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Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia

• Ayele Semachew Kasa   ORCID: orcid.org/0000-0003-3320-8329 1 ,
• Mulu Tarekegn 1 &
• Nebyat Embiale 2  

BMC Research Notes volume  11 , Article number:  577 ( 2018 ) Cite this article

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To assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia, 2017.

The study showed that the overall proper knowledge, attitude and practice of women towards family planning (FP) was 42.3%, 58.8%, and 50.4% respectively. Factors associated with the practice of FP were: residence, marital status, educational status, age, occupation, and knowledge, and attitude, number of children and monthly average household income of participants. In this study, the level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies. Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced. Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Introduction

Family planning (FP) is defined as a way of thinking and living that is adopted voluntary upon the bases of knowledge, attitude, and responsible decisions by individuals and couples [ 1 ]. Family planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods [ 2 ].

Family planning deals with reproductive health of the mother, having adequate birth spacing, avoiding undesired pregnancies and abortions, preventing sexually transmitted diseases and improving the quality of life of mother, fetus and family as a whole [ 3 , 4 ].

The Federal Ministry of Health (FMOH) has undertaken many initiatives to reduce maternal mortality. Among these initiatives, the most important is the provision of family planning at all levels of the healthcare system [ 5 , 6 ]. Currently, short-term modern family planning methods are available at all levels of governmental and private health facilities, while long-term method is being provided in health centers, hospitals and private clinics [ 6 ].

The study done in Jimma Zone, Ethiopia showed that good knowledge on contraceptives did not match with the high contraceptive practice [ 7 ]. Different researchers showed that the highest awareness but low utilization of contraceptives making the situation a serious challenge [ 8 , 9 ].

Most of reproductive age women know little or incorrect information about family planning methods. Even when they know some names of contraceptives, they don’t know where to get them or how to use it. These women have negative attitude about family planning, while some have heard false and misleading information [ 10 , 11 ] and the current study aimed in assessing the knowledge, attitude and practice (KAP) of FP among women of reproductive age group in South Achefer District, Northwest Ethiopia.

Methods and materials

Study design and setup.

A community-based cross-sectional study was conducted in South Achefer District, Amhara Region, Northwest Ethiopia from March 01–April 01, 2017. Systematic sampling technique was used to recruit the sampled reproductive age women (15–49 years old). Based on the number of households obtained from the Kebele’s (Smallest administrative division) health post, the sample size (389) was distributed to the households. The sampling interval was determined based on the total number of 4431 households in the kebele. The first household was taken by lottery method and if there were more than one eligible individual in the same household one was selected by lottery method.

The data collection questionnaire was developed after reviewing different relevant literatures. The questionnaire, first developed in English language and then translated to Amharic (local language). Pretest was done on 5% of the total sample size at Ashuda kebele. After the pretest, necessary modifications and correction took place to ensure validity.

Those reproductive age women who answered ≥ 77% from knowledge assessing questions were considered as having good knowledge, those women who scored ≥ 90% from attitude assessing questions were considered as having favorable attitude and those women who scored ≥ 64% from practice assessing questions were considered as having good over all practice towards FP [ 7 ].

Data processing and analysis

The collected data was cleaned, entered and analyzed using SPSS version 21 software. Descriptive statistics were employed to describe socio-demographic, knowledge, attitude and practice variables. Chi squared (χ 2 ) test was used to determine association between variables. Associations were considered statistically significant when P-value was, < 0.05.

Socio-demographic characteristics of participants

The response rate in this study was 97.9%. Among 381 participants included, 185 (49%) were from rural villages. About 47% of the participants were illiterate and 52% were completed primary education. The monthly household income of the majority (42.5%) of the participants was between 1000 and 3000 Ethiopian birr. Regarding the family size of the participant’s, majority (48.3%) of them had ≥ 3 children.

