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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 3 | Page : 352-358
Sexual autonomy and the use of modern contraceptives in Nigeria: Evidence from the 2018 demographic and health survey
Temitope Ilori1, Boluwatife A Adewale2, Taiwo A Obembe3, Oyewale Mayowa Morakinyo4
1 Department of Community Medicine, College of Medicine, University of Ibadan; Department of Family Medicine, University College Hospital, Ibadan, Nigeria
2 Medicine and Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Department of Health Policy and Management, University of Ibadan, Ibadan, Nigeria
4 Department of Environmental Health Sciences, Faculty of Public Health, University of Ibadan, Ibadan, Nigeria
Correspondence Address:
Temitope Ilori
Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_86_22
Abstract
Objective: The objective of the study was to determine the prevalence and relationship between sexual autonomy and modern contraceptive use among Nigerian women. Methods: Secondary data analysis of the 2018 Nigerian Demographic and Health Survey was conducted among Nigerian women aged 15–49 years who were married or had a partner. Analysis was conducted using descriptive analysis and univariate and multivariate logistic regression. P < 0.05 was considered statistically significant. Results: Participants that had never heard or seen a family planning awareness message were 59.6%, whereas 55.9% were capable of deciding whether to refuse their husband/partner's sex or not. The prevalence of modern contraceptive use was 12%, and the likelihood of using modern contraceptives increased with the level of education, wealth status, and the number of living children. Sexual autonomy was also a significant predictor of modern contraceptive use (odds ratio = 1.35, 95% confidence interval: 1.25–1.46). Conclusion: There is a very low prevalence of modern contraceptive use among women in Nigeria. Sexual autonomy, poverty, education, and the number of living children play a major role. Thus, women empowerment and girl-child education are critical interventions needed for the best outcomes on contraceptive use in Africa. Male involvement in sexual autonomy is also key since they are major decisionmakers regarding women's issues.
Abstract in French Résumé
Objectif: L'objectif de l'étude était de déterminer la prévalence et la relation entre l'autonomie sexuelle et l'utilisation de méthodes contraceptives modernes chez les femmes nigériennes. Méthodes: L'analyse des données secondaires de l'enquête démographique et sanitaire nigérienne de l'année 2018 a été menée auprès de femmes nigérienne âgées de 15 à 49 ans mariées ou en couple. L'analyse a été effectuée à l'aide d'une analyse descriptive et d'une régression logistique univariée et multivariée. P < 0,05 était considéré comme statistiquement significatif. Résultats: Les participants qui n'avaient jamais entendu ou vu un message de sensibilisation à la planification familiale étaient 59,6 %, tandis que 55,9 % étaient capables de décider ou refuser les rapports sexuelles avec leur mari/partenaire. La prévalence de l'utilisation de méthodes contraceptives modernes était de 12 % et la probabilité d'utiliser des contraceptifs modernes augmentait avec le niveau d'éducation, la richesse et le nombre d'enfants. L'autonomie sexuelle était également un prédicteur significatif de l'utilisation de méthode contraceptives modernes (rapport des chances = 1,35, intervalle de confiance à 95 % : 1,25-1,46). Conclusion: Il y a une très faible prévalence de l'utilisation de méthodes contraceptives modernes chez les femmes nigériennes. L'autonomie sexuelle, la pauvreté, l'éducation et le nombre d'enfants jouent un rôle majeur. Ainsi, l'autonomisation des femmes et l'éducation des filles sont des interventions essentielles nécessaires pour obtenir les meilleurs résultats en matière d'utilisation des méthodes contraception en Afrique. L'implication des hommes dans l'autonomie sexuelle est également essentielle car ils jouent un rôle important dans les décisions concernant la vie de couple.
