Reaching Young Married Women in Northern Nigeria with Information on Healthy Timing and Spacing of Pregnancy: Findings from

a Community Survey

Cate Lane, Senior Advisor on Youth Health, ESD Yaikah Jeng-Joof, Program Officer, ESD Aisha Hassan, Amira of FOMWAN, Kano Chapter Shannon Pryor, Monitoring and Evaluation Program Officer, ESD

September 2010

ACKNOWLEDGEMENTS
The authors would like to thank the Federation of Muslim Women Association of Nigeria (FOMWAN) for working with the Extending Service Delivery team to quickly mobilize their resources and members to conduct this community-based survey with men and women in five local government areas of Kano City. We also thank Dr. Carla White, Monitoring and Evaluation Advisor for her assistance in analyzing the data as well as Dr. Maureen Norton of USAID, Dr. May Post, Senior Reproductive Health Advisor, Dr. Fabio Castano, Technical Director, and Ms Jeanette Kesselman, Senior Advisor for Capacity Building for ESD, for their review of the document. The Pathfinder International Nigeria staff took time to ensure our analyses, conclusions and recommendations were appropriate and relevant, and we appreciate their input. Thanks also to Priscilla Villarreal and Shannon Pryor for formatting the report. If you would like more information on this activity or the findings, please contact ESD at: Extending Service Delivery Project 1201 Connecticut Avenue NW #700 Washington, DC 20036 USA 202-775-1977 (tel) 202-775-1988 (fax) esdmail@esdproj.org

This publication was made possible through support provided by the Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, under the terms of Award No. GPO-A-00-0500027-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.

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EXECUTIVE SUMMARY
One of the major factors contributing to poor reproductive health outcomes, including maternal and child morbidity and mortality, is the persistent problem of early and closely spaced pregnancies. In Northern Nigeria, where modern contraceptive use rates remain lower than in the rest of the country, the risk of illness and death is exacerbated among mothers and their children due to the prevalence of early marriage, early childbearing and closely spaced pregnancies. A technical working group to the World Health Organization and the United States Agency for International Development recommended that following a birth, a woman should space her next pregnancy by at least 24 months, and following a miscarriage or abortion, a woman should space her next pregnancy by at least six months, for better health outcomes. UNICEF, UNFPA and WHO also recommend that a woman should delay her first pregnancy until she is 18, also for better health outcomes. These three recommendations make up the concept of healthy timing and spacing of pregnancy (HTSP), which focuses on the healthiest time to become pregnant after a live birth, stillbirth or miscarriage, and when a womans first pregnancy should take place. Improving womens ability to practice HTSP is priority for USAID. The Extending Service Delivery Project (ESD) is funded by USAID to increase the use of family planning services, especially in underserved communities. In addition to working with facility-based health care providers ESD also partners with religious leaders, opinion leaders, community health workers and other health stakeholders across the world, and has found that many communities embrace HTSP as a culturally appropriate way to address maternal and child health and family planning. This paper presents the results of ESDs partnership in Northern Nigeria with the Kano Chapter of the Federation of Muslim Women Association of Nigeria (FOMWAN), which reached young married women, their husbands and mothers-in-law through household visits with information about the benefits of using family planning to practice HTSP in five local government areas. FOMWAN members also trained Muslim religious leaders on HTSP, who subsequently disseminated this information during Friday sermons and in one-on-one counseling sessions with their followers. A community survey implemented in June 2010 found high recall on the HTSP recommendations, and many respondents reported hearing about HTSP directly from religious leaders and FOMWAN members. Young women, especially, reported favorable attitudes towards spacing and indicated that they were talking more about spacing and family planning with their friends, and in the community. There are still a number of constraints, however, to increasing womens use of family planning, and a significant number of respondents (both men and women) remain concerned about the side effects of family planning methods. Nevertheless, the intervention, which lasted from February 2009 to May 2010, demonstrates the positive effect of simultaneously engaging religious leaders and community health workers to create awareness of and support for HTSP and family planning.