The mean age of participants was 29.7 ± 6.4. Two hundred forty six (64.6%) and 133 (34.9%) were house wife’s and farmers respectively by their occupation. Almost two-third (65.4%) of participants were married, 24.9% were divorced by their marital status (Table  1 ).

Knowledge status of participants

All of participants ever heard about family planning methods. The major sources of information were from health workers (57.5%) and radio (41.5%). Regarding perceived side effects of using family planning, 13.1%, 24.9%, 9.7% and 52.2% of participants were responded heavy bleeding, irregular bleeding, an absence of menstrual cycle and abdominal cramp respectively were mentioned as a side effect. Among those who have children; 24.6% gave their last birth at home and 75.5% gave their last birth at the health institution. Regarding the overall knowledge of study participants, 161 (42.3%) had good knowledge towards family planning and the rest 220 (57.7%) had poor knowledge.

Attitude status of participants

The majority (88.5%) of the respondents ever discussed on family planning issues with their partners and wants to use it in the future. About 24.5% of the participants reported that they believe family planning exposes to infertility. Almost 23 (22.8%) of study participants reported that using family planning contradicts with their religion and culture. Regarding the overall attitude, 224 (58.8%) of the participants had favorable attitude and 157 (41.2%) had unfavorable attitude towards family planning.

Practice on family planning

Three fourth (75.3%) of study participants ever used contraceptive methods. The main types were pills (7.4%) and injectable (77.2%). The most common current reasons for not using were a desire to have a child (53.2%) and preferred method not available (46.8%). Almost half (50.4%) of study participants had good practice and the rest 49.6% had poor practice.

Factors associated with family planning practice

Study participants’ religion was not included in the analysis due to lack of variance, since almost all (99.2%) of participants were Orthodox Christians by their religion.

Women who had good knowledge were more likely to practice FP than those who have low knowledge (χ 2  = 117.995, d.f. = 1, P  < 0.001) and women who had favorable attitude towards FP were more likely to practice FP (χ 2  = 106.696, d.f. = 1, P  < 0.001). It was also seen that residence, age, educational status, occupation, marital status, number of children and monthly income of the were significantly associated with the practice of FP [(χ 2  = 69.723, d.f. = 1, P  < 0.001), (χ 2  = 104.252, d.f. = 2, P  < 0.002), (χ 2  = 119.264, d.f. = 1, P  < 0.001), (χ 2  = 41.519, d.f. = 1, P  < 0.001), (χ 2  = 39.050, d.f. = 1, P  < 0.001), (χ 2  = 144,400, d.f = 3, P  < 0.001) and (χ 2  = 179.366, d.f. = 1, P  < 0.002)] respectively (Table  2 ).

Increasing program coverage and access of family planning will not be enough unless all eligible women have adequate awareness for favorable attitude and correctly and consistently practicing as per their need. Increasing awareness/knowledge and favorable attitude for practicing FP activities at all levels of eligible women are strongly recommended [ 6 ].

The results of the present study showed that 42.3% of study participants had good knowledge, 58.8% had favorable attitude, and 50.4% had good practice towards family planning. This finding was lower than a study conducted in Jimma zone, Southwest Ethiopia [ 7 ], Sudan [ 9 ], Tanzania [ 12 ] and another study done in Rohtak district, India [ 13 ]. The difference may be due to; studies done in Jimma zone, Sudan, Tanzania and Rohtak district involve only those coupled/married women. Married women might have good knowledge and attitude for practicing family planning. But in the current study, all women of reproductive age group regardless of their marital status were studied and this may lower their knowledge and attitude.

The current study showed that, 50.4% of reproductive age women were practicing family planning which was almost in line with a study done in Cambodia [ 14 ] and higher than a study done in rural part of Jordan [ 15 ] and India [ 16 ]. But it was lower than studies conducted in Jimma zone, Ethiopia [ 7 ], Rohtak district, India [ 13 ], urban slum community of Mumbai [ 17 ] and in Sikkim [ 18 ] in which 64%, 62%, 65.6% and 62% of participants respectively used family planning. The difference might be due to that study participants in Jimma zone, Rohtak and Mumbi were relatively residing in large city/town and this may help them to have a better access for family planning compared to the study done in South Achefer District.