Mots-clés: Utilization méthodes contraceptives, Enquête démographique et sanitaire, planification familiale, autonomie sexuelle, autonomisation des femmes
Keywords: Contraceptive use, demographic and health surveys, family planning, sexual autonomy, women empowerment
Introduction 
Sub-Saharan Africa has the highest Maternal Mortality Ratio (MMR), with Nigeria recording a national MMR of 512 deaths/100,000 in 2018.[1] Sustainable Development Goal (SDG) 3 seeks to significantly reduce the number of maternal deaths to 70/100,000 live births by 2030.[2]
The risk of dying from maternal causes is related to getting pregnant. Hence, the lifetime risk of dying from maternal causes is higher in low- and middle-income countries with higher fertility rates.[3] Therefore, maternal mortality can be reduced through better access to modern methods of contraception and by ensuring that women have access to high-quality care before, during, and after childbirth. SDG 5, Target 5.6 aims at ensuring universal access to sexual and reproductive health-care services, including family planning, information and education, and integration of reproductive health into national strategies and programs.[2]
Nigeria's current contraception prevalence rate of 15% poses a significant barrier to attaining SDGs 3 and 5.[1],[2] Contraceptive use among women is an index of reproductive and health-seeking behavior. It reflects how well women desire family size and effectively cater to their young ones. A good family planning program is essential for maternal and infant survival, child education, improvement of women's status, and poverty reduction.[3] Family planning puts the power in the hands of women to prevent unwanted pregnancies and abortion-related deaths.[4] It was garnered from the 2013 Nigerian Demographic and Health Survey (NDHS) that only 14.5% of Nigerian couples use modern contraceptives.[5]
Decision-making in the home is primarily assumed to be the man's prerogative in a patriarchal setting like Nigeria.[6] In most patriarchal societies, men are perceived to have full ownership of and control of their partners' bodies (whether within a marital relationship or otherwise sexual relationships). At the same time, women are expected to satisfy their partners' sexual urges on request, regardless of how they feel about it. This feeling of entitlement engenders harmful practices and behaviors such as marital or partner rape.[7],[8] Women should be empowered to make informed decisions regarding their sexual relations, contraceptive use, and reproductive health care.
Autonomy can be described as the ability to decide on one's environment and health.[9] Women's autonomy is an indicator of women's empowerment and is vital in reproductive health service utilization. Women's access to reproductive health services improves maternal and child health outcomes. According to Khan, autonomy consists of two dimensions: economic and household decision-making.[9] Sexual autonomy entails a woman's capacity to independently decide when, with whom, and under what circumstances she engages in sexual activity. It involves her rights to either have sex or refuse.[10] Sexual autonomy is a key component of sexual and reproductive rights in Nigeria and is core to women's health.
Historically, women have had relatively low autonomy in most cultures. Alabi et al. found an association between women's autonomy in Northern Nigeria and the low contraceptive use in the region.[11] Viswan et al. also reported a similar association between sexual autonomy and contraceptive use from the 2013 NDHS.[12] Therefore, we hypothesize that a woman's ability to make decisions regarding her sexual relations independently could determine whether or not she uses modern contraceptives. Thus, we investigated this relationship in the context of other sociocultural backgrounds among Nigerian women in a marital relationship or cohabiting with a partner using the latest NDHS conducted in 2018. The study aims to investigate the relationship between sexual autonomy and the use of modern contraceptives using the (NDHS 2018).
Methods Study setting
Nigeria, a federal republic in West Africa, is administratively divided into 36 states and a federal capital territory. The States are grouped into six geopolitical zones namely North West, North Central, North East, South East, South West, and South South. People in each geopolitical zone are homogeneous and distinct in their lifestyles.
Data source
This research is a cross-analysis of nationally representative data from the year 2018 NDHS. Women of reproductive age (15–49 years) are questioned for the NDHS about their reproductive health, marital status, child health, and other related topics.
A stratified two-stage cluster design was used to recruit survey respondents, with all census enumeration areas (EAs) in the country split into rural and urban areas. Each stratum was then assigned a specific number of EAs. Households in selected EAs were identified, and 45 were randomly chosen from each.[5] Data were obtained from eligible women in chosen households by professional interviewers using a pretested questionnaire. A nationally representative sample of 41,821 women aged 15–49 years living in 40,427 households, as well as 13,311 men aged 15–59 living in one-third of the sampled households, were interviewed. A total of 99% of women and men responded.[1] The women that were interviewed were either permanent residents or visitors in the families on the night before the survey. The sample employed in this study included 29,089 women of reproductive age who had given birth within the previous 5 years.