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In May of 2008, staff from the Extending Service Delivery (ESD) Project and Pathfinder International Nigeria conducted a training of 25 outreach workers in the city of Kano, Nigeria, to orient them to the health and psychosocial needs of young married women in Northern Nigeria. In one exercise, the participants were asked to draw a picture of a typical adolescent and to include in their drawing the health, social and cultural issues that confront young women each day. The participants were not allowed to use any wordsonly images. One group sketched a young woman whom they named Aisha. Aisha had abnormally small eyes, small ears and a small mouth. When asked to explain their drawing, the participants replied that young women are repressed socially, culturally and economically, and are often controlled by external forces. Aisha cannot see or hear because she is isolated, has no access to information and cannot voice her own concerns or needs.

Aisha illustration

1. INTRODUCTION
One of the major factors contributing to poor reproductive health outcomes in Nigeria is the persistence of early pregnancy. Thirty-four percent of Nigerias population is between the ages of 10 and 24, which translates to over 45 million youth and adolescents. 1 On average, 27.8% of all Nigerian

Population Reference Bureau (PRB). 2006. The Worlds Youth 2006 Data Sheet. Washington, DC: PRB.

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women aged 15 to 19 are married and 23% have begun childbearing. 2 Nine percent of women aged 25 to 49 have given birth by age 15, and 47% have become mothers by age 20. These numbers, however, do not convey the regional variability in the country. Because Northern Nigeria is predominantly Muslim, for example, early marriage is often sanctioned and the use of modern contraception may be frowned upon. Young women from Northern Nigeria, therefore, are more likely to have had a live birth or be pregnant with their first child than young women from Southern Nigeria. Box 1: Regional Variation in Percentages of Young Mothers Aged 15 - 193 Twenty-two percent of young women from North Central, 39.3% from North East Nigeria and 44.6% from Northwest regions have begun childbearing, as compared to 6.3% in the South East, 10.4% in the South South and 6.9% in the South West regions. Modern contraceptive use is extremely low: 10.5% of married women in North Central Region report using a modern method, while only 3.5% of married women in North East Region and 2.5% of married women in the North West Region report current use of a modern contraceptive method. 4 Only 2.4% of married women aged 15 to 19 use contraceptives. Low rates of contraceptive use also contribute to high rates of closely spaced births. Young women 15 to 19 years old have the highest rates of closely spaced births: among 15 to 19 year olds, 84.7% of births are spaced less than 36 months apart, and nearly 70% of women aged 20-29 also experience closely spaced births. 5 Anecdotal evidence also suggests that once young women in Northern Nigeria marry, they face tremendous pressure from their husbands and family members to become pregnant and bear several children right away, despite abundant evidence that early and closely spaced pregnancies can be unsafe and even fatalfor young women and their babies. 6,7

2. INTERVENTION
ESD partnered with the Kano State Chapter of the Federation of Muslim Women Association of Nigeria (FOMWAN)8 to reach young married women, their families and the community to promote knowledge about and use of family planning (FP) for healthy timing and spacing of pregnancy (HTSP). Known in the community through their work on numerous health and social issues, FOMWAN members were well-positioned to integrate the HTSP messages of delaying first pregnancy to age 18 and spacing of subsequent pregnancies by at least two years through improved use of FP into ongoing outreach activities in compounds, schools and the wider community.
2

National Population Commission (NPC) [Nigeria] and ICF Macro. 2009. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro. 3 ibid 4 ibid 5 ibid 6 United Nations Population Fund (UNFPA). 2004. State of World Population, 2004. New York, NY: UNFPA. Accessed September 10, 2010 at http://www.unfpa.org/swp/2004/english/ch9/page5.htm. 7 Department of Reproductive Health and Research, World Health Organization (WHO). 2006. Birth Spacing- Report from a WHO Technical Consultation. Geneva, Switzerland: WHO. 8 FOMWAN was a partner on the 2004 - 2009 Pathfinder International led COMPASS (Community Participation for Action in the Social Sector) Project implemented in four Northern Nigeria states and Lagos state to improve the quality of health and education services.