In the current study, urban residents were more likely to use family planning methods (71.4%) than their rural counterparts (28.1%). This finding was in line with the findings from Ethiopian Demographic Health Survey (EDHS) [ 2 ]. This might be due to the reason that urban residents are more aware of family planning and hence practicing better.

It has also found that women who completed primary & secondary education were practicing family planning than those who were uneducated (77.1% and 20.6%) respectively. This finding was in line with a study done in Jimma, Ethiopia [ 19 ]. This might be due to the fact that women who were able to read and write would think in which FP activities are useful to be economically, self-sufficient and more likely to acquire greater confidence and personal control in marital relationships including the discussion of family size and contraceptive use.

This study showed that, age of the study participants had an association with practicing FP. Those reproductive age women’s whose age > 30 years were practicing family planning better than those whose age < 18 years. This finding was in line with a study done in India [ 20 ]. This might be due to the reason that, when age increases mothers awareness, attitude and practice towards family planning may increase. In addition, as age increases the chance of practicing sexual intercourse increases and as a result they would be interested to utilize family planning in one or another way.

It has also revealed that women’s average monthly household income has an association with their FP practicing habit. Those study participants whose average monthly income < 1000 ETB were using FP better than whose average monthly income > 3000 ETB. This is might be because those relatively who had better income may need more children and those with low income may not want to have more children beyond their income.

The current study also showed that knowledge and attitude of reproductive age women were related to FP utilization. Those reproductive age women who had good knowledge were utilized FP better than from those who were less knowledgeable. Those participants with favorable attitude were practicing better than those who had unfavorable attitude. This is might be due to the fact that knowledge and attitude for specific activities are the key factors to start behaving and maintaining it continuously.

Conclusion and recommendation

The level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies.

Study participant’s residence, marital status, educational level, occupation, age, knowledge, attitude, their family size and their monthly average income were associated with FP utilization habit of reproductive age women.

Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced.

Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Limitation of the study

As the data were collected using interviewer administered questionnaire, mothers might not felt free and the reported KAP might be overestimated or underestimated.

We do not used qualitative method of data collection to gather study participant’s internal feeling about family planning, so that triangulation was possible. In addition, barriers for utilizing contraception not addressed.

Abbreviations

Ethiopian Demographic Health Survey

Ethiopian birr

Federal Ministry of Health

family planning

knowledge, attitude and practice

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Authors’ contributions

AS: approved the proposal with some revisions, participated in data analysis. MT: wrote the proposal, participated in data collection analyzed the data and drafted the paper. NE: approved the proposal with some revisions, participated in data analysis. All authors read and approved the final manuscript.

Acknowledgements

We are very grateful to all study participants for their commitment in responding to our questionnaires.

Competing interests

The authors declare that they have no competing interests.

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Ethical clearance was obtained from the Ethical Review Committee of Bahir Dar University, College of Medicine & Health Sciences, and School of Nursing. The objective and purpose of the study were explained to officials at the Woreda and Kebele (smallest governmental administrative division) and a written permission consent was obtained from the study participants. For those study participants whose age is below 18 years consent to participate in the study was obtained from their parent during the data collection time.

