Does Spousal Intimacy Improve Contraceptive Use? A Cross-Sectional Household Survey in Nigeria

Introduction

Achieving universal coverage of family planning has been one of the overarching public health objectives of the Nigerian government. Specifically, the Family Planning 2020 (FP2020) initiative of the Federal Government of Nigeria was designed to enable 120 million additional women and girls to use modern contraception by 2020. This initiative is motivated by the understanding that women health is critical for their socioeconomic empowerment, and contribution to the overall economic growth and development of the country.

Studies have shown that increasing the rate of contraception use presents some socioeconomic benefits to developing countries. Economically, evidence shows that for every dollar invested in reproductive health services, $2.20 is saved in pregnancy-related healthcare costs. In addition, the longer a woman waits to have a child, the longer she can engage in income-earning activities, thereby contributing to improving the economic welfare of her household [1].

From social perspective, family planning is linked to improved birth outcomes for babies, either directly or through healthy maternal behaviors during pregnancy. Contraception use reduces pregnancy-related morbidity and mortality and the risk of developing certain reproductive cancers [2]. Evidence from Benin Republic shows that if access to and use of family planning alone is increased from 7.9% (in 2015) to 33.95% (by 2030), lives of about 200,000 under five-year children, and 10,000 mothers can be saved. This will reduce the average number of children per woman to 3.5, thereby increasing female life expectancy by 5 years [3].

From policy perspective, increasing contraceptive use could support efforts at advancing human development by empowering women to plan the size and timing of their families, allowing them to avoid unwanted pregnancies, and the associated unsafe abortions, as well as improving infant and child health. These could contribute to achieving goals 3, 4, and 5 of the Sustainable Development Goals (SDGs). Small family size ensures increased household savings and investment, leading to reduced poverty. It also ensures improved educational investment per child, leading to increased demographic dividend. Contraceptive use supports moderation in human population growth and reduced pressure on the environment and natural resources, enabling progress towards a sustainable human population [4]. These benefits are likely to elude developing countries if the facilitators and barriers to contraceptive use are not identified and incorporated into population control policies. The imperative of identifying these factors provides a compelling justification for this study.

Various studies have examined how spousal relationship (intimate or violent) affects the decision to use contraceptives. Findings in Nigeria show that women who have experienced any type of intimate partner violence (IPV) are 1.28 times more likely to discontinue contraceptive use than those who have not experienced IPV [5]. Evidence from Nepal suggests that lifetime exposure to any form of IPV is associated with sterilization [6]. Results from studies focusing on the three forms of violence, namely, emotional, physical, and sexual violence suggest that emotional violence is associated with greater odds of discontinuation of contraceptive use in Egypt [7].

A positive association between sexual violence and discontinuation is found in Jordan, while a negative correlation is the case in Tajikistan [7]. A study in South Asia finds that sexual violence against women is associated with pre-pregnancy modern contraceptive use, and higher rate of contraceptive discontinuation [8].

Positive but weak association exists between physical violence and contraceptive discontinuation in Egypt and Honduras [7]. In Bangladesh, women exposed to physical violence were almost two times more likely to use contraceptives compared with their non-abused peers [9]. Nigeria women who have been physically abused had 28% higher odds of not using any contraception, while those who have suffered both physical and psychological abuse had 52% higher odds compared to those who have not experienced any form of violence [10].

Studies on the effect of IPV on method choice reveals that women experiencing physical IPV were significantly less likely to use condoms and IUDs than women not experiencing violence [11]. Women who suffered both sexual and physical violence are more likely to engage in traditional contraceptive use in South Asia [8].

Having a cordial spousal communication about family planning is assumed to positively influence couples’ decision to use family planning products and services. Findings from the work of Challa S, et al. [12] reveal that spousal communication is positively correlated with ever-use of modern contraception. Spousal communication reduces the chances of covert use of modern contraceptive. Similar association between spousal communication and modern contraceptive use is found in Malaysia Najafi-Sharjabad F, et al. [13] and in Bangladesh [14].