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Recognizing the influential role that husbands and mothersin-law play in reproductive health decision-making for young married women, religious leaders were involved from the beginning. FOMWAN trained 30 imams and five ulamas on the health needs of young married women and the benefits of FP and HTSP, antenatal care, postpartum care and wellbaby services provided at health facilities. The intervention was targeted to five local government areas (LGAs) in Kano State: Gwarzo, Bichi, Bebeji, Nassawara and Dala. Information on HTSP and FP was disseminated in two ways: Trained religious leaders discussed HTSP and FP as part of their sermons (to mostly men) during Friday prayers and through one-on-one counseling activities with men, couples and youth. FOMWAN members provided education and information about HTSP and FP through house-tohouse visits with young women and their mothers-inlaw; with young women attending Islamiyya schools;9 and during public gatherings, including weddings, naming ceremonies and other community events. FOMWAN implemented training and outreach activities between February 2009 and May 2010. Project outputs include: More than 60,000 young married women, their mothers-in-law and other influential women in the community reached by FOMWAN members with information on HTSP and FP in the five target LGAs; More than 60,000 community members reached by the 30 trained imams in the five target LGAs during Friday prayers and through one-on-one counseling; An additional 1,000 imams oriented to the benefits of HTSP and FP in all 45 LGAs of Kano State as part of a roll-out training initiated and organized by the original 30 trained imams and five ulamas (see sidebar); and

SCALING-UP RELIGIOUS LEADERS TRAINING [In February 2009, ESD partnered with the
COMPASS Project and FOMWAN to train 35 religious leaders from five LGAs in Kano State on the health and social benefits of using FP for HTSP. Religious leaders were encouraged to incorporate these messages into their Friday sermons and into one-on-one counseling sessions and to encourage husbands and other family members to support young womens use of RH/FP services and HTSP practices, especially for their wives and daughters. The imams applauded HTSPs emphasis on healthy fertility versus limited fertility and were pleased that the HTSP postpartum message was congruent with Islams teaching that women should breastfeed for two years. These influential imams immediately began discussing the benefits of HTSP and FP with their followers. When other imams saw what these 30 imams were doing and the positive response it engendered among their followers, they requested to be trained as well. The Sharia Commission and Council of Ulama decided to scale-up the training and trained the majority of imams in the state, reaching nearly 1,000 imams in all. Some imams have even reported disseminating information on FP and HTSP in madrassas in Niger and Senegal.

More than 500,000 community members reached in all 45 LGAs by imams oriented as part of the scale-up training.

Many FOMWAN members run Islamiyya schools, which integrate Quranic teachings with basic literacy and numeracy education, especially for women.

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Religious leaders at a training conducted by FOMWAN

3. METHODOLOGY
At the end of the intervention, in June 2010, ESD developed a short survey to assess knowledge, attitudes and practices related to pregnancy spacing and contraceptive use among women in the target LGAs and to identify the sources of their information (the survey appears as Appendix 1). Select FOMWAN members administered the survey at the compound level (multiple households) to 148 married women (both pregnant and not pregnant) ranging in age from 15 to 55. FOMWAN also interviewed 28 men aged 20 to 55 (usually the husband of the respondent) to gauge their awareness of and support for young married women following the HTSP recommendations. One of the primary reasons for involving the religious leaders was to influence the attitudes of the husbands of young women. FOMWAN members randomly selected a starting point in each target LGA and visited every other compound until they reached their target number of respondents for each LGA. Conducting their interviews in Hausa, they recorded the responses in English by the interviewers and sent the completed surveys to the ESD office for coding and analysis. Since part of the purpose of ESD and FOMWANs outreach and community education was to draw attention to the higher rates of maternal mortality and morbidity among young married women and to promote the health and social benefits of using FP for HTSP, ESD was particularly interested in learning if the key stakeholdersthat is, young married women (aged 15 to 19), their husbands and their mothers-in-law and/or older women in the compound (aged 40 to 55) were receptive to and had assimilated this information.

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4. LIMITATIONS
When ESD first analyzed the survey data, it showed that only 15 young women aged 15 to 19 had been interviewed. To increase the sample size of younger women, the sample was grouped as young women aged 15 to 20 (33 respondents), women aged 21 to 24 (19 respondents), women aged 25 to 39 (79 respondents) and women between the ages of 40 and 55 (11 Figure 1: Distribution of Female Respondents by Age Group respondents). This allowed ESD to better assess the impact of community education on the 100 knowledge and behaviors of the 80 target group of young married 60 women and on influential older 40 women (who may include senior 20 wives and mothers-in-law).
# of Female Respondents

The sample group of men was 15-20 21-24 25-39 40-55 limited to only 28 respondents Age Group because the interviewers found that most men were not home during the day when the interviews were conducted. Eight respondents did not give their age [6 women and 2 men (See Figure 1)]. Furthermore, the interviewers received limited training in the administration of the survey. As a result, there was occasional variability in the number of respondents to a given question when compared to the total number of possible respondents in each age group.