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Department of Nursing, College of Medicine & Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Ayele Semachew Kasa & Mulu Tarekegn

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Semachew Kasa, A., Tarekegn, M. & Embiale, N. Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia. BMC Res Notes 11 , 577 (2018). https://doi.org/10.1186/s13104-018-3689-7

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Received : 28 June 2018

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A narrative review of evidence to support increased domestic resource mobilization for family planning in Nigeria

• Chinyere Ojiugo Mbachu 1 , 2 ,
• Ifunanya Clara Agu   ORCID: orcid.org/0000-0001-9048-064X 1 ,
• Chinazom N. Ekwueme 1 , 2 ,
• Anne Ndu 2 &
• Obinna Onwujekwe 1 , 3  

BMC Women's Health volume  23 , Article number:  235 ( 2023 ) Cite this article

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Family planning (FP) is an important public health intervention that is proven to reduce unplanned pregnancies, unsafe abortions, and maternal mortality. Increasing investments in FP would ensure stability and better maternal health outcomes in Nigeria. However, evidence is needed to make a case for more domestic investment in family planning in Nigeria. We undertook a literature review to highlight the unmet needs for family planning and the situation of its funding landscape in Nigeria. A total of 30 documents were reviewed, including research papers, reports of national surveys, programme reports, and academic/research blogs. The search for documents was performed on Google Scholar and organizational websites using predetermined keywords. Data were objectively extracted using a uniform template. Descriptive analysis was performed for quantitative data, and qualitative data were summarized using narratives. Frequencies, proportions, line graphs and illustrative chart were used to present the quantitative data.

Although total fertility rate declined over time from 6.0 children per woman in 1990 to 5.3 in 2018, the gap between wanted fertility and actual fertility increased from 0.2 in 1990 to 0.5 in 2018. This is because wanted fertility rate decreased from 5.8 children per woman in 1990 to 4.8 per woman in 2018. Similarly, modern contraceptive prevalence rate (mCPR) decreased by 0.6% from 2013 to 2018, and unmet need for family planning increased by 2.5% in the same period. Funding for family planning services in Nigeria comes from both external and internal sources in the form of cash or commodities. The nature of external assistance for family planning services depends on the preferences of funders, although there are some similarities across funders. Irrespective of the type of funder and the length of funding, donations/funds are renewed on annual basis. Procurement of commodities receives most attention for funding whereas, commodities distribution which is critical for service delivery receives poor attention.

Nigeria has made slow progress in achieving its family planning targets. The heavy reliance on external donors makes funding for family planning services to be unpredictable and imbalanced. Hence, the need for more domestic resource mobilization through government funding.

Peer Review reports

More than 200 million women in developing countries want to avoid or delay pregnancy. Yet, they lack access to effective and safe family planning services [ 1 ]. In Nigeria, fewer than two out of every ten married women use modern contraceptives, and 19% of women have an unmet need for family planning [ 2 ]. The reasons for this include supply-side issues such as unavailability of FP services and information, and demand-side issues such as lack of funds and poor support from partners or communities [ 2 ]. Limited access to FP services prevents women of reproductive age from delaying pregnancy, limiting family size and safe spacing [ 3 , 4 , 5 , 6 ].

In order to address the socio-cultural issues that limit access to family planning services, the Federal government designed a strategy for engaging with stakeholders to discuss issues about large family size, religious beliefs, and women's power to make decision about their sexual and reproductive health [ 7 ]. This approach has been effective in addressing some of the cultural barriers to contraception and the increase in contraceptive use in some communities in Nigeria has been attributed to the involvement of community leaders to promote family planning [ 8 ].

Family planning (FP) is an important public health intervention that is proven to improve maternal and child health outcomes by reducing unplanned pregnancies and unsafe abortions [ 9 , 10 , 11 , 12 , 13 ]. To ensure progressive improvements in maternal and child health outcomes through family planning, there is need for sustained and dedicated funding of family planning programmes [ 14 , 15 ]. Evidence from the United States international family planning assistance in 2014 showed that investments in family planning services and contraceptive supplies saves millions of lives [ 16 ]. Through improving access to contraceptives for 30 million women and couples, 7 million unintended pregnancies, 2 million unsafe induced abortions and 13 thousand maternal deaths were averted [ 16 ].

