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Effectiveness of CBD of Injectables in Nigeria
80
ORIGINAL RESEARCH ARTICLE
The effectiveness of Community Based Distribution of Injectable
Contraceptives using Community Health Extension Workers in
Gombe State, Northern Nigeria
1
FHI360, Plot 1073 J.S Tarka Street, Area 3 Garki Abuja, Nigeria;
3
Association for Reproductive and Family Health (ARFH);
4
Department of Family Medicine, Medical University of Southern Africa
*For correspondence: mabass@sidhas.org; Tel: 09-461555
Abstract
This study reports on findings of a pilot of community-based distribution (CBD) of injectable contraceptives in two local
government areas (LGAs) of Gombe State, Nigeria. From August 2009 to January 2010, the project enrolled, trained and
equipped community health extension workers (CHEWs) to distribute condoms, oral and injectable contraceptives in
communities. The project mobilized communities and stakeholders to promote Family Planning (FP) services in the selected
communities. Using anonymised unlinked routine service data, the mean couple years of protection (CYP) achieved through
CBD was compared to that achieved in FP clinics. The CBD mean CYP for injectables- depo medroxy-progesterone acetate
(DMPA) and norethisterone enantate was higher (27.72 & 18.16 respectively) than the facility CYP (7.21 & 5.08 respectively)
(p<0.05) with no injection related complications. The CBD’s mean CYP for all methods was also found to be four times higher
(11.65) than that generated in health facilities (2.86) (p<0.05). This suggests that the CBD of injectable contraceptives is feasible
and effective, even in a setting like northern Nigeria that has sensitivities about FP. (
Résumé
Cette étude porte sur les résultats d’un projet pilote de distribution à base communautaire (DBC) des contraceptifs injectables
dans deux Administrations Locales (AL) de l’Etat de Gombe, Nigeria. D’aout 2009 au janvier 2010, a inscrit, a formé et a équipé
des membres de personnel de santé communautaire (MPSC) pour distribuer des préservatifs, des contraceptifs oraux et des
injectables dans les communautés. Le projet a mobilisé les communautés et les parties prenantes pour promouvoir la
planification familiale (PF) dans les communautés choisies. , les L’utilisation des données de service de routine anonyme et non
corrélées, la moyenne de couple d’années de protection (CAP) obtenue par la CDB a été comparée à celle obtenue dans les
cliniques de PF. La DBC de CAP pour les produits injectables Depomedroxy-acétate de progestérone (DMPA) et l'énanthate de
noréthistérone était plus élevé (27,72 et 18,16 respectivement) que l'installation (7,21 et 5,08 respectivement) CYP (p <0,05),
sans des complications liées à l’injection. On a trouvé que la CAP moyenne de la DB pour toutes les méthodes a également était
quatre fois plus élevée (11,65) que celles générées dans les établissements de santé (2,86) (p <0,05). Ceci suggère que la DBC
des contraceptifs injectables est réalisable et efficace, même dans un milieu tel que le nord du Nigeria qui a des sensibilités de la
PF. (
Keywords: Community-based provision, contraceptives, injectable, PHC
Introduction
Access to modern methods of contraception
(female sterilisation, intrauterine device, hormonal
contraceptives and condoms) in least developed
countries is very limited. The global unmet need
for family planning (FP), estimated at 200 million
women in 2008, disproportionately affects women
in remote and underserved areas
1
. In sub-Saharan
Africa for example, about 63% of women are at
risk of unintended pregnancy and 25% of women
married or in a union have an unmet need for FP
2
.
Factors associated with this unmet need are varied,
ranging from the unavailability of services to
cultural or religious barriers, rural residence, and
lack of knowledge about family planning
3-4
. The
Effectiveness of CBD of Injectables in Nigeria
81
shortage of skilled health care workers and a weak
distribution chain for health commodities further
limits access to FP service.
In Nigeria, estimates of unmet need for FP
grew from 17% to 20% between 2003 and 2008
3
.
Despite the fact that 72% of Nigerian women
know of at least one contraceptive method, the
proportion of women of reproductive age who are
using (or whose partner is using) a contraceptive
method at any given time, known as the
contraceptive prevalence rate (CPR) for any
method was only 15% (and 10% for modern
methods), one of the lowest in Sub-Saharan
Africa. As a consequence, fertility rate remains
high in Nigeria with a total fertility rate (TFR) of
5.7 births per woman. About 11% of all
pregnancies are unintended (unwanted or
mistimed)
3
. Since FP can directly or indirectly
contribute to the achievement of all eight
Millennium Development Goals (MDGs),
addressing FP needs in Nigeria becomes even
more important
4-7
.