The effect of relationship characteristics on current use of effective contraception has been documented in the literature. Evidence from the US suggests that women in casual relationship, and those whose relationship is less than one year old are less likely to use effective contraceptive method compared to women in consistent and up to one year relationship [15]. A study in Ghana shows that women who were satisfied with their relationship were more likely to use overt contraceptives rather than not using at all [16]. In another study, young adults in relationships with less intimacy are found to be less likely to use hormonal and dual methods, while those in relationship with greater intimacy are more likely to use hormone-based methods [17].

While there is a plethora of studies on partner violence, to the best of our knowledge, no study has focused on the role of spousal intimacy in determining spousal attitude towards contraceptive use in Nigeria. This study intends to fill this gap and contributes to the rather sparse literature on innovations for improving family planning in developing countries. This study becomes more important considering that emotional aspects of relationships that may influence reproductive decision making are often unrecognized in family planning interventions in developing countries [16]. The results will support policymakers and donors in the public health space to leverage on spousal relationship to recalibrate their family planning policies and programmes to improve contraceptive prevalence rate (CPR) in Nigeria.

The choice of Nigeria as the location of the study is informed by the demographic projection that the population of the country may reach 400 million by 2050 [18]. Historically, the Nigerian population grew from 161 million in 2010 to 217 million in 2022, comprising 49.9% male and 50.1% female. It is projected to rise to 228 million in 2024. The population of women of childbearing age (15 – 49 years old) in Nigeria stands at 40 million. Total fertility rate declined from 5.50 births per woman in 2013 to 5.14 births in 2022, and is projected to further decline to 5.0 births in 2024 [19].

The objective of the study is to understand if spousal intimacy encourages the use of contraceptives among women of child-bearing age in Nigeria. Providing an empirical insight into the role of spousal intimacy in family planning decisions enables policymakers to address the question: can we leverage on spousal intimacy to improve CPR in Nigeria?

Data Collection

The 2018 NDHS collected data from women aged 15- 49 in the sampled households. Respondents were either permanent residents of the selected households or visitors who stayed in the households the night preceding the interview.

Four variants of the questionnaire were used for the survey: the household questionnaire, the woman’s questionnaire, the man’s questionnaire, and the biomarker questionnaire. This study uses information from the household, woman’s, and man’s questionnaires merged as CR data file. The household questionnaire collected basic demographic information on each person listed, including age, sex, marital status, education, and relationship to the head of the household. Responses on age, sex, and marital status of household members were used to identify women and men who were eligible for individual interviews.

The woman’s questionnaire was used to collect information from all eligible women aged 15-49 years. Information collected included background characteristics (including age, education, and media exposure), knowledge, use, and source of family planning methods, antenatal, delivery, and postnatal care, fertility preferences (including desire for more children and ideal number of children, women’s work, and husbands’ background characteristics.

Prior to the data collection exercise, enumerators were trained for four weeks, including the field work. The training focused on orientation on data collection instruments, and procedures. The field work was implemented by 296 enumerators, supervisors, and coordinators, and lasted for over four months.

Results and Discussion

Table 1 shows the descriptive statistics of the study variables. About 34.3% of women who have ever-used contraceptives reported having emotional, physical, and sexual intimacy with their spouse, while only 18.3% of women currently using contraceptives reported experiencing such forms of intimacy.

Education attainment differs markedly between women who have ever used, and those currently using contraceptives. Fifteen percent of women who have ever used contraceptives has no education, while 5.6% of those currently using reported having no education. There are more women with secondary (50.6%) and higher (57%) education who have ever used contraceptives than there are for those currently using – 29.5% and 35.3% respectively for secondary and higher education.