In Nigeria, the national budget for family planning was cut short by 90% in 2019, owing to lack of counterpart funding to match grants from donors [ 17 ]. This resulted in the stock-out of contraceptive commodities in the primary health centers, and worsened access to family planning services for women [ 18 ]. Moreover, with the withdrawal of donor funds, domestic resource mobilization (DRM) for family planning services and contraceptive supplies became an urgent need for the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) program in Nigeria to improve [ 2 ]. Granted that increasing investments in FP would ensure stability and better maternal health outcomes in Nigeria, evidence is needed to make a case for more domestic investment in family planning.

Evidence generation is a critical component of the National and State roadmaps for improved domestic resource mobilization for family planning in Nigeria [ 19 ], and reliable evidence is needed to motivate policymakers and domestic funders to allocate more resources towards family planning services and contraceptive supplies. Therefore, we undertook a literature review to determine the unmet needs for family planning and analyze the funding landscape in Nigeria, with a view to highlight the need for increased domestic funding of family planning services. The findings will be invaluable to policymakers and family planning program officers in advocating for domestic funding for family planning interventions .

We undertook a narrative review of literature from February to May 2022 to generate evidence that showcases the need to allocate more domestic funds to family planning services in Nigeria.

Our review sought to answer two key questions,

What is the unmet need for family planning in Nigeria?

How is the family planning programme in Nigeria funded, and what does this imply for reliability and predictability of funding?

To answer these questions, we analyzed the trends in fertility rate and contraceptive prevalence rate from 1990 to 2018 and estimated the gaps in wanted and actual fertility. Then we undertook a funding landscape analysis using the bespoke framework that highlights the types and characteristics of funding organizations (in terms of reliability and predictability), as well as their interests or areas of funding.

Document search

Electronic search was performed on Google Scholar, organizational websites and blogs to source for relevant documents, such as peer-reviewed articles, reports from national surveys, and reports from family planning programmes and interventions.

The reports from the Nigeria Demographic and Health Survey (NDHS) were collated from 1990 to 2018, while the reports for the Multiple Indicators Cluster Survey (MICS) were collated for 1999 to 2016. Peer-reviewed journal articles and website articles that were published in English language from January 2008 to June 2021 were included in the review, and the scope of the review was limited to Nigeria only. The search for articles was performed using various combination of key terms including, “family planning”, “contraceptives”, “fertility rate”, “contraceptive prevalence rate”, “financing”, “funding landscape”, “funders”, “unmet need”, “unwanted pregnancy”, “family planning investment”.

A total of 30 documents were reviewed including, 16 journal articles, ten web blogs, and six national survey reports [ 2 , 7 , 8 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ].

Data extraction and synthesis

Data were objectively extracted by two independent researchers using a uniform template that was designed in Microsoft Excel.

The template was structured according to themes, including a description of the article under review, and the findings from the review were synthesized according to the thematic areas, namely,

Fertility rates

Contraceptive prevalence rates

Variations in fertility and contraceptive prevalence rates

Nature of funding, including

◦ Name and type of funding organization

◦ Interest of funding organization (areas/aspects of family planning services that are funded)

◦ Type of funding (e.g., grant, loan)

◦ Duration of funding

◦ Funding route (e.g., third party financing, direct facility financing, etc.)

◦ Conditions of funding (e.g., counterpart funds, results-based)

Narrative summaries are presented for the qualitative data. Proportions are reported for quantitative data.

Trends in fertility rates

Figure  1 shows that the total fertility rate in Nigeria has gradually declined over time from 6.0 children per woman in 1990 to 5.3 in 2018, and that the wanted fertility rate has decreased from 5.8 children per woman in 1990 to 4.8 per woman in 2018 [ 2 , 20 , 21 , 22 , 23 , 24 ].

Trends in total fertility rates and wanted fertility rates in Nigeria from 1990 to 2018

However, the gap between wanted fertility and actual fertility has increased over time from 0.2 in 1990 to 0.5 in 2018. This signifies that a Nigerian woman has 0.5 more children than she wants to have.