Although the use of modern contraception in
Nigeria remains low, CPR has increased modestly
over the last 18 years (from 4% in 1990 to 10% in
2008), mainly in the use of injectables (from 1% to
3%). DMPA (63%) and norethisterone enantate
(21%) are the most commonly used injectable
contraceptives
3
. For most women in rural areas,
oral contraceptive pills and injectable
contraceptives are the methods of choice for FP.
This is mostly because of their effectiveness and
ease of use, particularly for injectables due to the
fact that they can be used discreetly
8
.
Injectable contraception in Nigeria is provided
almost exclusively in health facilities; mostly
public sector hospitals (25.5%) and health centres
(21.0%)
3
. However, FP clinic utilization in Nigeria
is low with one in three women experiencing a
difficulty with transportation and distance to
health facility as a major barrier to accessing
health care
3
.
Community based distribution of
injectable contraceptives has been used
successfully in other countries to promote FP
uptake. In rural Afghanistan, within eight months
of introduction of a CBD to FP program,
contraception increased by 24 - 27%; with
injectables contributing the most to the increase
9
.
In a rural district of Uganda, contraceptive
prevalence increased by about 5% after a
community-based provision of DMPA was
introduced
10
. A study in Bangladesh demonstrated
a 25% decline in fertility rates in areas that utilized
the community-based provision of DMPA model
when compared with areas where the use of
DMPA was rare
8
.
Community based provision of
injectable was also found to increase contraceptive
uptake in rural Madagascar with 41% of clients
reported as being new FP users
11
. Despite evidence
elsewhere showing that CBD of injectable
contraceptives can be successfully implemented,
community based channels of provision of
injectable contraception remain largely unexplored
in Nigeria
12, 13
.
CHEWs are a low cadre of trained medical
professionals working in primary health care
(PHC) facilities and are also the main health
workforce in rural areas. The CHEW was
introduced into the Nigerian health care system in
the 1970s to alleviate shortages of medical
personnel at the PHC level particularly in the rural
areas
14
. CHEWs are expected to spend half of their
time in the communities, and the other half in their
assigned clinic. However, because of shortages of
higher cadre medical personnel in many rural parts
of the country, CHEWs spend most of their time in
the clinics with very little time for community
activities.
The United Nation Fund for Population
Activities (UNFPA) since 2003 has supported the
community reproductive health project in selected
LGAs in Nigeria, using trained community
volunteers, to distribute condoms and re-supply of
oral pills only. Little is known of the feasibility
and effectiveness of CBD for injectables in
Nigeria, particularly in the predominantly Moslem
northern states. Family Health International (FHI)
in collaboration with the Association for
Reproductive and Family Health (ARFH), the
Federal and the State Ministries of Health,
supported a project to use pre-existing CHEWs in
two LGAs in Gombe State, on CBD to injectable
contraceptives from October 2009 to February
2010. This paper describes the results of a
secondary analysis of routine data which
demonstrate the effectiveness of adding injectable
Effectiveness of CBD of Injectables in Nigeria
82
contraceptives to the mix of community-based
family planning methods provided in northern
Nigeria.
Methods
The study was conducted in northern Nigeria, a
region with the worst maternal and reproductive
health indicators. The maternal mortality rate
(MMR) in Gombe State is estimated at
1,002/100,000 live births, two times higher than
the national average
13
.
Gombe’s population was
estimated at 2,353,879 people in 2006, with two
dominant ethnic groups — Hausa and Fulani.
Women of childbearing age account for 22% of
the population.
Gombe has 11 predominantly rural local
government areas (LGAs) and 554 health
facilities, 110 of which provide FP services.
Gombe State has an established CBD program
consisting of trained male and female community
volunteers who distribute condoms and provide
resupply of oral pills. The federal ministry did not
however approve of the provision of injectable
contraceptive by non-medical professionals based
on safety concerns. Five wards each, in Funakaye
and Yamaltu/Deba LGAs, were selected in
conjunction with stakeholders at the federal, state
and local government level as sites for the CBA
for injectable project. Since the purpose of the
project was to add injectables to the method mix
already available in the existing CBD for oral pills,
the selection of sites was based on five factors: (1)
an established community-based contraceptives
program for oral contraceptive, with linkages to
the health facilities; (2) an established
commodities logistics system; (3) a functioning
supervisory system with identified supervisors;
(4)scheduled and effected supervisory visits to
oversee community volunteers; and (5) an
informal data collection and data flow process.