Twenty seven percent of women who have ever used contraceptive has less than two children, compared to 13.8% of their currently using counterparts. More ever- used women have 2-4 children (40.4%) than currently using women (23.6%) and having more than four children is more common with ever-used woman (36.4%) than with currently using women (19.8%).

Thirty percent of women aged 15-30 years has ever used contraceptives, while 16.6% of women within that age bracket are currently using. Thirty eight percent and 30.5% of women that have ever used contraceptives are respectively aged 31-49, and above 50 years. Twenty one percent of those currently using contraceptive are aged 31-49 years, while 15.3% of them are above 50 years.

Higher family income seems to be associated with contraceptive use. Seventeen percent of women that have ever used contraceptive are poor, 33.7% and 52.9% are of the middle-, and higher-income levels, respectively. For those currently using contraceptive, 7.9% are poor, 17.3% belong to the middle-income level, while 31.1% are rich.

The regressions results presented in Table 2 highlight the findings for women who have ever used contraceptives. The results reveal that, respectively, emotional, and physical intimacy are significantly negatively and positively correlated with ever-use of contraceptive. While contraceptive use tends to decrease with rising emotional intimacy, it increases with increased physical intimacy. The odds ratio indicates that women who enjoy physical intimacy are 1.66 times more likely to have ever used contraceptives than women who do not enjoy such intimacy.

Education is significantly associated with ever-use of contraceptive, and it tends to increase as educational attainment increases. For any one unit change in the primary, secondary, and tertiary education, probability of ever-used contraceptive rises by 0.99, 1.48, and 1.66 units, respectively. The odds ratios show that women who completed primary education are 2.71 time more likely to have ever used contraceptive than women who had no education. Likewise, women with secondary and tertiary education are respectively 4.43 and 5.27 times more likely to have ever used contraceptive than women without education.

Number of children is negatively and significantly associated with ever use of contraceptive. The odds against using contraceptive diminishes with increasing number of children. Households with less than two children and those with 2-4 children are respectively 0.36 and 0.75 times less likely to have ever used contraceptive.

Household income is a significant positive determinant of contraceptive use. Compared to low-income households, middle income households are 1.56 times more likely to have ever used contraceptive. Similarly, households in the high-

In Table 3, we present the results when current use of contraceptive is the dependent variable. The results are slightly different from those presented in Table 2. Women who enjoy physical intimacy are 1.6 times more likely to be currently using contraceptive than those enjoying sexual intimacy. Conversely, those reporting emotional intimacy are 0.73 times less likely to be currently using contraceptive.

The effect of educational attainment on contraceptive use among women who are currently using it is similar to those that have ever used, although with varying magnitude. While the three levels of educational attainment show positive correlation with contraceptive use, the odds in favour of currently using contraceptive is highest for women with tertiary education. Specifically, women with primary education are 3.25 times more likely to use contraceptive than women without education. The odds are higher for women with secondary and tertiary education; respectively, both categories are 5.04 and 6.42 times more likely to be currently using contraceptive, than woman who had no education.

A significant inverse relationship is observed between number of children and the probability of currently using contraceptives. Respectively, women with less than two children and those with 2-4 children are 0.34 and 0.77 times less likely to adopt family planning. Household income is a significant causal factor for contraceptive use. The higher the income level, the higher the odds of using contraceptive. Specifically, while middle-income households are 1.45 times more likely, households in high income group are 2.33 times more likely to be currently using family planning than low- income households.

Current use of contraceptive is significantly associated with age. However, the magnitude and nature of the association varies by age groups. While women within 15- 30 years are 1.2 times more likely to be currently using contraceptive than those between 31 and 40 years old, women aged 50 years and above are 0.72 times less likely to adopt family planning.

Discussion

The findings on spousal intimacy suggest that different measures of intimacy exert different effects on the probability of using contraceptive. The finding on emotional intimacy may imply that couples that share emotional intimacy rarely engage in conjugal activities or that the women are not able to elicit their partners’ support for family planning. It could also imply that such couples may have a firm resolve to manage as much children as they could have, thus diminishing their demand for family planning services. This finding corroborates that of MacQuarrie KLD, et al. [7] in Egypt.

