Contraceptive Utilization and Sexual Practices of Female Undergraduate Students in University of Benin

CHAPTER ONE

INTRODUCTION

1. BACKGROUND

There has been considerable concern in many countries about the sexual and reproductive health of young people, in part because of their perceived increased vulnerability to the risk of sexually transmitted infections (STIs), including human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).¹ The potential risks to health due to early and unintended pregnancy, unsafe abortion and other negative consequences of early and non-marital childbearing to young people’s life prospects are major issues of great concern to health policy makers. These reproductive health problems observed among Nigerian youth have become great Public Health problem and has drawn the attention of researchers, non-governmental organizations (NGOs) and policy makers to examining the driving force behind the upsurge amongst the adolescent group.²

Sexual and reproductive health is an important issue to every stakeholder in the global health sector particularly with regard to the youth and adolescents.³ A number of factors are responsible for the high level of importance attached to adolescents/youth’s sexual and reproductive health. Various authors indicate that adolescent/youth’s sexual and reproductive health for most countries is in bad shape. The health risk faced by adolescent girls during pregnancy is very high, accounting for 15% of Global Burden of Disease (GBD) for maternal conditions and 13% of all maternal deaths.⁴ The cause of this degenerating health condition of adolescent girls is lack of knowledge and access to contraception.³ Consequently, active and intensive promotion of sexuality education, and contraceptive use among the youths in Sub-Saharan Africa is a way of addressing this anomaly.⁵ In Nigeria, it was observed that the country’s high maternal mortality ratio (MMR) is attributed to her youth’s sexuality.⁶ The latter is characterized by low contraceptive usage by the youth, high incidence of illegal abortion amongst the youth, ignorance of contraception among the youth, and lack of sex education from parents and teachers.⁶

In sub-Saharan Africa and most developing countries including Nigeria unintended pregnancy poses a major challenge to the reproductive health of young adults.⁷ Some young women with unintended pregnancies obtain abortions of which are performed by quacks and/or in unsafe conditions and others carry their pregnancies to term, incurring risks of morbidity and mortality higher than those for adult women. Given increasing adolescent sexual activity and decreasing age at first sex in developing countries like Nigeria and other sub-Saharan African countries, the use of contraceptives to prevent unwanted pregnancy and unsafe abortion is especially important. The attitude, knowledge and practice of contraceptives among sexually active Nigerian youths is important because of high rate of unwanted and unintended pregnancies as well as sexually transmitted infections (STIs) and human immune virus/acquired immune deficiency syndrome (HIV/AIDS). However in Nigeria, contraceptive use among adolescents is low though the knowledge of contraceptive is very high especially among young people.⁸ Therefore the deliberate avoidance of its use during sexual intercourse may have resulted in many Nigerian female undergraduates coming with unintended pregnancies and STIs causing morbidity and mortality among them. Many studies have shown that there is high level of knowledge about contraceptives among Nigerian youths. This high knowledge as shown by many studies seem to have not translated into equivalent use amongst the youths, since the prevalence and incidence of unwanted pregnancy and induced abortion among this group of Nigerians are still on the high side.⁹

Unintended pregnancy which is the outcome of poor utilization of contraceptive commodities, is the leading cause of death for young women ages 15 through 19 because the reproductive health of adolescent women depends on biological, social, cultural, and economic factors. Nearly one-quarter of women age 25-49 have had sexual intercourse by age 15 and more than half by age 18.⁸ Often, the adolescent girl faces many sociocultural challenges and problems that beclouds their decision making thereby leading to seeking counseling from their peers who in turn are not experienced enough to proffer solution to their dilemma, especially when they are faced with unintended pregnancy. As a result, they usually seek termination of the unplanned and unintended pregnancy from unskilled providers and quacks many of which are complicated by permanent disabilities and related fatal consequences.^10,11 As a consequence of unsafe abortions; 70,000 women die every year, and five million suffer permanent or temporary disability.¹⁰

Abortion which is the termination of a pregnancy, resulting in or closely followed by the death of the embryo or fetus: or a spontaneous or induced expulsion of a human fetus during the first 12 weeks of gestation,¹² can be avoided by avoiding unwanted pregnancy. This can be achieved through the use of different available contraceptive methods and this is of great importance and can maximize the reduction in complications and mortality as a result of unsafe abortion.

1.2 PROBLEM STATEMENT

Abortion rates have declined significantly since 1990 to 2014 in the developed world (such as Europe and North America), but not in the developing world (such as Sub-Saharan Africa the Caribbean and some other Middle Eastern countries) where abortion rate has made no significant decline over the same period.¹³ A survey carried out on abortion incidence between 1990 and 2014 in global, regional and sub-regional levels across the world shows that knowledge, access and availability of contraceptive commodities and methods in the developed countries are much more than their developing counterparts.¹³

With a population of over 175 million people, Nigeria is the most populous country in Africa and the seventh most populous country in the world. The country’s annual population growth is 3.2%, and the total fertility rate is 5.5 children, with variations across states and regions.⁸ Most projections place Nigeria as the third most populous country behind India and China by 2050. There are approximately 35 million women of reproductive age in Nigeria, and the country had nearly 7 million births in 2012 alone.⁸ According to the 2013 Nigeria Demographic and Health Survey (NDHS), nearly one-quarter (23%) of adolescent women age 15-19 are already mothers or pregnant with their first child.⁸ Young motherhood is highest in North West Zone (36%) and lowest in South East and South West Zones (the two zones having 8% each). The survey reported that half of adolescent women with no education in Nigeria have begun childbearing, compared with 2% of those with more than secondary education. It also reported that teenagers from the poorest households accounting for 43% of the total households, are more likely to have begun childbearing than those from the wealthiest households (5%). The survey also shows that 84% of all women in Nigeria know of one modern method of contraception or the other, while only 56% know at least one traditional method.⁸ Notwithstanding, the rate of abortion has always increase in Nigeria.  Ensuring access to sexual and reproductive health care could help millions of Nigerian avoid unintended pregnancies thereby eliminate induced abortion or reduce it and its attendant complications, and ensure reduction in maternal mortality and morbidity the results from unsafe abortion.⁸

The promotion of effective contraceptive use among Nigerian adolescents is a major challenge that requires serious attention, if their reproductive health is to be improved. Due to an increasingly interest in acquiring a formal education, Nigerian youths are now marrying later. Moreover, there is an increasingly rate of premarital sex amongst the youths which makes it clear that allowing the existing gap between contraceptive need and contraceptive utilization to be left unfilled will result in a dramatic rise in the prevalence of unsafe abortions. This will further compound overall levels of maternal mortality in Nigeria. Other than identifying at-risk groups that are often unaware of contraception, a comprehensive study of the knowledge, utilization and outcome of contraceptive methods and of societal views on risks associated with abortion is highly needed. In particular, social and cultural barriers to contraceptive utilization among adolescents need to be analyzed and this is one of the main thrust of this research work.

1.3 JUSTIFICATION OF THE STUDY

Unwanted pregnancy, induced abortion and low access to, and lack of knowledge of contraceptive commodities are serious problems of developing countries in general and Nigeria in particular. The majority of under reported cases of induced abortions in Nigeria is mainly because of the social and cultural norms as well as the religious preachments about contraception in our society. Abortion is probably the fourth leading cause of maternal mortality in Nigeria and accounts for significant proportions of maternal morbidity and long term reproductive ill-health.¹⁴ Understanding the magnitude of unwanted pregnancy and induced abortion as a result of low use of contraceptives among undergraduate students in Nigeria, as well as the factors that are associated with them is very crucial in designing and implementing interventions that could be tailored to effective provision of the reproductive health needs of this group of young people in our society.

This study would help to determine the knowledge of contraceptive and the extent of its use amongst female students of university of Benin. This will enable us to know the modalities for further educating the students on different forms of contraceptives, proper use of such contraceptives, side effects and suitability and benefits of contraceptives on individual basis.

1.4 RESEARCH QUESTIONS

The study tends to provide answers to the following questions:

1. What is the prevalence of contraceptive utilization among female undergraduates of University of Benin?
2. What is the proportion of the University of Benin female undergraduates that are sexually active?
3. What is the association between knowledge and contraceptive utilization among female undergraduate students of University of Benin?
4. What are the factors associated with contraceptive practices/utilization of female undergraduate students in University of Benin?
5. What are the outcomes experienced of sexual practices/behavior of female undergraduate students of University of Benin?
6. What are the reasons that influence the utilization of contraceptive methods by female students?
7. What are the sexual and reproductive health services available for the female undergraduate students in the University of Benin Health Center?

1.5 RESEARCH OBJECTIVES

1.5.1 BROAD OBJECTIVE

The main objective of this study is to determine the rate of contraceptive use, sexual activity and sexual outcome of female undergraduate students in the University of Benin, Benin City, Edo State, Southern, Nigeria.

1.5.2 SPECIFIC OBJECTIVES

1. To determine the prevalence of contraceptive utilization among female undergraduates of University of Benin.
2. To ascertain the factors associated with contraceptive practices/utilization of female undergraduate students in University of Benin.
3. To determine the sexual practices/behavior of female undergraduate students of University of Benin.
4. To identify the outcome of sexual practices among female undergraduate students of University of Benin.
5. To determine the sexual and reproductive health services available for the female undergraduate students in the University of Benin Health Center.