5. FINDINGS
The majority (93%) of women aged 15 to 20 had been pregnant, with almost half (46%) having been pregnant three or more times. All women in their early 20s reported having had at least one pregnancy, the frequency of which increased with age. Among women aged 40 to 55, the number of pregnancies ranged from seven to 18 (See Table 1). As evidenced in Table 1, early childbearing is common in Northern Nigeria. The majority of young women aged 15 to 20 have given birth to at least one child, with 35% reporting having had three or more children and 13% reporting having had six children. This suggests that closely spaced pregnancies are common. Among women aged 21 to 24, 11% reported having given birth seven times, and among women 40 to 55, three women reported having given birth to 10 and 11 children, respectively, and one woman said she had given birth to 18 children.

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Table 1: Pregnancy and Children Born by Age Group

Frequency of Pregnancy by Age Group (How many times have you been pregnant?) Age Group 0 pregnancies 1 pregnancy 2 pregnancies 3+ pregnancies

Women 15 -20 7% 29% 18% 46% (N=28) Women 21 24 0% 12% 6% 82% (N=17) Women 40-55 0 0 0 100% (N=7) Total Number of Children Born by Age Group (Total number of children born to the respondent) Age Group Women 15-20 (N=31) Women 21-24 (N=19) Women 40-55 (N=10) 0 children 7% 5% 0 1 child 26% 5% 0 2 children 32% 16% 0 3+ children 35% 74% 100%

When asked whether the respondent had a baby less than six months in age, 42% of young women aged 15 to 20 and 32% of women aged 21 to 24 reported that they currently have a baby who is less than six months. No women aged 40 to 55 had a baby of less than six months, while 50% of men reported having a baby who is less than six months. The following tables present information on the desired pregnancy spacing practices of respondentsthose who have a baby that is less than six months in age (Table 2) and those who do not (Table 3). None of the young mothers (aged 15 to 20 and 21 to 24) with a baby less than six months old reported wanting to get pregnant again soon and only 7% of men wanted to have another baby soon.

Table 2: Desired Pregnancy Spacing Interval of Respondents with Baby Less Than Six Months by Age Group and Sex (When do you want to get pregnant again?)
Age Group/ Sex Women 15-20 (N=13) Women 21-24 (N=6) Women 40-55 Men 20-55 (N=14) Soon 0 0 NA 7% Wait 12-24 months 62% 67% NA 43% Wait more than 24 months 38% 33% NA 43% Dont want to get pregnant 0 0 NA 7%

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In comparison, young women who did not currently have a baby less than six months in age, were more likely to report wanting to become pregnant soon (33% of young women aged 15 to 20 and 15% of women aged 21 to 24). Slightly older mothers reported an interest in waiting more than 24 months and men were relatively evenly divided between desired spacing intervals. However, older men aged 40-55 were more likely to state that they did not want to get pregnant again compared to younger men.

Table 3: Desired Pregnancy Spacing Interval of Respondents without Baby Less Than Six Months by Age Group and Sex (When do you want to get pregnant again?)
Age Group/ Sex Women 15 20 (N=15) Women 21- 24 (N=13) Women 40-55 (N=11) Men 20-55 (N=9) Soon 33% 15% 9% 22% Wait 12 24 months 40% 15% 18% 22% Wait more than 24 months 27% 54% 18% 22% Dont want to get pregnant 0 15% 55% 33%

Table 4 shows that despite articulated interest in delaying the next pregnancy (whether a shorter or longer interval), the majority of women were not currently using any modern or traditional method to space the next pregnancy. Slightly older women were somewhat more likely to be using a method and 58% of men reported using a method to space. Since polygamy is common in Northern Nigeria, some of the discordance between men and womens reported use of a spacing method may be as a result of men reporting use for at least one of their wives, or of womens reluctance to publicly disclose use of a method. It could also be due actual non-use by women, due to their desire to have many children.

