At a glance…

  • There is evidence in Nigeria of bias against certain family planning (FP) methods by service providers for reasons that include a woman’s age, marital status, number of births and religion.
  • The Nigerian Urban Reproductive Health Initiative’s (NURHI) Distance Learning Program gives FP providers an ongoing learning opportunity and support to educate them on medical eligibility criteria for
  • During Phase I of the initiative, in 2013, 285 mobile phones with learning modules were distributed to service providers in the cities of Abuja, Ibadan, Ilorin and Kaduna.

“For me, cue-card if I have any quick thing to check …at my convenience I check the phone… For a critical problem where you don’t have an answer, you move away and check the phone.” – Distance learning program participant during a focus group discussion

According to the 2010/2011 Nigeria Baseline Household Survey for the Urban Reproductive Health Initiative, an average of 27.9% of married women were using modern family planning (FP) methods in the cities of Abuja, Ibadan, Ilorin and Kaduna. However, the 2010/2011 Baseline Facility Survey showed that service providers were restricting the use of many FP methods for reasons that included age, parity, marital status and/or spousal consent. For example, on average across six cities, 68.4% of providers restricted the use of injectables based on the number of times a woman had given birth (parity). Consideration of marital status led 71.2% of providers to restrict the use of injectables; 69.7% of providers restricted the use of female sterilization if a woman was not married. Lack of spousal consent led 68.7% of providers to restrict injectables and 66.3% to restrict intrauterine devices (IUD). As highlighted below, condoms were the least restricted method.

Although many service providers had received pre-service training on FP, the baseline survey found that very few had received in-service refresher training in the previous 12 months. Between 0% and 34.8% of the service providers in high-volume, public preferred or private preferred facilities had received refresher training in the year prior to the survey.

The Distance Education Program
The Nigerian Urban Reproductive Health Initiative (NURHI) has trained FP providers in the clinical and non-clinical aspects of FP service provision, including medical eligibility criteria for use of modern contraceptive methods, interpersonal communication between clients and providers, counseling and method-specific clinical skills.  The training is usually followed up by supportive supervision.  Constant practice and reinforcement are needed to maintain the skills acquired during the training.  NURHI staff have found that provider bias – the personal opinion of service providers – is difficult to change, and often remains even following the refresher training.

…it keeps you abreast on what you are expected to do. When you are going off track, it has been a sort of reminder to us and to make us give good services. – Participant in the distance learning course during a focus group discussion

To address provider bias, NURHI launched a distance education program in November 2013. The program uses smart phones loaded with educational content to provide re-enforcement of skills post-training with the aim of increasing providers’ ability and willingness to deliver FP methods to their clients that are appropriate and based on the clients’ desires and medical eligibility. NURHI developed eight videos with four scenarios featuring examples of good (“supportive”) and bad (“unsupportive”) providers. Each scenario features examples of provider biases, including those based on age, marital status and parity.  Each scenario begins with a pre-test, and at the end, a post-test is given to gauge what the provider has learned from each scenario.

In 2013, the Nigerian Urban Reproductive Health Initiative distributed a total of 285 mobile phones to participants. The smart phones contained educational material on family planning methods to support service providers engage with clients

Results of the Distance Education Program

During Phase 1 of the program (in 2013), 285 phones were distributed to service providers in Abuja (50), Ibadan (84), Ilorin (62) and Kaduna (89). The usage patterns of the phones show minimal disruption to the providers’ work flow given that they accessed the videos either before or after their work day. Users of the program included nurse midwives and nurses that NURHI had trained. There were no doctors among the users as they are rarely involved in FP counseling. The users found the videos and quizzes especially useful.

According to data collected as a part of the 2013 Nigeria mid-term household survey for the Urban Reproductive Health Initiative, important gains were made in quality of care and use of modern FP methods between the baseline and mid-term surveys. With the exception of Abuja, all cities saw increases in the prevalence rates for modern FP methods at mid-term as compared to baseline.

Moreover, in the cities of Ibadan and Ilorin, there was an increase in the percentage of women who stated that a health or FP worker told them about side effects of their chosen methods. Additionally, in Ilorin, there was a 13 percentage point increase in women stating that a health or FP worker told them about methods, other than their method of choice.

NURHI staff is developing a three-volume set of modules for Phase II of the distance education program. The first volume will support counseling efforts by stressing the importance of compliance and allowing for questions and discussions, thereby promoting active engagement between the provider and the client. The second volume will focus on clinical services to support community health extension workers. The third volume will focus on logistics management. NURHI is also working to integrate recommendations of the Phase I participants, including the addition of videos depicting the use of male and female condoms and new counseling methods.

“It is our hope that the data from this research can help confirm what the midwives have been self-reporting: that the videos help them recognize the biases they held against their clients and allow them to start changing those behaviors and remove bias as a barrier to adoption of contraceptive services.” – NURHI distance education program design team

According to data collected at baseline, service providers often place restrictions on which women can use selected family planning (FP) methods. The main reasons given by service providers for restricting certain modern FP methods included parity, marital status and spouse’s consent. As illustrated, condoms were the least restricted.  
The percent of providers who received family planning (FP) training in the year prior to the baseline survey was low. Although a high percentage of service providers received pre-service FP training, very few had attended a refresher course in the year prior to the baseline. This trend is the same among high-volume facilities, public facilities and private facilities.      
The Nigerian Urban Reproductive Health Initiative (NURHI) is training family planning (FP) providers in both clinical and non-clinical elements of FP service delivery.      
A key strategy used is to integrate family planning (FP) services into maternal and child health (MCH) services with the aim of improving contraceptive use among mothers. The proportion of women who reported receipt of FP information or counseling after delivery when at the facility for delivery increased from baseline to mid-term in all four cities, with the largest increase reported in Kaduna.