CHAPTER TWO

LITERATURE REVIEW

Adolescents are generally defined as young people under various laws, conventions and culture. They are people who are within the ages of 10-24 years, according to World Health Organization.¹¹ It is a period of life from puberty to attainment of full maturity (adulthood) or growth, a time of being young when one’s appearance is full of freshness, vigor and young spirit. Adolescents also share certain characteristics that distinguish them from other generation. Such characteristic include, desire for independence, zealousness, radicalism, rebellions, curiosity, sexual risk behaviours, etc. It is both a period of opportunity as well as a time of vulnerability- a time of experimentation with new ideas and options and marked with vulnerability to health risk and those related to unsafe reproductive health outcomes.

Young people make up over a third (31.6%) of Nigeria’s large and growing population.¹⁵ until around 2010/2012, adolescents in Nigeria were seen as a healthy segment of the population and received low priority for services, but biology and society bring an additional health challenges to them; those resulting from unprotected sex, violence and substance abuse.¹⁶ According to a report by Babatunde Ahonsi in 2013, adolescents in Nigeria have high burden of reproductive health problems.¹⁶ “Adolescents and young adults are a critical segment of human society being the direct link between its future (children) and past (older adults) since they are for the most part preoccupied with preparation for the full assumption of adult roles and responsibilities”.¹⁶ This assertion supported earlier surveys conducted on sexual behaviours of Nigerian Adolescents which show that Nigerian adolescent (15‐19) in almost half of the females (46.2%) and about a quarter of males (22.1%) have engaged in sexual intercourse.^17-19 This figure varies from state to state. For some states like Cross Rivers it can be as early as 7 years.¹⁹

The data from the Federal Ministry of Education in 2009 found that 21% of upper primary school children surveyed indicated that they have been involved in sexual intercourse yet only 40.6% who had two or more sexual partners in the past 12 months reported using a condom during their last sexual intercourse thereby exposing themselves to the danger of HIV/AIDS epidemic.¹⁷ Young people are clearly disproportionately affected by the epidemic in absolute terms even with the decline in overall HIV prevalence. The survey indicated that 2.9% of young people aged 15-19 years are infected while female adolescents aged 15-24 is most disproportionately affected by the HIV epidemic among the 4 broad age-gender categories of the sub-population.¹⁹

In addition to the risk of sexually transmitted infections (STIs), risk of unplanned pregnancy increases with frequency of unprotected sexual intercourse. Estimates have suggested approximately 23% of adolescent girls have begun childbearing while 54% have given birth to a child by age 20. Hospital based studies also show that adolescent girls make up over 60% of women treated for complications from unsafe abortion with many such complications resulting in death or permanent injury, disability or infertility.²⁰

Female adolescents often consider risky sexual behaviours as an elevation of status rather than being vicious.²¹ These patterns broadly conform to data from across Africa which suggests that the combination of being young, poor, female and lacking access to sexual health information and services carry particularly high risks for sexual reproductive health challenges.^22-24 Pregnancy among adolescent and the resulting abortion are interrelated problems facing the youths in most countries of the world especially the developing countries. Nigerian youths for example, are also faced with the phenomenon. This necessitates the need to examine the attitudes and beliefs of these young adults towards the use of different contraceptive methods in the prevention of STIs, unwanted and unintended pregnancies and induced abortions.

Some researchers have argued that teenage pregnancy is a shameful thing to experience because the society feels that the parents of the girl have failed in their roles as parents. Others have also argued that young people should not be thought sexuality education as well as not be encouraged to make use of contraceptive methods. To the latter, the knowledge and access to contraceptives is a direct license to promiscuity among the youth. It is in the light of all these, that one can appreciate the explanation that some parents can tell their wards (children) to abort.

2.1 CONTRACEPTIVE UTILIZATION

Contraceptive use for family planning refers to a conscious effort by a couple or sexual partners to prevent the occurrence of pregnancy thereby limit or space the number of children they want to have through the use of contraceptive commodities or methods. Contraceptive methods are classified as modern or traditional methods. Modern methods include female sterilization, male sterilization, the pill, the intrauterine device (IUD), injectables, implants, male condoms, female condoms, the diaphragm, foam/jelly, the lactational amenorrhea method (LAM), and emergency contraception. Traditional methods include the rhythm (periodic abstinence) and withdrawal methods and folk methods such as strings and herbs.

Comprehensive and timely estimates on global trends in family planning are critical for assessing current and future contraceptive demand and setting policy priorities to ensure universal access to sexual and reproductive health and the realization of reproductive rights.²⁵ According to Trends in Contraceptive Use Worldwide 2015 report; In 2015, 64% of women of reproductive age worldwide were using some form of contraception. However, contraceptive use was much lower in the least developed countries (40%) and was particularly low in Africa (33%). Among the other major geographic areas, contraceptive use was much higher, ranging from 59% in Oceania to 75% in Northern America. Worldwide in 2015, 12% of women are estimated to have had an unmet need for family planning.²⁵ The level was much higher (22%), in the least developed countries of which many of these least developed countries are in sub-Saharan Africa. This region is also the region where unmet need was highest (24%), double the world average in 2015. The same report have it that 57% of women of reproductive age used a modern method of family planning, constituting 90% of contraceptive users. When users of traditional methods are counted as having an unmet need for family planning, 18% of women worldwide are estimated to have had an unmet need for modern methods of contraceptives.²⁵

Contraceptive use and unmet need for family planning levels in Africa vary widely across countries. Within Africa, countries or areas with contraceptive prevalence of 50% or more are mainly islands (Cabo Verde, Mauritius and Réunion), or located in the north of the continent along the Mediterranean coast (Algeria, Egypt, Morocco and Tunisia) and in Southern Africa (Botswana, Lesotho, Namibia, South Africa and Swaziland). Five countries in Eastern Africa (Kenya, Malawi, Rwanda, Zambia and Zimbabwe) also had contraceptive prevalence levels of 50% or more in 2015.²⁵ In contrast, 17 countries of Africa had contraceptive prevalence levels below 20%. This group includes the populous country of Nigeria, where contraceptive use was at less than half the level in Ethiopia (16% and 36%, respectively). Less than 10% of women of reproductive age (15-49 years) were using contraception in Chad, Guinea and South Sudan in 2015.²⁵ It is estimated that the percentage of women to have had an unmet need for family planning in 2015 ranges from less than 10% in 36 countries across all major areas to 30% or more in 15 countries concentrated in Africa (also including Haiti and Samoa). In 59 countries, at least one in five women on average had an unmet need for family planning in 2015, and 34 of these 59 countries are in Eastern Africa, Middle Africa or Western Africa.²⁵

In a descriptive, cross-sectional, research study conducted among 346 randomly selected students to investigate the awareness and utilization of various contraceptive methods, among university students in Botswana, using confidential, self-administered questionnaires. The study show that both the male and the female students had almost similar awareness level of contraceptive use. All the female students (100%) were ‘aware’ that the effectiveness of the contraceptives used, as compared to male students, being 93.7%. A greater proportion of the female students (90.6%) knew that using contraceptives irregularly would result in pregnancy, in contrast to 76.4% males.²⁶ More than half (59%) of the students indicated that they had engaged in sexual acts. Significantly, more male students (68.5%) had sexual experiences prior to the study, compared to 54.5% of their female counterparts.²⁶ The majority of the students (76%) reported that they had always used contraceptive methods. The most commonly used contraceptive method was the condom (95.6%), followed by oral contraceptive pill (86.7%). There was no significant association found between the level of awareness and the use of contraceptives. Results suggested that many students still engaged in risky, contraceptive practices by engaging in unprotected sexual acts.²⁶ The limitation of the study is the study population which consisted of students at one university, and therefore might not be advisable to generalize the results with regard to other universities and the general population. The study also did not assess the outcome of non-use of contraception which may include unintended pregnancy, unsafe abortion, STDs etc.

Despite years of huge investments by international donor agencies in promoting family planning, Nigeria still has one of the lowest overall contraceptive prevalence rates (less than 10%) and highest unmet need for contraception (>20%) in Africa.²⁷ This rate is very low in spite of the high rate of sexual activity and widespread awareness of the various contraceptive methods among Nigerian adolescence and youths. As a result there are many unintended pregnancies and illegal abortions contributing to a high maternal mortality ratio, which seems to indicate a large unmet need for contraceptive use. There is ample research evidence identifying the various factors that contribute to the low prevalence of modern contraceptive use in Nigeria, with the most common factor being the myth about the side effects of modern contraceptives. However, what is lacking is a political will in Nigeria to provide family planning programs on a much larger scale, using community-oriented approaches and communication programs, to help change the myth about the side effects of modern contraceptives.²⁸ It is also now evident that resistance to contraception in the country is based on cultural and religious preachments that favor high fertility and the erroneous perceptions by women that contraception is associated with serious long term side effects.²⁹ This may suggest the disparity that exist between the knowledge of contraceptive methods among women of reproductive age and induced abortion incidence in Nigeria.

