Injectable contraceptives were available and valid in 31 (96.9%) health facilities, while 28 (87.4%), 27 (84.4%), 18 (56.3%), and 13 (40.6%) of the surveyed health facilities had valid condoms, oral contraceptive pills (OCP), IUCD, and implants respectively. Emergency contraceptives were available and valid in only one (3.1%) health facility (Table 1).

Twenty-one (65.6%) of the health facilities surveyed offered at least five modern methods of family planning (Fig. 1). Stock-outs of emergency contraceptives, implants, IUCD, OCP, condoms, and injectables were observed in 31 (96.9%), 17 (53.1%), 13 (40.6%), 4 (12.5%), 2 (6.3%), and 1 (3.1%) of the surveyed health facilities respectively (Fig. 1).

Proportion of health facilities offering at least five modern methods of family planning on day of assessment

On the day of survey, 8 (25.0%) and 11 (34.4%) of the health facilities had contraceptive commodity checklists and IEC materials, and family planning guidelines respectively. Seventeen (53.1%) of the health facilities did not have complete records of family planning activities (Fig. 2).

Bar chart showing the proportion of health facilities with stock outs of the various contraceptive methods

To triangulate quantitative findings, key qualitative results from both IDIs and KII were summarised to themes that emerged during discussion. The major factors or themes that emerged were the low demand by clients for contraceptives, inadequate training of staff, stock-outs of contraceptives, and unavailability of services on weekends. Some of the facility managers spoke extensively about these themes (Fig. 3).

Proportion of health facilities with available family planning materials and complete records on day of assessment

Most of the respondents rated the demand for family planning among women as being poor. However, a few said the demand was for specific commodities as one respondent stated:

“The women are not coming. They have so many false beliefs and misconceptions. The few that come around requests for only injectables and condoms.” (51-year-old nurse).

Most of the respondents stated that training of staff to deliver family planning methods has not been a priority for government. Staff do not undergo regular training on contraceptives, and this has resulted in low staff confidence in counseling and administering certain contraceptives. A respondent stated:

“As far as counseling is concerned some nurses are more confident than the CHEWS, however, it depends on their level of training or exposure.” (56-year-old Nurse).

A few respondents acknowledged the significant role of non-governmental organizations like Marie Stopes in staff training. A respondent stated:

“Before now, the government trained all staff, but in recent times only the focal person for family planning has been trained, who will then step down when she comes back from such training. We were thinking they would come back and pick others to train but we are yet to see them”. (48-year-old nurse).

Another respondent said, “I have been working for a long time, only Marie Stopes has trained me. I have not gone for any training organized by the State government.” (48-year-old RHS).

Majority of the respondents said that they get their supply of family planning every 2–3 months. However, in recent times, the supply has been interrupted resulting in periods of stock-outs ranging from 6 to 18 months. One respondent said:

“Initially we were getting supplies every 2 months that was like 4–5 years ago, but since 2015 supply has been irregular from the State. There was no supply from the central stores. Sometimes transporting them to the various LGA is a big problem. The last time we received commodities was 4 months ago and they brought more than enough for the LGA, we don’t know when they will come again” (49-year-old RHS).

Another said: “We had stock outs for about 19 months from March 2015 to September 2016. It was really a difficult time. The nurses made contributions among themselves to buy some commodities and we charged the clients for it” (49-year-old nurse).

Another respondent said, “I did not have any supply of family planning commodities for 18 months. I had to discuss with a nearby pharmacy shop to subsidise the commodities for us. We tell the clients that government has not supplied and that is why they are paying for it.” (48-year-old RHS).

Most of the respondents when asked on the availability of family planning services in their health facility stated that the service was available all days of the week including weekends despite having a fixed day for the clinic. However, for facilities that open, not all services are given as one respondent noted: “We do not provide implants on weekends because the staff that was trained on this method does not work on weekends.” (40-year-old nurse).

A respondent noted that security concerns were a huge setback, she said: “We do not open on weekends, because of security reasons. This place is usually very quiet during weekends compared to weekdays and the local government has not given us any form of security.” (57-year-old Nurse).