Conversely, women that experience physical intimacy have high demand for contraceptive because such intimacy may lead to sexual activities, warranting the need for use of family planning services. Furthermore, the result is supported by the argument that physical intimacy engenders communication between couples, which has been found to be positively and significantly associated with contraceptive use [12, 13, 14].

The results on education confirm that there is an incremental propensity to use contraceptive as educational attainment rises. As women attain higher level of education, their desire to have small- to medium-sized family increases. This could be because of their understanding of the cost implications of training large number of children. That desire could also be informed by their preference for and pursuit of career fulfilment over childbearing. This finding is similar to the results obtained by Brice NNG, et al. [28], that female education is strongly associated with the contraception choice of women in Cameroun, and Ajefu JB, et al. [29] in Nigeria.

Women with at most four children are less likely to use contraceptive. This could be attributed to their desire to have more children. In Nigeria, average number of births per woman is 5.2 children [21]. Indicating an inherent tendency to have more than four children. Similar findings were reported by Islam AZ, et al. [26] in Bangladesh, and Abate M, et al. [30] in Ethiopia. The desire to have more children may be informed by the socioeconomic benefits of having a large family size. These benefits include that the children support family sources of income; provide support to parents at old age; and serve as replacements in the case of child mortality.

Family income exhibits an incremental effect on the odds of using contraceptive: the odds of using contraceptive almost double as households move from middle to high income level. Rising income serves as a form of financial support to families who would have otherwise relied on their children for financial assistance. Thus, increased family income replaces the preference for more children, and increases the odds of adopting family planning. This finding aligns with those of [31, 32]. They found that women who receive payment for their labour had more consistent use of contraceptive.

The findings on age are in line with expectation and corroborate the findings of Forty J, et al. [24, 33] and [34, 35]. These studies find that, in sub-Saharan Africa, contraceptive use is significantly higher among women aged 15–19 years than those aged 40 years and above. Women between the ages of 15 and 30 years are more likely to use contraceptive because their fertility level tends to be higher than that of women above 30 years. Conversely, women above 50 years old, besides reduced fertility rate, may have had the number of children they desire. This explains why they are less likely to use contraceptive than their counterparts aged 31-49 years.

Conclusion

The study is limited by a few factors: first, the responses to survey questions are subjective and may be affected by judgement or recall bias, and distortions. Second, data for the study were collected in 2018. More recent dataset may be used to determine if any changes has occurred in the spousal intimacy-contraceptive use relationship. Third, the study relies on cross-sectional data. Longitudinal studies may be necessary to gauge the dynamics of the relationship between spousal intimacy and contraceptive Achieving universal coverage of family planning has been one of the overarching public health objectives of the Nigerian government. This is motivated by the evidence that population control through family planning could produce socioeconomic gains for developing countries. Evidence

suggests that encouraging spousal intimacy may provide a leverage for policy makers in increasing the adoption of contraceptive. However, in Nigeria, nothing is known about how spousal intimacy affects contraceptive adoption, warranting this study.

The objective of the study is to understand if spousal intimacy encourages the use of contraceptives among married women of child-bearing age. The findings are expected to support policymakers in upscaling contraceptive demand through male involvement and couple-based approaches. Logistic regression method was employed for the study with data sourced from the NDHS of 2018.

The findings show that spousal intimacy, particularly the physical measure of intimacy, is significantly and positively associated with contraceptive use. A neutral effect of sexual intimacy is found, while emotional intimacy exerts a negative effect. Evidence further reveals that education, family income, number of children, and age are significant determinants of contraceptive use. For policy, the study recommends that policymakers in the public health space should identify and incorporate spousal-oriented innovations in their family planning programs as these have the potency to improve contraceptive uptake in developing countries.