The NDHS, 2013 shows that; the overall contraceptive prevalence among women in Nigeria is 16 percent.⁸ The use of any family planning method increases with age from 6% among women age 15-19 to 21% among women age 35-39, after which it declines to 12% among women age 45-49.⁸ Most women currently using contraception use a modern method (11%), while 5 percent use traditional methods. The survey also show that the use of family planning methods is higher among sexually active unmarried women than among currently married women (68% versus 15%), and more sexually active unmarried women (55%) than currently married women (10%) use modern family planning methods.⁸ There is also a notable difference between sexually active unmarried women and currently married women in use of the pill (8% versus 2%). The survey further shows that knowledge of any contraceptive method is widespread in Nigeria, with 85% of all women and 95% of all men knowing at least one method of contraception.⁸ Modern methods are more widely known than traditional methods; 84% of all women know of a modern method, while only 56% know a traditional method. Similarly, 94 percent of all men know of a modern method, while 65% know of a traditional method.⁸

2.2 KNOWLEDGE OF CONTRACEPTION

A study to assess the knowledge and use of contraceptives among tertiary education students in South Africa, the authors demonstrated that the knowledge, use and perceived problems in the use of contraceptives is predicated upon young people’s social and demographic characteristics most importantly, the study showed that gender and ager are significant variables in understanding knowledge and use of contraceptives among university students.³⁰ Some other studies showed that having heard of contraceptives was significantly different for men compared to women and for respondents of different age groups. It was reported that there is a significant relationship between student’s attitudes towards contraceptive use and their knowledge of contraception.³¹ Another study similarly reported that attitude of young adults and adolescent affect their knowledge of reproduction.³² In other studies this relationship between students’ attitude and their knowledge of contraception has been well established. For example, an investigative study on sexual attitude and behaviour among adolescence concluded that sexual attitude and behaviour among adolescents have been significantly sharpened by socio-psychological factors and consequently affect their knowledge of contraception.³³ In other studies on attitudes towards abortion and contraception among secondary school girls, a near collaborative finding was reported.³⁴ However, females may be expected to have more knowledge of a wider array of contraceptives because of the number of contraceptives that are used by females is more than those for males who often use only condoms.³⁰

Several studies in the six geopolitical zones in Nigeria indicate that contraceptive knowledge and awareness, especially among female students aged 15 to 24 years, is very high.^{4-5,9,35-39,59} In a study done among 400 Ahmadu Bello University students on the sexual behaviour, contraceptive practice and reproductive health outcomes, the investigators found out that 32.4% of the sexually exposed respondents had ever used or were using a method of contraception.³⁵ They also found that condom was only used by about 30% of the sexually active respondents which made the use of effective contraceptives very low. In all, 23.3% of the overall respondents had experienced symptoms suggestive of sexually transmitted infections within six months of proceeding of their study and they also found out that the utilization of the university health services for their reproductive health needs was very low.³⁵

In a study which was conducted to assess knowledge, attitude, and contraceptive usage, and associated factors among women of reproductive age attending a health facility in Benin City. The authors used a total number of 161 women of age 15-49 (reproductive age) attending immunization clinics in a health facility in Benin City. Their result shows that 85.7% of the women were aware of contraception with 92.8% having correct knowledge of contraception while 64.5% were using contraception at the time of their study.³⁶ They concluded that the level of awareness and knowledge on contraception among women studied was high,³⁶ but they did not show whether the high awareness and knowledge of contraception actually translates into the use as a preventive tool against STIs and unwanted pregnancy. In addition the study was health facility based as such subject to the “ice-berg phenomenon”, a community based study would have enriched research findings.³⁶ Finally, the fact that the study was health facility based implies that the findings may not be generalizable as being reflective for Benin City.

Also, in a study on awareness and practice of contraception among university students in Abakaliki, the authors concluded that the poor knowledge and use of emergency contraception has resulted in high rates of unwanted pregnancies and consequently unsafe and induced abortions among these vulnerable groups with its attendant consequences especially in resource poor settings like many Nigerian communities.³⁷

In another descriptive study, using a pre-tested, self-administered semi-structured questionnaire, to assess the knowledge, attitude and practice of contraception among male and female public secondary school students in Ekpoma. The study population consisted of male and female junior secondary III (JS III) and senior secondary III (SS III) school students in Ekpoma aged 12-24 years, and in all 690 male and 814 female students were recruited for the study.³⁸ Results obtained showed that 398 (57.7%) out 690 male students that participated in the study were sexually active while only 216 representing 26.5% of the female population for the study were sexually active. Data showing age of first sexual intercourse for sexually active boys and girls revealed that 68 (17%) male students had their first sexual intercourse at about 9 years of age, while 131 (33%) had their first intercourse experience at 10-14 years, and 147 (37%) at 15-18 years.³⁸ For the female students, 119 (55.1%) had their first sexual intercourse experience between ages 15-18 years and while only about 61 (28.5%) had their first sexual intercourse at less than 15 years. Also about 292 (42.3%) male and 492 (60%) female participants had good knowledge about contraception. About one third of the male students 206 (29.9%) and 122 (15%) of the female students had no knowledge of contraception.³⁸ The researchers concluded that there is a dearth of information about contraception among secondary school students in Nigeria thus culminating in their low level of knowledge on the safety and importance of contraception in the prevention of unwanted pregnancy and sexually transmitted diseases (STDs).³⁸ Having this number of students being sexually active, it could have been good and a plus if the authors assessed the outcome of the students’ sexual activities.

These are in contradiction to the assumption that there is high knowledge of emergency contraceptive methods amongst youths across the nation as posited by a cross-sectional study which looked at the knowledge, attitude and practice of contraceptives among undergraduates in Lagos state university.²⁹ Three hundred and sixty four (364) individualized self-questionnaires with open and close ended questions were administered to both male and female students attending undergraduate courses in the four main campuses of Lagos state university.²⁹ At the end of the study, it showed that knowledge of contraceptive use among university undergraduates is as high as 98.9%, the attitude to contraceptives being positive and welcoming and was also high 92.0%.²⁷ They concluded that undergraduates not only believe that young adults should use contraceptives, but are also ready to encourage partners to use them. But unfortunately, they observed that the practice of contraception is low 54.1% among these students, they attributed it probably, due to discrimination against young adults by family planning providers and low parental influence on contraceptive.²⁷

Emergency contraception (EC), just as the name implies, refers to the use of a drug or device in the menstrual cycle to prevent pregnancy after an unprotected sexual intercourse or a contraceptive failure. The most common form is the Emergency contraceptive pill (ECP) sometimes called “morning-after pills or “post-coital contraceptives”. Several methods have been used over the years, ranging from the Yuzpe regime (which comprised of 100µg of ethinyl estradiol and 0.5mg of Levonorgestrel) taken within 72 hours of unprotected sexual intercourse and a repeat 12 hours later. Others include Copper IUD which is inserted within 120 hours after unprotected sex, progesterone only pills and low dose Mifepristone.^39-40

Emergency contraception is an underutilized form of primary pregnancy prevention. There is therefore growing interest in the potential impact that emergency contraception could have on unwanted pregnancies and unsafe abortions.^40-41 Studies has shown strong evidence that the use of effective contraception leads to a decline in abortion.^39-40,42 Emergency contraception provides a safe and effective means of post coital treatment and has been estimated to prevent at least 75% of pregnancies expected from unprotected intercourse. Emergency contraception is particularly for youths because of their pattern of sexual behaviour and contraceptive use. They do not often plan their first intercourse or may have infrequent intercourse with no contraceptive options⁴³.

The use of emergency contraception among female university students in Nigeria has been low. The findings from a study conducted among University of Port Harcourt, southern Nigeria showed that there is limited knowledge and abysmally low utilization of emergency contraception at 13.3%, even when over 86% of the students are sexually active and single.⁴¹

A pilot cross-sectional study about EC awareness and practices among female undergraduates was conducted at a private university in southwest Nigeria between July and August 2013. The authors studied awareness and practice of emergency contraception among 94 female students and the result show that out of the 94 female students, 42 (44.7%) had sexual experience, but only 32 (34.0%) were currently sexually active.⁴² Six students (6.4%) had had unwanted pregnancies, of which all but one were terminated. Fifty-seven respondents (60.6%) were aware of EC, though only 10 (10.6%) ever practiced it. The study concluded that though awareness of EC was higher among the private university students than at most public universities, there was no difference in Emergency Contraceptive usage. A high pregnancy termination rate was observed; dilatation and curettage were mainly adopted.⁴² Considering the financial implications of attending private university in Nigeria, one would say that it is possible that the students’ high awareness of EC was based on the fact that they are more exposed and have easy access to the media and internet facilities than their counterparts in public university.