The project trained 30 CHEWs employed by
government in the study sites to provide injectable
contraceptives in the community setting. Prior to
the intervention, the CHEWs provided health
services including FP services in PHCs within
selected LGAs and were not previously involved
in CBD of FP methods. In the preparatory phase,
FHI identified and engaged stakeholders at all
levels; federal, state and community. At the
community level, FP uptake was promoted
through community meetings and outreaches
where FP information was shared and
misconceptions on FP were clarified. Advocacy
visits to community gate keepers – traditional
rulers, religious leaders, ward heads and opinion
leaders within the project communities paved way
for larger community gatherings to promote male
involvement and generate demand. CHEWs were
introduced to the communities they served during
community sensitization meetings. Clients were
able to identify the CHEWs and schedule
appointments with them by direct contact or via
phone calls. Clients either visited the CHEWs at
home or invited the CHEWs to their homes after
scheduling appointments. Social gatherings such
as weddings and naming ceremonies were also
used to reach clients.
Cultural sensitivities in this predominantly
Moslem community guided the selection criteria
of CHEWs, final selection was done by the local
authorities. All the 30 selected CHEWs were
female aged 28-40 years, and resident in the
community they served. The CHEWs were trained
for forty hours over five days as community-based
providers of FP counselling, and a mix of
contraceptives which included DMPA and
norethisterone enantate injectables. The training
involved both theory and practical sessions based
on an adapted curriculum from the Federal
Ministry of Health. It included modules on
reproductive anatomy and physiology,
contraceptive technology, counselling, client
screening using job aids and checklists, injection
techniques, infection control and waste disposal,
HIV, managing supplies, referrals, and data
collection. The CHEWs were expected to pass a
post training evaluation test, and also demonstrate
proficiency in administering injections. CHEWs
who met these criteria received a certificate of
participation; all 30 CHEWs met the criteria.
Safety was addressed by training the CHEWs on
universal safety precautions and providing sharps
Effectiveness of CBD of Injectables in Nigeria
83
disposal boxes which were incinerated at the
referral health facilities.
The 30 trained CHEWs were deployed in the
two LGAs (15 per LGA) to provide community
based FP services and link eligible clients through
referrals to health facilities for clinic-based
methods – IUD, implant, and sterilization – or for
other medical conditions. Each CHEW received
job-aids, checklists, and a seed stock of
contraceptive commodities which was replenished
from state MOH stores using the user-fees charged
for the service. Clients were charged the
following; 80 Naira ($0.6) for DMPA and
norethisterone enantate injectables, 15 Naira ($0.1)
for a cycle of oral pills, 20 Naira ($0.13) for each
female condom and 1 Naira ($0.01) for a unit of
male condoms (at an exchange rate of 150 Naira to
1USD). The CHEWs kept records of each service
encounter using daily activity sheets (described
below). Seven CBA supervisors were selected
among officers-in-charge of PHC facilities in line
with the existing supervisory structure of the
health system. CHEWs were linked to the CBA
supervisor in the health facility located within the
community served. These facilities served as the
referral centres for clinic-based FP methods. At
the time of the intervention, there were five
facilities that provided FP services in each of the
two LGAs.
Data collection
The data on community-based activities used a
collection tool adapted from the Nigerian national
FP register by adding three columns that captured
information on i) clients who switched over from
clinic provision to community-based provision, ii)
reported complications, and iii) referrals. At each
encounter with a client in the community, the
CHEWs recorded client age, sex, and type of FP
commodity provided, and referrals on these daily
activity sheets. To monitor safety, during
encounters with revisit clients for injectables, the
CHEWS also recorded cases of injection abscesses
or very painful injections. Each supervisor collated
data monthly from the CHEWs she supervised and
filled in the monthly summary forms to aggregate
the community-based activities. The data on
facility-based uptake during the study period were
derived from the routine FP service statistics in the
public health facilities (primary and secondary
health facilities) located in the two pilot LGAs.
Prior to the intervention, the facility M&E system
was weak, no data capturing tools and lack of M&
E supervision. For this reason, pre-intervention
data is unavailable.