Outcome variable
The outcome variable was sexual autonomy. Sexual autonomy was determined by combining the “can respondent refuse her partner/husband sex?” and “can respondent ask her partner/husband to use a condom?.” A respondent was only considered sexually autonomous if the responses to both questions were “Yes.”
Independent variables
The independent variable was the use of contraceptives. Other independent variables were age, region, type of place of residence, occupation, religion, number of living children, the highest level of education, wealth index, assess to family planning information, and the current use of contraceptives.
Data analysis
Data were analyzed using the Statistical Package for the Social Sciences (IBM SPSS Co., Armonk, NY, USA) software version 23.0. All of the study variables were described using frequencies and percentages in the analysis. Univariate logistic regression was then used to analyze the relationship between sexual autonomy and other sociodemographic characteristics versus the use of modern contraceptives. Further, multivariate logistic regression was used to test this relationship while controlling for other factors.
Results The age distribution of the study participants is presented in [Table 1]. Women aged 25–29 years comprised the largest proportion (20.8%) of the participants. Women from the Northwestern region were ≥2 times more than women from any other region. About 26% of the women are unemployed. The predominant category of occupation is sales/services (48.0%), followed by agriculture (15.4%) and professional/clerical occupations (7.1%). Manual and domestic jobs are done by the minority (3.5%). Rural dwellers are more (59.5%) than urban residents. Majority (44.5%) of the women are uneducated. However, secondary education is the highest level of education (30.1%) among the majority of educated people. Islam is the predominant religion (59.8%), followed by Christianity (39.8%). Most (32.2%) women have 1–2 living children. The wealth distribution is shown in Table 1 using the wealth index. More than half (59.6%) of the participants had never heard or seen a family planning awareness message.
Slightly more than half (55.9%) of participants can decide whether to refuse their husband/partner's sex or not. A fewer proportion (41.3%) can ask their partners to use a condom during sex [Figure 1]. Thirty-seven per cent of the women were considered sexually autonomous [Figure 2].
Figure 1: Women's responses to questions on their autonomy to make decisions about sexThe prevalence of modern contraceptive use was 12% [Figure 3]. The univariate model [Table 2] shows that the odds of using a modern contraceptive increase with age and peak at ages of 35–39 years (odds ratios [OR] = 8.41, 95% confidence interval [CI]: 6.19–11.43), then decreases with age. Northeastern (OR = 0.53, 95% CI: 0.46–0.61) and Northwestern (OR = 0.42, 95% CI: 0.37–0.47) women are less likely to use modern contraceptives compared to women from North Central Nigeria. Women from South-South (OR = 1.17, 95% CI: 1.02–1.34) and South-West (OR = 2.02, 95% CI: 1.80–2.25) are more likely to use modern contraceptives than women from North Central. Women in urban areas are 2.63 times more likely to use modern contraceptives than rural dwellers. Employment status, occupation, the highest level of education, wealth index, number of living children, and sexual autonomy (OR = 2.32, 95% CI: 2.16–2.48) were all significant predictors of modern contraceptive use in the univariate model [Table 2].
Table 2: Univariate and multivariate models for the predictors of modern contraceptive use among Nigerian womenThe multivariate model shows the degree of likelihood of modern contraceptive use by the predictors identified earlier while accounting for the effect of other explanatory variables. The results suggest that the age of a woman is mostly a nonsignificant predictor of modern contraceptive use. Women aged 45–49 years are 1.7 times less likely to use modern contraceptives than those aged 15–19 years. The chances of a woman using modern contraceptives increase with an increasing level of education. Muslim women (adjusted OR [aOR] = 0.56, 95% CI: 0.50–0.62) and traditional religious practitioners (aOR = 0.12, 95% CI: 0.02–0.67) are less likely to use modern contraceptives than Christian women. Moreover, the likelihood of using modern contraceptives increases with increasing wealth status. Sexual autonomy is also a significant predictor of modern contraceptive use (aOR = 1.35, 95% CI: 1.25–1.46). Our findings reveal that the number of living children is the most important predictor of modern contraceptive use because the observed effect sizes (OR) were the largest. This association is even more pronounced in the multivariate model [Table 2]. Women with ≥5 living children are about 22 times more likely to use modern contraceptives than those who have none.