Rates of emergency contraception (EC) use in sub-Saharan Africa are highest in Kenya and Nigeria, although little is understood about user characteristics and use dynamics in these countries⁴⁴. In order to better meet the emergency contraceptive needs of women, and contribute to the limited knowledge base on EC in Africa, a study that examined a large, representative sample of EC users was initiated by Morgan Gwendolyn and co-researchers. The study drew on data collected from household surveys that included 7,785 sexually experienced women in urban Kenya and 12,653 sexually experienced women in urban Nigeria. Using bivariate and multivariate analyses, it was found that among these urban women, knowledge of EC was higher than reported in other nationally representative surveys (58% in Kenya and 31% in Nigeria).⁴⁴ About 12% of sexually-experienced women in Kenya and 6% in Nigeria ever used EC, although fewer women (less than 5%) reported using EC in the past one year. Recent users of EC were more likely to be in their twenties, unmarried, and more highly educated than never users or ever users of EC in both countries.⁴⁴

2.3 REASONS FOR NON-USE OF CONTRACEPTIVE METHODS

As the global trend toward greater control over childbearing and smaller desired family size continues, improvements and expansions of both contraception and abortion services will be needed. To identify areas with the greatest unmet need for contraception, demographers estimate numbers of women who do not want to become pregnant but who are not using a method of contraception.⁴⁵ Infrequent sex and concerns regarding side effects and health risks are the most common reasons for non-use in countries with high levels of unmet need for family planning.⁴⁶ Comparative studies of the reasons for non-use of contraception despite a stated desire to prevent pregnancy show that infrequent sexual activity (in part associated with labour migration) and fear of health side effects (in part associated with narrow contraceptive options, inadequate counselling or a lack of knowledge about contraception in general) are the most common reasons for non-use of contraception.⁴⁶

However, a report from the Guttmacher Institute has shown that most of these women do not lack access to contraception but, rather, choose not to use it.¹³ Sedgh and Hussain argued that expanding access to contraceptive supplies and services is not sufficient on its own to satisfy demand for family planning, but more crucially, providing information and counselling to users about all the modern methods that are available, how to use them, support for switching methods if needed, as well as expanding the range of modern methods available are necessary, not only to reduce unmet need but also to improve the uptake of more effective methods.⁴⁶

Bongaarts in agreement with Sedgh and Hussain stressed that these services can be provided by strong family planning programmes, which have two distinct effects on reproductive behaviour: (1) they reduce unmet need by making modern contraceptive methods more widely available and by removing obstacles to their use, encouraging more women and adolescent girls to practice contraception if they wish to avoid pregnancy; (2) they raise total demand for family planning through the implementation of IEC (Information, Education and Counselling) activities concerning the benefits of family planning and the proper way to use each of the different methods that are available in schools, consequently helping in the diffusion of ideas about contraceptive methods.^46,47 Information, education and counselling activities are particularly relevant for sub-Saharan Africa, where the countries with low contraceptive prevalence and high unmet need for family planning are concentrated.⁴⁸

In a cross sectional study of 400 senior secondary schools students mainly adolescents of age 10-19 in Ojo military barracks, Lagos, selected using the multistage sampling technique and self-administered structured questionnaires. Two hundred and seventy (67.5%) of them had correct knowledge of the use of condoms while 48 (31.1%) of the sexually active respondents have ever used any form of contraceptive with no statistically significant difference between the male and female respondents.⁴⁹ The most common barrier to contraceptive methods as reported by 131 (85.1%) of respondents was their being too embarrassed to source for the commodities.⁴⁹ Some other studies reveal that a high percentage of adolescents and young adults have had at least one unwanted pregnancy leading to induced abortion. The reasons given in these studies for not using contraceptives were fear of side effects, objections from their partner, conflicts with their religious beliefs, objections from family members, not thinking about using contraceptives, not having sexual intercourse to have a baby, and unplanned sexual debut.^50-51,46

A Nationally-representative, household-based surveys of female and male adolescents’ age, 12–19-year-olds was conducted in early to mid-2004 in Burkina Faso, Ghana, Malawi and Uganda. In these sub-Saharan African countries, the results revealed that sexually active adolescents were reported to have very similar perceptions of barriers to getting contraceptive methods as they do for STI diagnosis and treatment.⁵² They reported that feeling afraid, embarrassed or shy to seek such services (a barrier rooted in the social context surrounding adolescent sexuality) was one of the most common barriers named among sexually-active adolescents for obtaining contraceptive methods: 42–64% of sexually-active females and 38–59% of sexually-active males mentioned this as a barrier.⁵² More females than males reported feeling afraid, embarrassed or shy about obtaining either contraceptive services or STI treatment, but this difference was only statistically significant in Malawi and Uganda and the reverse pattern was true in Burkina Faso (though this was related to the fact that a larger proportion of female adolescents do not know about STIs, compared to males).⁵²

The cost of services and not knowing where to go were also important barriers to obtaining contraceptive methods in some countries, especially in Uganda, though still not as formidable as the social-psychological barriers. Compared to females, significantly more males in all countries but Ghana reported that they did not know where to go for either STI or contraceptive services.⁵² In regard to contraceptive services, factors directly related to providers (an adolescent’s privacy not being respected or not being treated nicely by staff) were mentioned by a minority of sexually-active 12–19 year olds in three of the four countries: 10–18% of females and 5–11% of males in Ghana, Malawi, and Uganda. In Uganda and Malawi, females were more likely than males to perceive provider-specific barriers in terms of both STI and contraceptive services. Although about at least half, and as much as three in four sexually-active 12–19-year olds in these four countries reported that they perceived having one or more barriers, one quarter or more reported that they either did not have or did not know of any barriers to obtaining contraceptive services.⁵²

There are other number of factors that inhibit the use of contraceptives among young people as shown in a study in South Africa. For example, parental levels of education and income, and students’ access to enough funds to buy contraceptives that are not provided for free determine levels of use of contraceptives. The apartheid regime in South Africa brought African education under control of the government and extended apartheid to black schools. Thus where parents are not educated or lacking education their children often lack a lot of information on life plan and early family planning decisions.³⁰ The study showed clearly that students’ knowledge of contraceptives affect their use of contraception.

Some other previous studies showed that the moderating factors that could influence students’ non-utilization of contraceptives includes demographic factors, such as age, gender and, and cultural/traditional beliefs and practices. Age is a very vital aspect when it comes to the utilization of contraceptives. However the ages of female students could be important in identifying the high risk age groups in order to make concerted efforts to provide such age groups with appropriate health education opportunities.³⁰ Students may not use contraceptives out of ignorance and the unavailability of contraceptives. They may also not make use of contraceptives because they are lacking enough information or they are not educated about the utilization of contraceptive, their benefits and effects. Students’ age might influence their decision to engage in sexual intercourse and contraceptive non- utilization.³⁰ If sexual and relationship education is started at an early age, prior to sexual debut, such knowledge could help both male and female students to delay their first sexual encounters. Female students need knowledge about contraceptives before sexual activities commence in order to prevent unplanned pregnancies and reduce the number of female pregnant students on campus. Thus sex education needs to be considered.⁵³ There might also be gender differences in knowledge, attitudes and behaviour among students of the University towards the contraceptives. Both female and male students may need interventions that could improve their sexual knowledge and skills, clarify attitudes and beliefs and enhance discussions and negotiation skills.⁵⁴

Social values, beliefs and practices influence decision making about the use of contraception. Some beliefs are beneficial and others are not. Students are influenced by socio-psychological variables in deciding about initiating sexual relations and contraceptives use, possibly allowing their individual perceptions to be greatly influenced by peer influence and expectations.⁵⁵ Students are coming from different cultural backgrounds, religion or traditions and might be influenced by different factors, or by the same factors but to different extents. This affects their decisions to use contraceptives. Values and norms are important in cultures because they tell us what should be done and what should not be done.⁵⁵ In many cultures young people or unmarried people are not allowed to engage in sexual intercourse without following some tradition. Ethnic background, educational level, socio-economic class, and local community standards are interrelated factors in shaping sexual ideas and behaviors. Most of the educated women tend to fetch greater bridal wealth which may encourage parents to support their daughters’ schooling, and perhaps their return to school following childbirth. However, encouraging their daughters to use contraceptives in order to complete their schooling prior to childbearing could be problematic for many parents especially those living in traditional communities. Cultural/traditional factors could pose a problem to female utilization of contraceptives leading to unplanned pregnancies.³⁰ Students should be informed about the benefits of contraception.⁵⁶ Contraception is the woman’s power to control her fertility and be able to complete her education, maintain gainful employment and make independent marital decisions.³⁰

The use of contraceptives saves women’s lives and improves their health by allowing them to prevent unplanned pregnancies. Lives are saved from high risk pregnancies or unsafe abortions. Effective use of condoms can prevent maternal deaths, cancers and STIs including HIV and AIDS.³⁰ By delaying childbearing, through the use of effective contraceptives, female students would be acting in the interest of their future children because infant mortality rates are reportedly higher for babies born to adolescent mothers than for babies born to women in their twenties or thirties. Contraceptive use saves children’s lives by allowing individuals and couples to delay and space births thereby providing greater opportunities for emotional support from the parents for each child. In addition the parents are able to provide for each child’s physical needs. Contraceptive use also helps men to provide better lives for their families with less emotional and financial strain than with having to provide tor a large family. Contraceptives provide parents with the freedom to choose when to have children, how many children to have and at what intervals.³⁰