Analysis
The main measurement of outcome was the
couple-years of protection (CYP), which was
calculated by dividing the total uptake of each FP
commodity by the duration of the protection
provided, assuming an average of 10 acts per
month. The number of each commodity required
to make up one CYP are as follows: 120 units for
condoms; 4 doses of DMPA injectable; 6 doses of
Norethisterone enantate injectable; 15 cycles of
oral contraceptives. The CYP for each method was
summed for all methods to obtain a total CYP.
Data were analyzed using 10 (Stata Corp,
2007). Frequencies were calculated and cross-
tabulated to compare contraceptive uptake in the
community-based service to routine facility-based
provision of contraceptives. A paired test of
difference in means was used to compare mean
CYP (all FP methods) from facility-based
provision to mean CYP (all FP methods) from
community-based FP service provision. Further
analysis was done to compare the difference in the
mean CYP of facility-based provision to
community-based provision by each FP method.
Statistical significance for all tests was defined as
p<0.05.
Results
Health facilities in Gombe do not keep client level
data in the registers. The socio-demographic
characteristics of clients attending health facilities
were not available. A total of 2,363 clients
accessed the community-based FP service
(injectables, oral pills and condoms) in the two
LGAs during the study period (October 2009 to
February 2010). Funakaye reported 1,066 (45%)
acceptors, slightly less than Yamaltu/Deba’s 1,297
Effectiveness of CBD of Injectables in Nigeria
84
(55%). This translates to an average of 12 and 14
clients per CHEW per month for Funakaye and
Yamaltu/Deba LGA respectively. Only 82 (8%)
and 247 (19%) of the clients in Funakaye and
Yamaltu/Deba LGAs respectively were males. The
majority of FP clients reached in the two LGAs
were between the ages of 25 – 34 years (55%),
followed by the age group 15 – 24 years (25%),
and the 35 and 44 years age group (18%). The age
distribution was similar across the two LGAs.
(Table 1)
In total, 1,216 cycles of oral contraceptive pills,
1,076 doses of Norethisterone enantate and 1,022
doses of DMPA were dispensed through the
community-based system during the study period.
FP uptake in the health facility was found to be
lower, with a total of 289 cycles of oral pills, 306
doses of Norethisterone enantate, and 299 doses of
DMPA dispensed through facility based provision
(Table 2).
Table 3 shows the comparison of mean CYP
from CBA and facilities; the CBA yielded a
significantly higher mean CYP for all methods
(11.65) compared to facility-based service (2.86)
(<0.01). Mean CYP by each FP method for
facility and community-based services
respectively were: male condom 0.01 and 5.91
(<0.01), female condom 0.03 and 0.15 ( =0.06),
DMPA 7.21 and 25.72 ( <0.01), Norethisterone
enantate 5.08 and 18.16 ( <0.01) and oral pills
1.98 and 8.29 ( <0.01)
Table 4 shows the comparison of the mean
CYP in the two LGAs for each FP method
provided through CBA and facility-based
provision. Both LGAs recorded a significantly
higher CYP for all contraceptive methods except
the female condom from CBA compared to the
facility-based service. In Funakaye LGA, a mean
CYP of 11.32 from all contraceptive methods was
provided via CBA compared to 4.50 mean CYP
provided by the facility-based provision in the
corresponding wards ( <0.05). Similarly, in
Yamaltu/Deba LGA, a mean CYP of 11.97 was
provided by the CBA while the facility-based
provision yielded a mean CYP of 1.22 ( <0.01).
DMPA provided the highest contribution to the
total CYP in both facility-based and CBA in both
LGAs. However, the difference in mean CYP from
CBA and facility-based provision was found to be
more statistically significant in Yamaltu/Deba
(=0.029) than in Funakaye LGA ( =0.099).
Norethisterone enantate also had good uptake in
both LGAs through the CBA and Yamaltu/Deba
again had a more statistically significant mean
CYP difference ( =0.026) compared to Funakaye
(=0.047).