Discussion The prevalence of the use of modern contraceptives observed in this study is relatively low (12%) and similar to what was observed previously from the 2008 (9%) and 2013 (10%) NDHS, despite a high prevalence of family planning knowledge.[5],[12] Alabi et al.[11] reported a 6.6% of prevalence among married women in Northern Nigeria, though having a regular sexual partner has been significantly associated with the use of modern contraception.[13] The low prevalence in Nigeria contrasts sharply with what has been previously reported in rural Zambia (43%),[14] among adolescents in Zimbabwe (45.75%),[15] and employed women in Bangladesh (67%).[16]
Similar to previous reports, women in rural regions have been found to have a lower likelihood of using modern contraceptives compared to those living in urban areas.[15],[16] Our findings also underscore the importance of women's education in promoting contraceptive use and reproductive health. Educated women are more likely to ask their partners to wear a condom during sex.[17] However, Olaolorun and Hindin. noted that women's decision-making power played an important role in women's use of modern contraceptive methods independent of their educational status.[18] Similarly, wealth index and religion have been identified in previous studies as significant predictors of modern contraceptive use.[15],[16],[17] In this study, Muslim women and African Traditional Religion practitioners are 1.8 and 8.3 times less likely to use modern contraceptives than Christians. The odds of modern contraceptive use also increase as one ascends the wealth ladder.
Interestingly, the odds of using modern contraceptives are pretty similar for sexually autonomous individuals and those who have heard or seen a family planning message [Table 2]. Similar results were obtained for the association of the use of modern contraceptives with awareness messages on family planning and sexual autonomy. There is a need to be more discussions centered on women asserting their sexual autonomy in relationships and exercising their rights to reproductive health care, particularly in the media. Men and women alike should be well-sensitized on the importance of women's empowerment. However, such interventions need to be well thought out with full sociopolitical considerations. Highly patriarchal and conservative societies tend to resist programs that appear to promote female sexual freedom and women empowerment. Hence, there is a need for men's involvement in formulating interventions that promote women's autonomy in Africa, considering that they are major decision-makers in key issues that affect women.[15],[16],[17],[18],[19]
The largest predictor of modern contraceptive use in this study is the number of living children. The relationship between the number of living children and modern contraceptives is significant in the univariate model and even larger after controlling for the other factors. Women with >4 children were about 22 times more likely to use modern contraceptives than those with no children. Whereas the OR among those with 3–4 children is almost double that of those with 1–2 children, the OR among those with 5–6 children is very similar to those with ≥7 children. The OR is maximum among those with 5–6 children. This is not too surprising considering that the average number of children per woman (fertility rate) in 2018 was 5.4.[20] Hence, women are most likely to seek contraception when they have between 5 and 6 children.
The number of living children was also found to have a large effect size on contraceptive use among women in Bangladesh.[16] Islam et al.[15] reported a 6.8 and 10.3 times likelihood of contraceptive use among women with 1–2 children and those with >2 children, respectively. Women in Tanzania with four children and above were also found to have a 20-time likelihood of using modern contraceptives.[21] Other studies in South Asia and sub-Saharan Africa have also demonstrated the association between modern contraceptive use, parity, and the number of living children.[14],[22],[23],[24] Contraceptive use was directly related to the number of living sons a woman had; those with no daughters had lower odds of using modern contraceptives than those with at least a child of both genders.[25] This espouses that expectations of gender ratio and desired family size are relevant factors affecting contraceptive use.
Conclusion The use of modern contraceptives among Nigerian women remains low and sexual autonomy, poverty, education, and the number of living children are significant predictors of low uptake. Consequently, interventions to promote contraceptive use among women should target the unemployed, those without formal education, as well as those in rural areas, as these are the most disadvantages when it comes to negotiating for safer sex. Hence, maternal mortality can be reduced through improved women's literacy, women's employment, and strengthening existing family planning programs to improve coverage and utilization.
Acknowledgments
We would like to thank the Demographic and Health Surveys (DHS) Program for granting us approval to review the NDHS 2018 dataset.
Financial support and sponsorship
This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand, South Africa and is funded by Sida (Grant No: 54100113), Carnegie Corporation of New York (Grant No. G-19-57145), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)'s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa's Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the Authors.
Conflicts of interest
There are no conflicts of interest.
References 
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