2.4 OUTCOME OF SEXUAL BEHAVIOR AND PRACTICE

2.4.1 UNINTENDED AND UNPLANNED PREGNANCY

The uptake of modern contraceptive methods worldwide has slowed in recent years, from an increase of 0.6 % points per year in 1990–1999 to an increase of only 0.1% points per year in 2000-2009.⁷ In Africa, the annual increase in modern contraceptive use fell from 0.8% points in 1990-1999 to 0.2% points in 2000-2009.⁷ An estimated 215 million women in the developing world have an unmet need for modern contraceptives, meaning they want to avoid a pregnancy but are using a low-efficacy traditional family planning method or no method at all.⁷ Some 82% of unintended pregnancies in developing countries occur among women who have an unmet need for modern contraception. In the developing world, women’s reasons for not using contraceptives most commonly include concerns about possible side-effects, the belief that they are not at risk of getting pregnant, poor access to family planning methods, and their partners’ opposition to contraception. Reducing unmet need for modern contraception is an effective way to prevent unintended pregnancies, abortions and unplanned births.⁷

Little descriptive knowledge about the experience of unplanned pregnancy for university women exists. Most tertiary education and college students engage in sexual activity generally with different partners. Most of the sexually active students do not use any contraceptives. As a result, many college students experienced unplanned pregnancy.³⁰ Studies showed that women experienced a significant number of long term effects related with the unplanned pregnancy. The most dominant of these effects are feelings of guilt and distress of being stigmatized for their experience. The guilt makes it challenging for them to interact with peers and family. The guilt, shame, fear, and sense of stigma reported are not just individual attributes but a reflection of wider social views about women’s responsibility for sexuality and reproduction. Furthermore, dropping out from school before completion often has a significant negative impact on the lives of the individuals. However, the costs go far beyond individual consequences. The dropping out of school has led to a serious economic and social repercussion for the larger society as well.⁵⁷ The individual who drops out of school before completing any course is at an economic disadvantage. Unemployment rates are very high among school drop-outs because those people they do not possess any skills. Thus they earn very low salaries compared to those who graduated. The economic consequence of the drop-out problem includes loss of earnings and taxes, loss of social security, and lack of qualified workers. Leaving school before completing the program of study often has a negative impact on an individual’s psychological well-being. The majority of students who drop-out later regret their decision to leave school; such dissatisfaction only intensifies the low self-esteem typical of potential dropouts. Dissatisfaction with self, with the environment, and with lack of job opportunity is also associated with lower occupational aspirations among young people.⁵⁷ School drop-outs are often unemployed or earn less money than their graduated people. Their children also experience negative consequence because they live in poor socioeconomic conditions. Proportionately few of these homes provide the study aids that children of graduates can expect to have. Parents who are not educated are less likely to provide schools-related activities for their children comparable to parents of higher socioeconomic status.⁵⁷

In addition, parents who are drop-outs work such long hours that it is difficult for them to monitor their children’s activities. Those parents who dropped out also have lower educational expectations for their own children. Young people who have babies at an early age are mostly dependent on their parents or government for support particularly child support grants. Some of those young mothers often come from the poor families. Young people who choose to keep their babies are more likely to suffer consequences in the form of health, poor housing, and poor nutrition and, unemployment and end to her schooling, have inadequate career training and suffer financial dependency.⁵⁷ Young mothers who are less or not educated do not develop the skills, resources and experience necessary to overcome poverty and the pervasive sense of powerlessness and vulnerability that usually accompanies it.

Most young girls who carry their pregnancies to term decide to keep their babies. Those who grew up in poverty are given very little margin of error in negotiating the tasks of adolescence. Breaking this cycle and fostering young women’s productive participation in society is critical to their adolescent parental role, their children, and society as a whole. The educational challenges faced by adolescent parents are frequently carried over into the next generation. A disproportionate number of the children born to young mothers show more emotional and behavioral problems while growing up. In addition, these children have more erratic attendance records, lower grade point averages, lower scores on standardized achievement tests and lower college expectations.⁵⁷

Teenagers who experience pregnancy are likely to experience poor health care, poor nutrition, prenatal, perinatal, and more postnatal problems than older mothers, and most of their babies die, likely because they seek prenatal care infrequently in their first trimester. Younger mothers stand high rates of giving birth to children with anaemia, toxaemia, STI’s and uterine dysfunction and other complications of labour and delivery.³⁰ These problems are compounded for teenagers who live in poor socioeconomic conditions. Teenagers also have problems with premature delivery and are at greater risk of very long labour. Children of teenagers stand high chances of having serious health problems. For example, 15 year old mothers are more likely than older mothers to have low-birth weight babies and the baby is three times as likely to die in the first eight days of life. Low birth weight has been related to a number of developmental difficulties and learning disabilities.⁵⁷

2.4.2 ABORTION

Unwanted pregnancies and abortion have existed since time immemorial. The history of abortion around the world points to the frequency of abortion across cultures and time. Chinese, Greek and Roman cultures all developed systems of dealing with unwanted pregnancies and regulating population growth in their respective societies. Also the Egyptians were the first to create abortion techniques, which were discussed and reported in some of their first, and the oldest medical texts.

On the global scale, abortion rate declined substantially between 1995 and 2003, but this trend could not be sustained as the rate stalled between 2003 and 2008.¹³ Between 1995 and 2003, the abortion rate (the number of abortions per 1,000 women of childbearing age i.e., those aged 15-49) for the world overall dropped from 35 to 29. Nearly half of all abortions worldwide are unsafe, and nearly all unsafe abortions (98%) occur in developing countries.¹³ It is estimated that there were 35 abortions per 1000 women aged 15–49 years worldwide each year in 2010–2014. This represents a non-significant 5 point decline since 1990–94, when the estimated rate was 40 abortions per 1000 women and 7 points increase from the 2008 estimate.¹³

Compared with just 6% in the developed world, 56% of all abortions in the developing world are unsafe. There is about eight percent increase in worldwide proportion of abortions that took place in the developing world between 1995 and 2008, from 78% to 86%. This was attributed to be in part, because the proportion of all women who live in the developing world increased during this period. Since 2003, the number of abortions fell by 600,000 in the developed world but increased by 2.8 million in the developing world.⁷ In 2008, six million abortions were performed in developed countries and 38 million in developing countries, a disparity that largely reflects population distribution, access to family planning commodities and illegality of abortion in most developing countries. The absolute number of abortions increased to 56.3 million per year in 2010-2014. A woman’s likelihood of having an abortion is slightly elevated if she lives in a developing region.⁷

In the developed world, the annual abortion rate declined significantly and substantially by 19 points from 46 abortions per 1000 women in 1990–1994 to 27 in 2010–2014. In the developing world, the 2 point decline in the abortion rate from 39 abortions per 1000 women in 1990–1994 to 37 in 2010–2014 was not significant.¹³ In the WHO sub regions of the world (AFRO, EMRO, EURO, SEARO, WPRO and AMRO/PAHO), the highest estimated annual rate of abortions in 2010–2014 was in the Caribbean at 65 abortions per 1000 women and the lowest were in Northern America at 17 and Western Europe at 18. The largest observed reduction between the first and last time periods was in Eastern Europe, where the rate fell from 88 abortions per 1000 women in 1990–1994 to 42 in 2010–2014. The abortion rate also fell in northern America and all the European sub regions, except Western Europe.¹³ Non-significant declines were noted in all the Asian sub regions and in Northern Africa, whereas the abortion rate is estimated to have increased significantly in Western Europe by 5 points from 13 abortions per 1000 women to 18. Non-significant increases were noted in western, middle, eastern, and southern Africa and in all the Latin American sub regions.¹³

Abortion is illegal in most of the countries of Africa, yet the vast majority of illegal and unsafe abortions take place in Africa. The overall abortion rate in Africa showed no decline between 2003 and 2008, holding at 29 abortions per 1,000 women of childbearing age (that is age 15-49).⁴⁵ The Southern Africa sub region has the lowest abortion rate of all African sub regions, at 15 per 1,000 women in 2008. East Africa has the highest rate, at 38, followed by Middle Africa at 36, West Africa at 28 and North Africa at 18.⁴⁵

Medical conditions are nonetheless, grossly inadequate in explaining health particularly, women’s reproductive health (RH) (which includes maternal health), because the major determinants of health are external to biology and medicine.⁵⁸ Health, ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.⁵⁸ It is determined by cultural, social, economic, political, psychological, and religious factors among others. This is particularly true of heterogeneous societies and underdeveloped countries such as African countries. Therefore solution to African women’s RH challenges should not be limited to medicine and biology but should also be sought within the social and cultural contexts under which pregnancies occur.⁵⁸

In Nigeria, unsafe abortion performed by unskilled persons or under insanitary conditions or both, has been found to contribute 40 percent of maternal deaths.⁵⁹ There are two categories of maternal deaths: direct and indirect obstetric deaths. The direct obstetric death is derived from complications during pregnancy, delivery or postpartum period, such as hemorrhage, obstructed labour, infection of pregnancy(sepsis), eclampsia(diabetes of pregnancy) and anemia, while the latter, is a factor of medical conditions that are aggravated by pregnancy or delivery.⁶⁰ Prominent among the socio-cultural factors that influence pregnancies and their outcome in Nigeria are: gender relations, gender roles, social taboos, and traditional beliefs surrounding sexual practices.⁵⁸

