Over a four-year period, new research suggests, a program led by the Johns Hopkins Center for Communication Programs (CCP) in six large Nigerian cities was associated with a 10 percentage- point increase in the use of modern contraceptive methods and a similar increase in the desire of women to have fewer children.
In clinics, on television programs, in brochures, the message of the CCP program was the same: Know, Talk, Go. Know the facts. Talk to your partner. Go for services.
The successes come in a nation where low use of family planning has long been a seemingly intractable problem. Higher rates of maternal and infant deaths are linked to lower use of modern contraception to space or limit the births of children. And Nigeria has some of the highest rates of maternal and infant mortality in the world.
For the study, published online in the journal Studies in Family Planning, researchers from the Carolina Population Center at the University of North Carolina at Chapel Hill evaluated CCP's Nigerian Urban Reproductive Health Initiative (NURHI), a six-city program that ran from 2010 until 2014. CCP is based at the Johns Hopkins Bloomberg School of Public Health. NURHI is funded by the Bill & Melinda Gates Foundation.
"This study demonstrates that even in a context like urban Nigeria, with high maternal mortality and low contraceptive use, targeted programs can lead to important changes in modern [contraceptive] method use and fertility desires in a short period of time," wrote the researchers, led by Ilene S. Speizer, PhD, a professor at the UNC Gillings School of Public Health.
In 2010-2011, the UNC researchers conducted a baseline survey in the Nigerian cities of Abuja, Ibadan, Ilorin, Kaduna, Benin City and Zaria, surveying more than 16,000 women. Respondents were asked questions about their contraceptive knowledge and practices as well as questions about exposure to family planning programming. They found that the use of modern contraceptive methods such as condoms, oral contraceptive pills and IUDs among women of childbearing age ranged from about five percent in Zaria to 30 percent in Abuja. They surveyed more than 10,000 of the same women in 2014 and found an average increase in the use of modern contraceptive methods of 10 percentage points. A similar increase was observed among the poorest women as was seen in the whole of the population.
Data were also collected from both private and public-sector health facilities in the six cities at the start and finish of the program. They found that women who lived within one kilometer of a health clinic which received support from the NURHI program were significantly more likely to use modern contraceptive methods after the program was completed.
NURHI's success, its leaders say, comes not solely from improving contraceptive access at health clinics in Nigeria's cities, but from creating a coordinated campaign to create the demand for those services. Much of CCP's family planning work is based on using communication tools to help people understand the benefits of family planning and empower them to make healthy decisions. On this project, CCP also targeted health providers as audiences in need of behavior change.
Before implementing the program, the team spent a year interviewing women and men, religious leaders, health providers and more, learning about the unique barriers to contraceptive use in Nigeria's cities and using that data to shape the customized program.
The work was done through countering the fears and misconceptions around family planning, providing fact-based information on the safety of contraceptive methods and the benefits of their use, making it acceptable to talk to partners, friends and religious leaders about contraceptive options and training health providers with the most up-to-date evidence around the value of birth spacing and smaller families.
NURHI also did "mini-makeovers" of government health clinics, cleaning up neglected facilities, fixing what was broken and raising the clinics' profiles by celebrating the makeovers with members of the community, boosting provider morale in the process. NURHI also worked to improve supply chain problems, creating a mobile app that helps clinics order new contraception supplies before they run out, a chronic problem in Nigeria.
"This research confirms that an integrated family planning program focusing on both supply and demand works, at least in Nigeria," says Lisa Cobb, who leads the NURHI team at CCP. "Many places have an 'if you build it, they will come mentality' about family planning clinics. But this showed that demand generation is a real driver of increasing the contraceptive prevalence rate and not a sidecar."
CCP is now working on a second phase of NURHI, remaining in Kaduna, while expanding to Oyo state which includes the city of Ibadan and also to Lagos, the capital. That work is being funded in part by the Gates Foundation and also by an anonymous donor to CCP. Based on the success of NURHI and similar projects in Kenya, India, and Senegal, the Gates Foundation has started a program called The Challenge Initiative, which is expected to build on the work of NURHI to bring these successful programs to new cities and states around Nigeria and globally.
"The promise of NURHI is that we can make rapid and significant changes in the use of modern contraception," Cobb says. "We hope that promise can be realized across Nigeria."
"Evaluation of the Nigerian Urban Health Initiative (NURHI) Program" was written by Ken L. Atagame; Aimee Benson; Lisa Calhoun; Meghan Corroon; David Guilkey; Patrick Iyiwose; Essete Kebede; Peter Lance; Rick O'Hara; Osifo T. Ojogun; Ilene S. Speizer; John F. Stewart; and Jennifer Winston, all of the Carolina Population Center.
The research was supported by the Bill & Melinda Gates Foundation and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2C HD050924).