as a way of improving reproductive health compared to those who did not have sexual challenges (50.00%) based on the chi-squared test (p=0.031). A higher proportion of those who had sexual challenges (29.17%) identified fertility as a reproductive health issue of concern compared to those who did not have sexual challenges (13.51%), however, the difference was not statistically significant (p=0.078). The presence of sexual challenges was not significantly associated with any other reproductive health issue of concern, any desired improvements in reproductive health, or the preferred medium for receiving information.

There was no significant difference between those who sought care for sexual health challenges and those who did not, with regards to reproductive health issues of concern, desired improvements in reproductive health, and the preferred medium for receiving information.

Family planning use

Almost half of the respondents (48%) were using contraceptives and 35% of the respondents were using modern contraceptive methods while the rest were using natural methods and withdrawal method. Figure 3 shows the details of the contraceptive methods used by respondents. The male condom, natural methods and intrauterine devices or intrauterine systems (IUD or IUS) were the most common methods used by respondents.

Among respondents currently using contraceptives, majority were satisfied (86.36%) with contraception while the rest (13.64%) were not satisfied. There was no significant association between the method of contraception being used and whether or not they were satisfied with contraception.

The proportion of married respondents using contraceptives (53.95%) was significantly higher than the proportion of unmarried respondents using contraceptives (20.83%) based on the chi-squared test (p=0.005). Similarly, contraceptive use was significantly higher among those who had 1 to 4 children (61.02%) compared to those who had no children (23.53%) and those who had 5 or more children (28.57%) with a p value of 0.001. A larger proportion of respondents that did not report sexual challenges (66.67%) were using contraceptives compared to the proportion of those who had sexual challenges (39.47%) that were using contraceptives (p=0.020). Current use of contraceptives was not significantly associated with age or sex of the respondent, religion, or a history of previous non-medically indicated abortion.

DISCUSSION

The most common reproductive health issue of concern to respondents was sexual health and this was significantly associated with the sex of the respondent, being more commonly cited as an issue by men. This finding is in keeping with a previous report and reflects the belief that other reproductive health issues are women’s issues only.^6,8 Men also more commonly mentioned the need for improved reproductive health services as an issue of concern and this may be due to the limited access they have to these services. Women more commonly cited contraception and the need for greater involvement of men as issues of concern, and this is not surprising as they are the main consumers of contraceptive services and as previously reported, their uptake of these services is greater when they have the support of their husbands/male partners.^10-12 The need for greater involvement of men was also mentioned by a greater proportion of those who had a previous termination of pregnancy for non-medical reasons and this is further indication of the need for their husbands/male partners support by women during reproductive health services. Sexual health was also more commonly mentioned by older persons as a reproductive health issue of concern and this is in keeping with previous reports that indicate a greater prevalence of sexual health challenges among older persons.^18,19 The need for improved access to services was more commonly mentioned as a required improved for reproductive health services by those who had sexual challenges regardless of whether they had sought care for their sexual health challenges or not. This finding is in keeping with previous reports that suggest that there is a need for improved sexual health information and services.^8,9,15-17 Fertility was mentioned as a reproductive health issue of concern more commonly by those who had sexual challenges and this is not unexpected as low fertility can result from such challenges.

The most common suggestions for improving reproductive health services were provision of more information, greater involvement of men, improved access to services and greater involvement of young people. These suggestions are probably a reflection of the gaps observed in services by the respondents and they have also been identified by previous researchers as priority areas for service delivery and research in Africa and the Eastern Mediterranean region.²⁰ The preferred sources of information included social media, email and health workers (including door to door services and seminars) and this highlights the need to utilize available technology to reach greater audiences. There have been reports that mobile phone technology is an acceptable means for providing reproductive health information and services.^21,22

The proportion of married respondents using contraceptives was significantly higher than the proportion of unmarried respondents using contraceptives in this study. This is in contrast to the finding of the Nigeria demographic and health survey of 2018 that reported a higher proportion of unmarried women (37%) using contraceptives compared to 17% among married women.¹ This difference in findings may be due to the fact the respondents in this study were all educated as it has been shown that contraceptive use and desire for fewer children is higher among educated individuals.¹ Similarly, the proportion of respondents using contraceptives was higher among those who had 1 to 4 children compared to those who had no children and those who had 5 or more children, as has been previously documented.¹ This is not unexpected as those who have no children would probably like to have children while those who have 5 or more children tend to be older and a lot of them would probably be menopausal.

CONCLUSION

In conclusion, the findings of this study suggest a need for the general public to be provided with accurate and practical information regarding reproductive health issues in order to enable them make informed choices on these issues. The findings also highlight the importance of education in improving reproductive health indices as evidenced by the high proportion that were using contraceptives among this group of educated respondents compared to the general population in the country. This is an additional reason for encouraging education especially among girls in the country. In order to have meaningful impact, reproductive health interventions should ensure availability of information and services that are inclusive of adolescents and young people, men and older persons, through various channels of communication such as school seminars, health workers, traditional and social media, and other technologies.

ACKNOWLEDGEMENTS

The authors would like to acknowledge all those who took time to respondent to this survey.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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