Roughly one in five pregnancies each year in Nigeria are unplanned; of those, slightly more than half end in abortion. Almost one-third of Nigerian women of childbearing age say they have had an unwanted pregnancy; of those, half have attempted to obtain an abortion at some time. About three-quarters of a million Nigerian women have an induced abortion each year.⁷ In the developing countries in general and in Nigeria in particular, unsafe abortion has remained a major public health problem. Although abortion is largely restrictive or illegal by the national law, the practice continues with dire consequences for women of reproductive age both married and unmarried.⁵⁹ Abortion is probably the fourth leading cause of maternal mortality in Nigeria and accounts for significant proportions of maternal morbidity and long term reproductive ill-health. Huge efforts have been made by several local and international organizations to reduce the incidence of unsafe abortion and its complications in Nigeria in the past 20 years. However, recent reports suggest that these efforts may not be leading to the optimal goal of reducing the overall incidence of unsafe abortion in the country.⁵⁹

Bankole et al¹⁴ after conducting interviews with 194 health professionals in 772 health facilities across Nigeria, reported an abortion incidence of 1.25 million abortions in 2012 alone. That means, there was 33 abortions per 1000 women of reproductive age in Nigeria in 2012.¹⁴ There are inherent flaws in this estimate due to the fact that the restrictive abortion law in the country hinders many abortion seekers from going to health professionals for induced abortion.²⁹ Therefore, induced abortions only come to the knowledge of health professionals when they are associated with complications. Many abortions that end up safely without complications are often not known to health professionals.²⁹ Self-induced abortions by women using abortion pills have become widespread throughout the world. Mifepristone and misoprostol, the two main abortion pills are widely available in Nigeria and have been reported to be highly effective in Nigerian women.⁴⁰ Therefore the weakness of this study is that it is facility based and the result cannot represent the true situation of abortion in Nigeria.

In a study to explore abortion among the Tarok people in the Central Nigeria, the author found that majority of respondents attributed unintended pregnancy to prevailing sexual practices.⁵⁹ Interestingly, reasons varied across age and gender. The opinions of most female are; lack of sexual discipline among young men and women (married or single); lack of a separate residence for husband and wife; fear of repercussion in terms of men’s withdrawal of essential support; threat from male spouse, in-laws and the male dominated institution of social control; female poverty; polygyny and competition among co-wives; and refusal of modern young women to move to their mothers’ homes during lactation.⁵⁹ The study did not however look into what is the effect of these unintended pregnancies. Were there induced abortions since they were not planned or were they accepted?

Measurement of the worldwide prevalence of abortion-related mortality and morbidity is difficult. At a population level, national vital registration systems routinely under-count such deaths.⁴⁸ Calculation of the proportion of maternal deaths due to abortion complications is even more challenging. Abortion-related mortality often happens after a clandestine or illegal procedure, and powerful disincentives discourage reporting. As a result, linking specific programmatic interventions to changes in maternal mortality at a population level is rarely feasible because of the difficulty in accurate measurement of deaths. Moreover, women might not report their condition or might not relate it to a complication of an earlier unsafe abortion.⁴⁸

Worldwide, an estimated 68 000 women die as a result of complications from unsafe induced abortions every year (about eight per hour).⁴⁷ This prevalence translates into an estimated case-fatality rate of 367 deaths per 100 000 unsafe abortions, which is hundreds of times higher than that for safe, legal abortion in developed nations.⁴⁷ This ratio is higher in Africa (709), lower in Latin America and Caribbean (100), and close to the worldwide average in Asia (324). These differences presumably indicate regional differences in the safety of abortion provision, the severity of complications, and access to care thereafter (WHO, 2004).⁶¹ By use of different methods, a recent systematic review of causes of maternal mortality worldwide estimated that abortion accounted for 1-49% of such deaths.⁶²

Morbidity is a much more common consequence of unsafe abortion than mortality, but is determined by the same risk factors. Complications include hemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus, and abdominal organs. High proportions of women (20-50%) who have unsafe abortions are hospitalized for complications. Morbidity and hospitalization rates have probably fallen since the early 1990s in response to safer abortion services.⁶²

CHAPTER THREE

METHODOLOGY

3.1 Study area

This study will be carried out in the University of Benin, sited in Ugbowo, Benin City, Edo State, Nigeria. Edo State lies between latitudes 6^o 10¹N and 6^o 20¹N and longitudes 6^o 10¹E and 6^o 15¹E with a population of over 2.5 million and a population density of 168 persons per square kilometer.  It is located in the South South region of Nigeria and shares boundaries in the West with Ondo State, in the South with Delta State and Kogi State, in the North.⁶³

The University of Benin was founded in 1970 and it is made up of two campuses. The main campus is located in Ugbowo, Egor Local Government Area (LGA), while the second campus is located in Ekenhua, in Oredo LGA, both in the State. The study will be carried out in both two campuses as both campuses house different departments of the University.

The University offers courses at various levels: Postgraduate, Undergraduate, Diploma and Certificate. Presently, the total student enrollment stands at over 40,000 made up of both full-time and part-time students shared among the various Faculties and about 5,000 staff.⁶³ The population of female students in the University is estimated at about 15,000 students. There are 14 faculties and schools (Faculties of Art, Education, Agriculture, Engineering, Environmental Science, Law, Management Science, Social Science, Life Science, Physical Science and Pharmacy. Schools of Medicine, Dentistry and Basic Medical Sciences) and over 70 departments. The university also accommodates a University Demonstration Secondary School (a co-educational secondary school), a University Staff School (Nursery and primary schools), a catholic church and protestant chapel, a mosque and University Health Services Center and other institutes of research and learning.⁶³ The University Health Services Center is established to offer services such as: provide efficient services to the members of the University community; provide an advisory health services to individuals who are in need of health counseling and to provide clinical services both for the students, workers and retirees. The students live both in the Halls of residence (that is on campus) and off campus (in the nearby communities such as Ekosodin, Osasogie and EDPA).

3.2 Study design

A descriptive, cross-sectional study design will be utilized in this study.

3.3 Study duration

The timeline for the study is hoped to take five months and the table that summarizes the study timeline is shown in the Gantts chart appendix 1.

3.4 Study Population

The target study population consists of all female students of reproductive age (that is 15-49 years) in the University of Benin. The sample is designed to accommodate all categories of female students in the University. The University has registered students and staff population of about 45,000 to 50,000 and 4,500 to 5,000, respectively. The female students population is estimated to be in the excess of 15,000 distributed across the over 70 departments and programs run by the University.⁶³

3.5 Selection Criteria

This study will be carried out in the main campus of the University of Benin, sited in Ugbowo, Benin City, Edo State, Nigeria. The reason Ugbowo campus is chosen is because all the faculties and more than eighty percent of the departments of the university are located there.

3.5.1 Inclusion criteria

All fully registered female students in the University of Benin who are within the reproductive age (15-49 years), are to be included in the sampling frame.

3.5.2 Exclusion criteria

All fully registered female students who are of the reproductive age bracket but not around during the time of the study. Also those who are qualified but declined from participating in the study will be excluded.

3.6 Sample size determination

In a previous study in Nigeria, conducted among the similar students population in Delta State University Abraka and Oleh campuses, the prevalence of contraceptive utilization (P) was 58.2%. Therefore, p= 0.582.⁶⁴ The sample size was determined using the Leslie Fischer’s formula for the calculation of sample size in populations > 10,000, n = Z²pq/d².⁶⁵

Where: n = Minimum sample size

Z = Standard normal deviate, (a constant set at 1.96 on the basis of using the 95% confidence interval for estimation).

p = Estimated proportion of sexually active female in Nigeria which is 58.2%⁶⁶

d² = degree of precision, given as 5% or 0.05

q = 1-P (P is in decimal points)

Substituting values:

n = 1.96² x 0.582 x 0.428   

0.05²

n = 374

To adjust the sample size for the design effect, it is multiplied with 2

n = 374×2 = 748

Therefore, the estimated sample size will be 750 females. This is to account for damaged and wrong answered questionnaire.

3.7 Sampling technique

Selection of respondent for quantitative study.

The sampling technique to be used shall be multi-stage sampling method.

Stage 1: Selection of faculties

University of Benin has fourteen (14) faculties including schools of medicine, dentistry and basic medical sciences. Seven (7) faculties out of the fourteen (14) faculties shall be selected for the study using simple random sampling technique (balloting).

Stage 2: Selection of departments

A list of all the departments in each of the seven selected faculties shall be obtained from the University’sCentral Record Processing Unit (CRPU) and numbers shall be allocated to each department. This shall be followed by the use of computer generated table of random numbers to select three departments each from the seven initially selected faculties, making a total of twenty one (21) departments. That is to say that 3 department shall be selected per faculty.

Stage 3: Selection of Respondents

A list of the total population of female undergraduates in each of the selected departments shall be obtained from the CRPU office. Proportional allocation shall then be used to obtain the total number of respondents that will participate from each of the selected departments.