Trends in contraceptive prevalence rate and unmet need for family planning

As shown in Fig.  2 , modern contraceptive prevalence rate (mCPR) improved from 3.5% in 1990 to 12.0% in 2018, which indicates an increase of 8.5% in 28 years [ 2 , 20 , 21 , 22 , 23 , 24 ].

Trends in modern contraceptive prevalence rate among currently married women and all women in Nigeria from 1990 to 2018

This translates to a yearly increase of 0.3%, which if sustained will not result in the achievement of the country’s mCPR target of 27% by 2024 [ 19 ].

Even though mCPR is traditionally reported for currently married women, it is noteworthy that mCPR among all women decreased from 11.1% in 2013 to 10.5% in 2018.

Figure  3 shows that the unmet need for family planning among currently married women reduced by 3.9% in 2003 and increased by 3.3% in 2008; and has since followed the pattern of falling and rising. Between 2013 and 2018, unmet need for family planning increased by 2.8% [ 2 , 21 ].

Trend in percentage of currently married women with unmet need for family planning from 1990 to 2018

Geographic variations in fertility and contraceptive prevalence rates

Over time, total fertility rate has been consistently higher in the rural areas compared to the urban areas, whilst mCPR has been higher in urban areas than in rural areas, expectedly.

Wide variations in TFR are also seen across geopolitical zones, with the northern zones having substantially higher rates than the south. It is noteworthy that over the years, the southern zones have consistently had lower fertility rates than the national average. Women in the north-east and north-west geopolitical zones reported having an average of two more children than their counterparts in the south.

Regarding contraceptive prevalence, there are wide regional variations in mCPR across the geopolitical zones and the States. The northern zones have consistently reported lower mCPR than the south, and the north-east and north-west geopolitical zones have had the lowest mCPR in the north.

These geographic disparities in fertility rates and mCPR are summarized in Tables 1 and 2 , respectively.

Funding landscape for family planning in Nigeria

Federal government budgetary allocation to family planning (2015 to 2020).

Family planning was not an item in budgets before 2015. Allocation by federal government to FP was on the increase from 2015 when line listing for family planning commenced in the national budget. However, there was a sharp decline in 2019 due to the removal of counterpart funding to match grants from international donor agencies which was budgeted for in 2018. See Table 3 below.

Typologies of funding organization

Funding for family planning services in Nigeria comes from both external and internal sources in the form of cash (grants or loans) or commodities. Internal sources of funding include the Federal and State governments, while external sources include multilateral and bilateral international organizations, and international Non-Governmental Agencies.

The key international and donor agencies that fund family planning services in Nigeria are shown in Fig.  4 , and the size of the circle indicates the relative contribution of the funder to family planning services in Nigeria.

External sources of funding for family planning in Nigeria

UNFPA is the major funder of family planning services in Nigeria, followed by the USAID. UNFPA provides family planning assistance in 19 States plus the Federal capital territory (FCT), while USAID partners with a variety of non-governmental and community-based organizations across the 36 States and the FCT [ 31 ].

Nature of funding (type, duration, routes and conditions for funding) for family planning

The nature of external assistance for family planning services depends on the preferences of funders, and whether the funding is in form of cash or commodities. External assistance in the form of grants and loans are typically provided to only Federal or State governments, while commodities are provided to public and/or private health facilities through government agencies or implementing partners.

Table 4 shows some similarities and variations among funding agencies in funding for family planning services. With the exclusion of the Saving One Million Lives Programme for Results (SOML PforR), government funding for family planning has been in the form of annual budgetary allocations. Whereas funding from external donors has been in the form of grants. Irrespective of the type of funder and the length of funding, donations/funds are renewed on annual basis.

Various funding routes are employed by external donors, notably the supply of family planning commodities through the State governments or through implementing partners.