From a total of 2,363 clients served during the
observation period, 721 (30.5%) reported a switch
from using services in fixed facilities to enrolling
in the CBD project. The highest proportion of
clients who switched to CBD was recorded among
those using Norethisterone enantate (38.6%) and
DMPA (30.8%). (See table 5)
Table 1: Demographic Characteristics of CBA Acceptors by LGA, August 2009 to January 2010
Funakaye LGA (n=1066) Yamaltu/Deba LGA (n=1297)
n (%) n (%)
Sex
Male 82 (7.7) 247 (19.1) <0.01
Female 984 (92.3) 1050 (80.9)
*Age group (years)
15 – 24 255 (26.2) 308 (25.3) 0.357
25 – 34 545 (55.9) 653 (53.7)
35 – 44 164 (16.8) 235 (19.3)
> 45 11 (1.1) 19 (1.6)
Effectiveness of CBD of Injectables in Nigeria
85
Table 2: FP commodity uptake in LGA by type of commodity and service delivery from August 2009 to
January 2010
Table 3: Comparison of mean CYP achieved by type of FP methods between facility-based and CBA services,
August 2009 to January 2010
Mean CYP (C I), both LGAs combined
Facility Community
All methods 2.86 (1.37-4.34) 11.65 (8.54-14.75) <0.001
DMPA 7.21 (1.11-13.30) 25.72 (18.46-32.98) <0.001
Norethisterone enantate 5.08 (1.47-8.69) 18.16 (12.29-24.03) <0.001
Oral Pills 1.98 (0.34-3.61) 8.29 (5.95-10.62) <0.001
Male condom 0.01(-0.01-0.03) 5.91 (3.97-7.85) <0.001
Female condom 0.03 (-0.04-0.11) 0.15 (0.05-0.26) 0.060
Table 4: Comparison of mean CYP achieved from facility-based and CBA services by LGA, August 2009 to
January 2010
Funakaye LGA Yamaltu/Deba
Mean CYP (C I) Mean CYP (C I)
Facility Community Facility Community
All methods 4.50 (1.87-7.13) 11.32 (7.11-
15.53)
0.018 1.22 (-0.06-
2.50)
11.97 (7.09-
16.86)
<0.001
DMPA 11.06 (-1.02-
23.14)
23.58 (11.76-
35.40)
0.099 3.35 (-3.65-
10.35)
27.86 (13.73-
41.99)
0.029
Norethisterone
enantate
8.00 (2.12-13.88) 18.84 (10.57-
27.11)
0.047 2.16 (-2.41-
6.73)
17.48 (4.68-
30.28)
0.026
Oral Pills 3.36 (0.41-6.31) 9.50 (6.50-
12.50)
0.018 0.59 (-0.82-
1.10)
7.07 (2.34-
11.80)
0.028
Male condom 0.00 4.6 (1.53-
7.67)
0.014 0.02 (-0.03-
0.06)
7.22 (4.14-
10.30)
0.003
Female condom 0.07 (-0.12-0.25) 0.07 (-0.12-
0.16)
0.935 0.00 0.24 (0.03-0.45) 0.033
Funakaye LGA Yamaltu/Deba LGA
FP commodity
CBD Facility CBD Facility
n (%) n (%) n (%) n (%)
DMPA 465 (12%) 232 (30%) 557 (9%) 67 (37%)
Norethisterone enantate 551 (15%) 241 (32%) 525 (9%) 65 (36%)
Oral Pills 685 (18%) 250 (33%) 531 (9%) 39 (22%)
Male Condom 2,050 (54%) 0 (0%) 4,326 (71%) 10 (5%)
Female Condom 34 (1%) 40 (5%) 139 (2%) 0 (0%)
Total 3,785 (100%) 763 (100%) 6,078 (100%) 181 (100%)
Effectiveness of CBD of Injectables in Nigeria
86
Table 5: Reported switch in service utilization from fixed health facility to CBD during observation period
Method Total number of
clients
No. clients reported switch from
fixed facility to CBD
%
DMPA 689 212 30.8
Norethisterone enantate 713 275 38.6
Oral Pills 561 135 24.1
Condoms 400 99 24.8
Total 2363 721 30.5
Injection Safety
During the course of the study, no needle stick
injury or any other any injection related adverse
event such as injection abscess was reported.
Safety boxes were filled appropriately, and
disposed according to facility protocol.
Discussion
The CBA pilot project expanded access to FP in
rural northern Nigeria by complementing fixed
facility-based service provision with the flexible
and culture-sensitive approach of community-
based access. The mean CYP of all methods in this
CBA pilot project was 4 times higher than that
from facility-based provision, a significant
difference observed in the two LGAs. The ability
to promote FP depends on the use of effective and
innovative strategies to deliver these services to
rural populations
15
.
Policy in Nigeria limits the provision of
injectable contraception to health facilities. The
findings of this study suggest the provision of
injectables beyond health facilities to include
mobile community-based provision by trained low
cadre health workers is feasible and safe. For the
observed increase in CYP, the workload (12 to 14
clients per CHEW per month) remained
manageable. This is critical since CHEWs play an
important role in the operation of PHCs in Nigeria,
and are expected to share their time almost equally
between facility and community tasks. An increase
in community workload might have negative
impact on the facility workload.