3.8 Tools for data collection

The data shall be generated by means of qualitative method (use of structured questionnaire) and quantitative research method (observational check list). A structured questionnaire instrument adapted and modified from “Profile of sexual and reproductive health of young adults and adolescents in Edo State”⁶⁷, shall be used to collect quantitative research data. This is a resource material from the Initiative of Policy Project/USAID and Women’s Health and Action Research Center (WHARC), Benin City, Edo State, Nigeria. Data required for the study include certain relevant socio-cultural characteristics of respondents, their knowledge and use of contraceptives and health implications, sexual relationships, knowledge of abortion and its complications, sexual history, age at first sex and practice of induced abortion. The questionnaire to be used shall be self-administered and a total of seven hundred and fifty (750) females would be selected from the faculties and schools of the University of Benin, to participate in the study. The data, which would be collected from the questionnaire, will be presented and analyzed using the simple percentage and chi-square methods. The questionnaire will be divided into different sections viz; (a) the socio-demographic characteristics of the respondents; (b) respondents’ sexual activities and; (c) pregnancy, contraception and abortion. From these sections, information on respondents’ parental background, distribution of contraceptive knowledge, awareness and use of different types of contraceptive methods by respondents will be enquired. Also, respondents’ sources of obtaining contraceptives, attitude towards the use of the different types of contraceptives available and barriers to contraceptive use among the sexually active will be enquired from the respondents. More so, an Observational Check list (OC) shall be used to gather information on the availability of reproductive health services for students (most especially the female students), at the University of Benin Health Center. The data collection will be done by trained research assistants.

3.9 Conceptual Framework

The conceptual framework to be used in the study will be the Health Belief Model (HBM) The HBM is a cognitive, interpersonal framework that views humans as rational beings who use a multidimensional approach to decision-making regarding whether to perform a health behavior. The model is appropriate for complex preventive and sick-role health behaviors such as contraceptive behavior.

Putting in mind that contraceptive use as a form of family planning is a dynamic and complex set of services, programs and behaviors towards regulating the number and spacing of children within a family. Contraceptive behavior, refers to activities involved in the process of identifying and using a contraceptive method to prevent pregnancy and can include specific actions such as contraceptive initiation, continuation or discontinuation, misuse, nonuse, and more broadly compliance and adherence.

Constructs of the HBM for Family Planning

The constructs of the Health Belief Model which will influence the utilization family planning are being discussed below.

Perceived Susceptibility and Severity – the perceived possibilities of an unwanted pregnancy and its associated problems provides the incentive to use contraception. This considers personal feelings of the seriousness of becoming pregnant, based upon subjective assessment of medical and social consequences of pregnancy and childbearing most especially in a conservative society where people frowns at outside wedlock pregnancies. This construct may include factors like fear of body changes or pregnancy complications, or worry of quitting school, which can impact the likelihood of contraceptive use.⁶⁸

Perceived Benefits- Perceived benefits relate to the perceived effectiveness, feasibility and other advantages of using a contraceptive method to prevent pregnancy vis-à-vis the perceived barriers. Through a cost-benefit analysis, the perceived ratio of a contraceptive’s benefits to its barriers helps determine the preferred and specific contraceptive action and method.⁶⁸

Perceived Barriers – Perceived barriers are negative consequences of using contraception. This dimension includes factors such as perceived side effects of hormonal contraception. These fears have been found to be potential reasons why people may not use contraceptive. Disadvantages have been found to inhibit contraceptive use.⁶⁸

Cues to Action – theseare internal and external stimuli that trigger a consciousness of the perceived pregnancy threat and facilitate consideration of using contraception to remedy the threat. This may include symptoms like missed menses after intercourse (internal stimuli) or contraceptive communication from the media, and worry from a sexual partner or counseling by a health care provider.⁶⁸ The table of constructs for the Health Belief Model as Applied to Contraceptive Behavior is shown in the appendix 1

3.10 Plan for data collection management

Data processing and analysis will be done using the Statistical Package for Social Sciences (SPSS) Version 20.0 for windows program. Descriptive statistics such as frequencies, percentage, and appropriate graphic presentation besides measures of central tendency and measures of dispersion will be used for Univariate analysis. Bivariate analysis will be used to analyze some of the variables. All the values will be expressed as mean and standard deviation and the mean values obtained in the different study groups will be performed with 95% confidence interval or 5% level of significance.

This research work shall commence by providing a background of the subject matter justifying the need for the study, followed by related literature on contraceptive usage and sexual practices by female youths. The research method shall then be outlined before results are presented and discussed, concluding comments shall reflect on the strength and limitations of the study and identify implications of the findings. The study variables are: Dependent Variables (Contraceptive use and sexual practice).Independent Variables include; Age, Religion, Marital status, Exposure to family planning information, Age at first sexual intercourse History of pregnancy.

3.11 Research assistants

Six persons will be recruited for the data collection as research assistants. These research assistants can come from the post-graduate students of the University. They will be trained in the correct methods for data collection and of questionnaire administration, for two days.

3.12 Pre testing of the Questionnaire

The pre testing of the instrument will be ascertained through the conduct of a trial test on 30 female undergraduate students sample from the Edo State University of Education, Ekiadolor. The questionnaire will be administered on these students to ascertain the reliability and validity of the instrument. The aim of pre-testing is to evaluate whether respondents interpret questions in a consistent manner as intended by the investigator, and to judge the appropriateness of each included question. The outcome of the questionnaire will greatly depend on how well the research participants understand the questions and their understanding may be affected by language skills and culture. The six research assistants will be used for the pre testing.

3.13 Ethical Consideration

Ethical approval will be obtained from the Ethical Review Board of the University of Benin. Consent will be obtained from the female students and the objectives of the study will be well communicated to them. Participation will be purely voluntary and there will be no inducement or undue influence on participants. Confidentiality and privacy will be respected during the study as all the participants will be assured that their identity and every information given will be kept secret and will not be disclosed. All subjects in this study will be given code numbers and no name will be recorded. Information collected cannot be linked to participants in any way and their names or identifiers will not be used in any publication or reported from this study. The respondents will be assured that there be no penalties or loss of benefits for refusal to participate in the study or withdrawal from it.

3.14 Limitations

We are anticipating that due to the social and cultural norms and attachment to the issue of sexual practices and contraceptive use in Nigeria, some students may find it difficult to divulge such information as whether they use contraceptive methods or not. This may pose as a drawback or a limitation. We shall try as much as possible to convince the respondents that every information obtained from them shall be kept in confidentiality. We shall also make sure that codes rather than names shall be used to identify each respondent, therefore the identity of the respondents shall not be known even to the researcher, and therefore we shall employ blinding technique throughout the study.

REFERENCES

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 APPENDICES

APPENDIX 1

Map of Edo state with Ovia North East in set.

 Gantts Chart for Study duration

TASK
	April	May	June	July	August
Obtain ethics approval
Data Collection Tools
Recruitment & training of research assistants
Pre testing of tools
Data collection
Data cleaning and entering
Data analysis and write up
Publish Findings

Constructs of the Health Belief Model, as Applied to Contraceptive Behavior

Source: Glanz et al, 2002, p. 52⁶⁹

APPENDIX 2

INFORMED CONSENT FORM

IRB Research approval number ………………

 

This approval will elapse on …………..

 

TITLE OF RESEARCH:

CONTRACEPTIVE UTILIZATION, SEXUAL PRACTICES AND OUTCOMES OF FEMALE UNDERGRADUATE STUDENTS IN UNIVERSITY OF BENIN, BENIN CITY, NIGERIA

 Purpose of research:

The purpose of the research is access and determine the contraceptive utilization and the sexual practices of female undergraduate students in University of Benin.

Procedure of the research:

Each participant that meets the inclusion criteria will answer some questions and provide information on the questionnaires that will be administered to her by the research assistants.

Expected duration of research and of participant’s involvement

Each participant is expected to spend about 30mins at only one visit and the study will last for at least one month.

Risk

There is no risk associated to this study.

Cost to the participant

The information you will give will not cost you anything.

Confidentiality

All information collected in this study will be given code numbers and no name will be recorded. This cannot be linked to participants in any way and their name or any identifier will not be used in any publication or reports from this study

Voluntariness and alternatives to participation:

Your participation in this research is entirely voluntary. If you choose not to participate, this will not affect you in any way.

Due inducement

You will not be paid any fee for participating in this research.

Consequences of participant’s decision to withdraw from research and procedure for orderly termination of participation:

You can also choose to withdraw from research at any time. Please note that some of the information that has been obtained about you before you choose to withdraw may have been modified or used in reports and publications. These cannot be removed anymore. However the researcher promises to make effort to comply with your wishes as much as possible.

Who has reviewed this study?

This study has been reviewed and approved by a panel of scientists at the University of Benin/UBTH Joint Ethical Committee, which consists of scientists and lay persons to protect your rights and wellbeing.

Any apparent or potential conflict of interest:

Neither the investigator nor the supervisor has any conflict of interest.

 

Statement of person obtaining informed consent:

I have fully explained this research to …………………………………. …. and have given sufficient information, including risk and benefits, to make informed decision.

Date……………………… Signature…………………………..

Name……………………………………………………………

 

 

Statement of person giving consent:

I have read the description of the research or have it translated into language I understand. I have also talked it over with the researcher to my satisfaction. I understand that my participation is voluntary. I know enough about the purpose, methods, risks and benefits of the research study to judge that I want to take part in it. I understand that I may freely stop being part of this study at any time. I have received a copy of this consent form and additional information sheet to keep for myself.

Date: ………………………  Signature: ……………………..

Name: ………………………………………………..

Witness’ signature ………………….……Witness’ Name ……………………..………………….