Table 4: Current Use of a Spacing Method by Age Group and Sex (Are you using a method to
delay your next pregnancy?) Age Group/ Sex Women 15 20 (N=29) Women 21 24 (N=17) Women 40-55 (N=7) Men 20-55 (N=24) Using a spacing method 31% 41% 43% 58% Not using a spacing method 69% 59% 57% 42%

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The majority of women aged 21 to 24 who reported they were using an FP method were using injectables, followed by the pill, while younger women aged 15 to 20, reported using pills, followed by injectables; two young women aged 15 to 20 reported using abstinence (Figure 2). Older women also reported the use of injectables and pills, followed by the calendar method and IUD. The

Figure 2: Type of Method Use by Respondent

60 50 % of Respondents 40 30 20 10 0 Women 15-20 (N=11) Women 21-24 (N=8) Women 40-55 (N=6) Men 20-55 (N=13) Pill Injectable IUD Condom Calendar Method Abstinence Other

category of other methods included Allahs method and withdrawal. Of men reporting current FP method use, the types of methods included injectables, pills, the calendar method and condoms. Respondents cited a number of reasons for not using an FP method (Figure 3). While some reasons related to pressure from a spouse or mother-in-law to get pregnant again, many women were concerned about the side effects of contraceptives. A few cited religious beliefs or cost as barriers. Men were also concerned about side effects of contraception, as well as religious beliefs.

Figure 3: Reasons for Not Using FP Methods Among Respondents Not Currently Using FP
45 40 35 30 25 20 15 10 5 0

% of Respondents

Women 15 - 20 (N=21) Women 21-24 (N=11) Men (N=12)

Reasons for not using FP

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While the majority of young women with a baby under the age of six months wanted to wait 12 to 24 months before becoming pregnant again, low or incorrect use of FP methods may result in a number of unplanned or mistimed pregnancies. A few women reported having obtained an abortion as shown in Table 5 (this number may be under-reported since abortion is illegal in Nigeria). It is possible that the women who obtained these abortions became pregnant shortly after having given birth.

Table 5: Total Number of Reported Abortions by Age Group (Total number of abortions obtained
by respondent) Age Group Women 15 20 (N=30) Women 21 24 (N=18) Women 40 55 (N=8) 0 abortions 93% 89% 75% 1 abortion 3% 11% 25% 2 abortions 3% 0% 0%

Awareness of HTSP was quite high among all respondents (see Table 6). Eighty-seven percent of young women aged 15 to 20 and 89% of women aged 21 to 24 had heard of HTSP. All male respondents reported having heard of HTSP.

Table 6: Ever Heard of HTSP by Age Group and Sex, multiple responses (Have you ever heard
of Healthy Timing and Spacing of Pregnancy?) Age Group/ Sex Women 15-20 (N=31) Women 21-24 (N=18) Women 40-55 (N=11) Men 20-55 (N=26) Has Heard of HTSP 87% 89% 91% 100% Never Heard of HTSP 13% 11% 9% 0

Table 7 shows sources of information on HTSP and FP. When asked where they had heard about HTSP and FP, young women were most likely to report learning from FOMWAN workers who visited their compounds (79% of young women aged 15 to 20; 82% of young women aged 21-24). Among older women aged 40 to 55, the majority of women had heard about HTSP from friends (36%) or at an Islamiyya school (36%), while 27% had heard about HTSP from an imam and 27% from their husbands. Only 18% had heard about HTSP from a FOMWAN outreach worker. Seventy-eight percent of men reported hearing about HTSP from their imam, 26% from FOMWAN outreach workers, and 44% from a friend.

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Table 7: Sources of Information on FP and HTSP by Age Group and Sex, multiple responses
(Where did you hear about HTSP?) Age Group/ Sex Women 15 20 (N=28) Women 21 24 (N=17) Women 40-55 (N=11) Men 20 55 (N=27) FOMWAN 79% 82% 18% 26% Friend 36% 47% 36% 44% Islamiyya School 36% 35% 36% 7% Husband 39% 29% 27% n/a Imam 32% 29% 27% 78%