Counterpart funding and output-based financing are the two most common conditions for funding.

Interests of funding organization (areas/aspects of family planning services that are funded)

The areas or aspects of family planning services that are funded by international organizations and non-government agencies include, (i) procurement of commodities; (ii) distribution and supply chain management (SCM); (iii) training of health workers; (iv) demand creation and community mobilization; (v) other advocacy interventions; and (vi) research. Whereas, government funding is used to procure and distribute commodities, and pay the salaries of health workers.

Table 5 shows that procurement of commodities receives the most attention for funding, while demand creation and research receive the least attention. It is also noteworthy that although State governments are primarily responsible for the distribution of commodities, many States do not allocate or release funds for this purpose. Hence, it can be said that this critical aspect of family planning services is very poorly attended to in Nigeria, and this may well explain the problems of unavailability of commodities at service points.

The Nigerian government maps out funds for the procurement and distribution of FP commodities to States. About US$4 million was approved in 2021 for the procurement of family planning commodities [ 32 ].

The UNFPA is primarily involved in the procurement of family planning commodities for the public sector. It also provides technical assistance to focus States in the form of training of health workers [ 26 ].

The U.S. Agency for International Development (USAID) is a bilateral organization that partners with NGOs to provide FP commodities to both public and private healthcare providers. It also funds programs that seek to improve the quality of FP services and to hold State governments’ accountable to ensuring that FP commodities reach the last mile [ 25 , 26 ]. The efforts of the USAID-funded Health Policy Plus’ advocacy to Cross-River State government resulted in the allocation of $600,000 for the distribution and security of FP commodities in 2013 and 2014 [ 25 ].

The (UK) Department for International Development (DFID) provides the majority of the FP commodities that are supplied to private healthcare providers in Nigeria [ 27 ].

Society for Family Health (SFH) and DKT International are social marketing organizations that provide and distribute FP commodities to private facilities [ 25 , 27 , 30 ] . They are also involved in advocacy and training of health workers with primary focus on private providers [ 26 , 30 ] .

Marie Stopes International offers a wide range of sexual and reproductive health services including FP to communities in urban locations, and it has become a major provider of long acting and permanent contraception in health facilities. The organization delivers FP services through static clinics, mobile outreach teams and social franchising [ 46 , 47 ].

The Gates Foundation focuses on the public sector, and its donations have been used to procure FP commodities [ 26 ]. Through the funding that was provided for the Nigeria Urban Reproductive Health Initiative (NURHI), access to FP commodities and services increased in the six intervention cities, resulting in an increase of mCPR by 20% in three years [ 8 , 26 , 29 ].

Conclusions

Ensuring that every sexually active woman in Nigeria has access to high-quality family planning and contraceptive services is imperative as it save lives and promotes positive maternal health outcomes. Our review highlights that Nigeria’s progress in achieving the targets of family planning has been slow and inconsistent, owing to poor government funding of family planning services. Additional to inadequate government funding of family planning intervention in Nigeria, there is a very wide gap between the estimated cost and the actual allocation of funds for procurement and distribution of family planning commodities [ 37 ]. For instance, between 2012 and 2016, the Federal government fulfilled only 11% of its FP2020 pledge to provide US$3 million annually for the procurement of family planning commodities [ 37 ].

According to the 2016 Appropriation Act, the government is referred to as provider of “counterpart” funding for family planning [ 37 , 48 ]. This means that while donors serve as principal sources of funds, the government serves as a secondary funder of family planning intervention. However, with the ongoing withdrawal of donors and decline in donor contributions, there is a need for government to take on the role of principal funder of family planning in Nigeria [ 49 , 50 ].