APPENDIX 3

 

QUESTIONNAIRE ON CONTRACEPTIVE UTILIZATION, SEXUAL PRACTICES AND OUTCOMES OF FEMALE UNDERGRADUATE STUDENTS IN UNIVERSITY OF BENIN, BENIN CITY, NIGERIA

 

Good day, I am a research student of MPH (Reproductive and Family Health), Center of Excellence in Reproductive Health Innovation (CERHI), College of Medical Sciences, University of Benin, Benin City. We are conducting a survey of contraceptive use and sexual practices of female undergraduate students of University of Benin. This survey will help us to understand reproductive health needs of the female students.

Regarding this, I would like to ask you some questions. Most of the questions are personal, but the answers you give will not be shown to anyone and we do not require your name. Your answers will only assist us in learning more about the needs of female students like you. It is on this note that I seek your consent and cooperation.

Do you agree to be interviewed:  (1) Yes  (2) No

Your Faculty/Department:………………………………/.………………………………………

Date: ………………………………………

 

SECTION A: RESPONDENTS’ SOCIO-DEMOGRAPHIC CHARACTERISTICS

 

INSTRUCTION: Please kindly tick [ ] as your response inside the boxes and you are also required to write in some questions as may be required by the question(s).

1. How old were you at your last birthday? ………………………………………………………………..
2. What is your Ethnic Group? (1) Igbo [ ] (2) Hausa (3) Yoruba (4) Others (specify) ……………………………………………………….
3. What is your Religious affiliation? (1) Catholic [ ] (2) Protestant [ ]   (3) Pentecostal [ ]  (4) Moslem [ ] (5) Traditional Religion  [ ]               (6) Others……………………………………………..
4. What is your marital status?

(1) Single   [  ]       (2) Married  [  ]    (3) Divorced  [  ] (4) Separated  [  ]  (5) Widowed  [  ]              (6) Others (Specify)……………………………………………

b. If married, what is the nature of your marriage?

1. Monogamous  [  ]  (2)Polygamous   [  ]

c. If polygamous, how many partners do you have? ……………………………………

5. How many children do you have? ……………………………………………………………………………
6. Are your parents living together? (1) Yes [  ]     (2)   No   [  ].    If no, what is their status? (1) Divorced/separated [  ]    (2) Father dead [  ]     (3) Mother dead [  ]
7. What is your current level of study?  (1) 100 level  [  ]       (2) 200 level  [  ]        (3) 300 level  [  ]         (4) 400 level  [  ]         (5) 500 level  [  ]         (6) 600 level  [  ]
8. Who do you currently live with? (1) Both parents (2) Father only      (3) Mother only (4) Relative              (5) Alone     (6) Boyfriend    (7) Husband                  (8) Others (Specify)
9. What is your father’s highest educational level? (1) None (2) Primary (3) Secondary (4) Tertiary              (5) Others (Specify)…………………………………………………
10. What is your mother’s highest educational level? (1)None (2) Primary (3) Secondary (4) Tertiary              (5) Others (Specify)…………………………………………………
11. What is your parents’ occupation?

Option	Father	Mother	Guardian
Farmer/gardener
Civil Servant
Business
Others (specify)

SECTION TWO: SEXUAL ACTIVITY

Now I would like to ask you some questions about your sexuality.

12. Have you ever had sexual intercourse?  (1) Yes    (2) No (If “NO” skip to question 28)
13. How old were you when you first had sexual intercourse? …………………………………………..
14. About how old was the person you had sexual intercourse with the first time? ……………….
15. What is your relationship to the person with whom you first had sex?  (1) Husband       (2) Boyfriend   (3) Other friend   (4) Casual acquaintance   (5) Father      (6) Brother     (7) Cousin   (8) Other relative   (9) Others (specify) …………
16. When was the last time you had sexual intercourse?  (1) Days ago   (2) Weeks ago        (3) Months ago   (4) Years ago   (5) Others (specify) ……………………………..
17. What is your relationship to the person with whom you last had sex?  (1) Husband        (2) Boyfriend   (3) Other friend   (4) Casual acquaintance   (5) Father      (6) Brother     (7) Cousin   (8) Other relative   (9) Others (specify) …………………………………
18. Have you had sex with anyone else in the past six (6) months? (1) Yes      (2) No           (3) No answer    . (b) If yes, how many other persons have you had sex with in the past six (6) months? ………………………………………………………………..
19. How many times have you had sex in the past six (6) months? …………………………………
20. Have you ever given or received money, gift or reward for sex? (1) Yes      (2) No           (3) No answer    .

b. If yes, which of the following applies to you?  (1) Given to partner                (2) Received from partner                            (3) Both                            (4) No answer

 

SECTION THREE: PREGNANCY, CONTRACEPTION AND ABORTION

Now, I would like to ask you some questions about pregnancy and having children

21. Do you know any method one can use to prevent pregnancy? (1) Yes      (2) No

b. If yes, which methods do you know? (Tick all that apply)    (1) Female sterilization               (2) Male sterilization   (3) Pills   (4) IUCD   (5) Injections   (6) Implants   (7) Condom              (8) Diaphragm/foam/jelly   (9) Withdrawal   (10) Rhythm or periodic abstinence                            (11) Others (specify)……………………………………………………………………

Skip questions 29-34 for respondents who are not sexually active

22. The first time you had sexual intercourse did you or your partner do something or use some method to avoid pregnancy? (1) Yes             (2) No           (3) Unsure/don’t know

b. If yes, what did you do or what did you use? (Tick all that apply). (1) Pills (2) Injections              (3) Condom   (4) Diaphragm/foam/jelly   (5) Withdrawal              (6) Periodic abstinence              (7) No answer                            (8) Others (specify)………………………………………………

23. The last time you had sexual intercourse did you or your partner do something or use some method to avoid pregnancy? (1) Yes         (2) No

b. If yes, which methods did you use? (Tick all that apply)    (1) Pills   (2) IUCD   (3) Injections   (4) Implants   (5) Condom                            (6) Diaphragm/foam/jelly   (7) Withdrawal   (8) Rhythm or periodic abstinence              (9) Others (specify) ….……………

24. Have you ever used any method to prevent pregnancy? (1) Yes      (2) No

b. If yes, which methods do you use? (Tick all that apply)    (1) Female sterilization               (2) Male sterilization   (3) Pills   (4) IUCD   (5) Injections   (6) Implants   (7) Condom                            (8) Diaphragm/foam/jelly   (9) Withdrawal   (10) Rhythm or periodic abstinence                            (11) Others (specify)………………………………

25. Are you currently using any method to prevent pregnancy? (1) Yes  (2) No

b. If yes, which method do you use? (Tick all that apply)    (1) Female sterilization (2) Pills   (3) IUCD   (4) Injections   (5) Implants   (6) Condom               (7) Diaphragm/foam/jelly   (8) Withdrawal   (9) Rhythm or periodic abstinence                            (10) Others (specify)…………

26. The last time you had sex, was any contraceptive method used? (1) Yes    (2) No

b. If No, what were your reasons for not using condoms? (Tick all that apply)

(1) Did not like it    (2) It makes sex uninteresting    (3) Partner did not like it    (4) Too costly    (5) Did not know where to get it    (6) Shy to buy it    (7) Afraid parents may know    (8) No knowledge of condom    (9) No answer    (10) Others (specify)………………………………………………………………………………

c. If yes, what is the main reason of using the contraceptive method at that occasion?

(1) To prevent STD/HIV    (2) To prevent pregnancy    (3) To prevent both STD/HIV and pregnancy    (4) Partner insisted                (5) Don’t know    (6) No answer    (7) Others (specify)……………………………………………………….

27. How often did you use contraceptive during sex in the past six (6) months? (1) Never used    (2) Used rarely    (3) Used sometimes    (4) Used all the time
28. Do you know of a place where one can get contraceptive? (1) Yes  (2) No

b. If yes, where is that? (Tick all that apply) (1) Government hospital    (2) Private hospital

(3) UNIBEN health center    (4) Pharmacy    (5) Chemist (Patent medicine store)     (6) Shop    (7) NGO    (8) Friend/relative   (9) Other (specify)……………………

29. If you want to, could you yourself get a condom? (1) Yes  (2) No

If No, why…………………………………………………………………………………..

Skip questions 35 and 36 for respondents who are not sexually active

30. Have you ever been pregnant? (1) Yes  (2) No

b. If yes, how many times have you been pregnant?

c. At what age did became pregnant?

d. Of the pregnancies, how many were planned and unplanned?

(1) Planned…………………………… (2) Unplanned…………………………………

e. Of the times you were pregnant, what were the outcomes

	Outcome	Frequency
1	Delivered baby alive
2	Still birth
3	Miscarriage
4	Termination
5	Other (specify)

e. If terminations were done, how were they carried out?

	Option	Frequency
1	By a doctor
2	By a pharmacist
3	By a nurse
4	By a chemist (patent medicine dealer)
5	By a traditional healer (TBA)
6	By a friend
7	By self
8	Other (specify)

31. Have you ever given birth? (1) Yes      (2) No

b. If yes, how many births have you had? (Both living and dead)

c. At what age did you give the birth(s)?

	Birth order	Age
1	1st birth
2	2nd birth
3	3rd birth
4	4th birth
5	5th birth
6	6th birth