It is important to note that the financial barrier
to access was not removed entirely in the pilot
project. The government prescribed fees for FP
methods was applicable. The only savings that
might have occurred was in client transportation
costs – clients did not incur transportation costs.
The removal of user fee will further increase the
uptake of FP in Nigeria. Factors other than cost
that may have played a role in increased uptake of
FP in the community, these may include
convenience – injections do not have to be
administered during clinic hours which often times
conflict with domestic or commercial priorities of
women; relaxed setting of homes; professional
providers who were part of the communities and
could be trusted; endorsement by traditional rulers
and key gatekeepers as well as other demand
creation activities engaged in by the CBA project.
Mekonnen et al argue that awareness of the
community-based service amongst other factors
could predict the success of a community-based
family planning program
16
.
The findings are even more significant when
the location of the project, the predominantly
Moslem Northern Nigeria, is considered. FP is
perceived as ‘foreign’ and ‘western’ and
organisations promoting FP are frequently
regarded with suspicion and as such gaining access
to communities and developing trust has usually
been a challenge
17
. Hence the low CPR for modern
methods (3.5%), and injectables in particular
(0.9%).
3
Despite the socio-cultural and religious
barriers to FP access that characterize northern
Nigeria, the pilot project has demonstrated that it
is possible to (1) gain the support of traditional and
religious leaders, (2) increase use of contraceptives
through community-based service systems.
Women are expected to secure consent of male
partners before accessing FP services. This project
however found that although male acceptors were
in the minority (8% to 19%), male condom uptake
Effectiveness of CBD of Injectables in Nigeria
87
was relatively high, representing 54 and 71% of
total FP commodity units dispensed in Funakaye
and Yamaltu respectively. In Nigeria, motivating
men to attend FP clinics is difficult
18
. The findings
therefore suggest that despite the prevailing belief
and religious influences, it is possible to reach men
through community-based provision of FP
services.
The higher CYP of the CBA pilot corroborates
the high-unmet need for FP services in Nigeria,
where unmet need for contraception is 20% (15%
for spacing and 5% for limiting). The prevalence is
even higher among rural dwellers.
3
Our findings of
a significantly high CYP contribution by injectable
contraceptives support the evidence of high
injectable contraceptive use elsewhere when
community-based FP programs are introduced,
including in Muslim countries
8,9,10,11
.
A major limitation to this study is the absence
of a control; it is therefore not possible to exclude
the influence of confounders on the findings of our
study. The unavailability of pre-intervention
community or facility data further limits the study,
as we are unable to tell if the observed
improvement would be significant compared to the
pre-intervention period. The pilot was conducted
for a period of six months, we are unable to
demonstrate that our findings could be sustained; it
is possible that the FP uptake via CBD would
wane over time. Our study is also limited in
generalizability, as the pilot was carried out in
only five wards each in the two local governments.
Conclusion
Our study demonstrates the feasibility of
community-based provision of injectable
contraceptives in Nigeria using low cadre of health
workers. Facility-based provision of FP services
can be effectively and safely complemented with
community-based service. Policy guidelines to
address human resources at PHC level, monitoring
and supportive supervision of CHEWs and
commodities supply chain issues will need to be
addressed to allow for scale up of CBA in Nigeria
and optimal impact.
Acknowledgment
The community-based project received funding
from the Contraceptive and Reproductive Health
Technologies Research and Utilization (CRTU)
program, USAID-sponsored assistance agreement
(2005-2010) with Family Health International
through the Cooperative Agreement No. 620-A-
00-04-00122-00.
Contribution of Authors
Rabiatu Abdul-hadi, Moyosola Abass, Bolatito
Aiyenigba, Lolade Oseni, Christoph Hamelmann,
and Otto Chabikuli contributed to study
conception, design, analysis and interpretation of
data. Moyosola Abass, Bolatito Aiyenigba and
Lolade Oseni conducted the statistical tests.
Rabiatu Abdul-hadi, Moyosola Abass, Bolatito
Aiyenigba and Lolade Oseni wrote the drafts of
the publication. Mohammed Ibrahim, Solomon
Odafe, Oladapo A. Ladipo and Otto Chabikuli
contributed to the critical revision of the article
.
References
1. United Nations Population Fund (UNFPA). Ensuring that
Every Pregnancy is wanted.
http://www.unfpa.org/rh/planning.htm#contraceptive.
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