Although the Federal government prioritizes family planning interventions by making provisions in the annual budget and earmarking funds through special interventions (such as the SOML-PfR), the funding landscape for family planning interventions at the subnational level is dominated by external donations which are short-lived, unpredictable (in terms of amount and timing), and focused on a single area which is the procurement of commodities [ 51 ]. The nature of external funding influences subnational planning and effective implementation of family planning services. Program managers find it difficult to make or execute plans when they cannot rely on the amount of money or quantity of commodities that will be available. Moreover, the only guarantee that family planning commodities will reach the last mile of distribution is that State governments honor their commitments to funding the distribution and supply chain management system.

Currently, State governments feature minimally in the funding for family planning services, as service delivery is primarily driven by the commodities supplied by external donors and the fee-for-service payments that are made by clients [ 37 ]. The health budgets of many States in the country lump family planning intervention with reproductive health, and this increases the likelihood that family planning services will be overlooked in the budgetary allocations. The ongoing global advocacy for programme-based budgeting as a tool for increasing transparency, accountability and data-driven decision making, provides an opportunity for family planning to be categorized as a stand-alone programme.

Evidence from this review validates the need for the Federal and State governments, particularly, to step-up and take on a greater share of the responsibility for financing family planning intervention, including the procurement and supply of commodities, and service delivery. The advent of the Basic Health Care Provision Fund in Nigeria in which one percent of consolidated revenue fund is earmarked for provision of health services at the primary health care level provides an opportunity for further earmarking a percentage of this fund for family planning at the primary and local government levels. Domestic funding of FP can further be improved by earmarking at least one percent of the annual health budget to funding of FP programs.

However, this is a review article, and the findings may have been influenced by the following factors, (i) the personal viewpoints of the reviewers; (ii) the omission of relevant research due to literature search procedures; and (iii) errors in the translation of data from the primary source. Moreover, the estimates presented in this paper should be interpreted with caution since some of them are based on older available data.

In conclusion, Nigeria has made slow progress in achieving its family planning targets. Over a period of 28 years, total fertility rate declined by 0.7 children per woman, wanted fertility rate decreased by 1, and the gap between wanted fertility and actual fertility increased by 0.3. Over a five-year period, mCPR decreased by 0.6%, and unmet need for family planning increased by 2.5%. Nigeria still relies heavily on external donations for family planning intervention. This makes funding for family planning services to be unpredictable and imbalanced. This highlights the need for increased budgetary allocation and actual release of funds for FP interventions at national and subnational levels. Improving domestic resource contributions to family planning would contribute to improvements in service delivery, because more funds will be available to ensure procurement and uninterrupted supply of sufficient amounts of contraceptive commodities to the last mile. These findings are invaluable to policymakers and family planning program officers for advocating for more funding for family planning interventions . A detailed financial analysis is required to identify opportunities to leverage within the fiscal space to mobilize resources for family planning. Family planning programme managers will also require capacity building on how to use evidence to advocate for more domestic resources for family planning.

Availability of data and materials

The study dataset is available on request.

Abbreviations

Family Planning

Modern Contraceptive Prevalence Rate

Domestic resource mobilization

United Nations Fund for Population Activities

Saving One Million Lives Programme for Results

United States Agency for International Development

Department for International Development

Society for Family Health

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Acknowledgements

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The project leading to the literature review has received funding from the Data for Impact (D4I) associate award 7200AA18LA00008, which is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill with the support of the United States Agency for International Development (USAID). The funder did not participate in the literature review, data analysis, or writing and reviewing the manuscript. The views presented in this manuscript belong solely to the authors and do not necessarily represent the funders’ views.

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CM and OO conceived the study. CM, IA and CE designed the protocol for the literature review. CM, IA and CE were involved in data extraction. All authors participated in data analysis. CM, IA and CE wrote the first draft of the manuscript. All authors reviewed and approved the final version for journal submission.

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Mbachu, C.O., Agu, I.C., Ekwueme, C.N. et al. A narrative review of evidence to support increased domestic resource mobilization for family planning in Nigeria. BMC Women's Health 23 , 235 (2023). https://doi.org/10.1186/s12905-023-02396-y

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