The majority of female respondents of all ages could recall the HTSP messages, and understood what HTSP advises women to do and the benefits of spacing (see Table 8). Eighty-one percent of young women aged 15 to 20 could recall at least one HTSP message. Of this group, 100% knew about waiting two years after giving birth before trying to become pregnant again, while 78% knew both that women should wait six months after a miscarriage or abortion before trying to become pregnant and wait until turning 18 to become pregnant for the first time. Among women aged 21 to 24 who recalled at least one HTSP message (89%), all knew that HTSP advises women to wait two years after giving birth before trying to become pregnant and to wait six months before trying to become pregnant after a miscarriage or abortion. Eighty-eight percent of this group mentioned delaying first birth until the age of 18. Men also demonstrated high recall, with 89% of men citing at least one HTSP message. All the men said that women should wait two years after a live birth before becoming pregnant, and 80% of respondents knew that women should wait six months after a miscarriage or abortion before trying to become pregnant again. Eighty-four percent of male respondents cited delaying first pregnancy until after the mother is 18 years of age.

Table 8: Knowledge of HTSP Messages by Age Group and Sex (What does HTSP advise you to
do?) Age Group/ Sex After a live birth, wait 2 years before trying to become pregnant again 100% 100% 91% 100% After a miscarriage or abortion, wait 6 months before trying to become pregnant again 78% 100% 27% 80% For young women, wait until 18 years before having your first child 78% 88% 46% 84%

Women 15-20 (N=27) Women 21-24 (N=17) Women 40-55 (N=11) Men 20-55 (N=25)

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When asked about the benefits of HTSP, the message to space for the health of both mother and baby seemed to have most weight among respondents (Table 9), although respondents also cited better nutrition for the baby and economic benefits as reasons to practice HTSP.

Table 9: Benefits of HTSP by Age Group and Sex (What are the benefits of HTSP?)
Age Group/ Sex Healthier babies 70% 94% 50% 88% Healthier mothers 85% 94% 90% 84% Better nutrition for baby 26% 69% 10% 40% Economic benefits 52% 63% 30% 68% Other

Women 15 20 (N=27) Women 21 24 (N=16) Women 40 55 (N=10) Men 20 55 (N=25)

4% 19% 0 0

6. DISCUSSION
ESD is encouraged by the findings of this community survey. While early and frequent childbearing are still common practice in Northern Nigeria, the basic concepts of HTSP and the benefits of child spacing are well known. The specific HTSP messages and the benefits of HTSP, however, have only recently been introduced to these communities. This snapshot of the five target LGAs in Kano suggests the possibility of and potential for changing behavior. HTSP may be a more acceptable even persuasive approach to promoting FP use than a general recommendation to space, given its emphasis on time-bound spacing practices to improve the health of mothers and babies; both of these messages seemed to resonate with women and men of all ages. The recommendation to space the next pregnancy by two years following a delivery gives very clear direction to women and men, and is congruent with the teachings of Islam. Both the household outreach by FOMWAN members and the involvement of the religious leaders seem to have contributed to improved understanding by women of all ages.

Religious Leaders The project performance and survey data both indicate that imams are effective
in reaching large numbers of men and women both directly and indirectly. Religious leaders play a powerful role in shaping community norms and behaviors, especially those of men. Many women reported hearing about HTSP from their imams as well as from their husbands, and men mentioned that they heard about HTSP from their imams and their friends. FOMWAN initially worked with the Sharia Commission and the Council of Ulama in Kano to orient 30 religious leaders from the five target LGAs about the high rates of maternal and child mortality and morbidity especially among young women under the age of 18, and how increased use of FP and better spacing co uld improve the health of young mothers and children. 10

FOMWAN The survey findings suggest that FOMWAN members have been successful in their
outreach, as the majority of young women and a significant number of men cited FOMWAN as a
10

The Council of Ulama is the educated class of Muslim legal scholars engaged in the several fields of Islamic studies. They are best known as the arbiters of sharia law and oversee the Sharia Commission.

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main source of information on HTSP. In many traditional communities like parts of Kano, the mobility of women (especially adolescents) may be limited. FOMWAN members are instrumental in bringing new ideas and innovations to women living in compounds. Because of their status in the community, their views and recommendations are respected.

Participants in FOMWAN orientation to HTSP and young married women

Childbearing Practices The survey findings reinforce the commonly held assumption that upon
marriage, young women are expected to become pregnant to demonstrate fertility to their husbands and to their families, especially their mother-in-laws. Young women aged 15 to 20 may feel more pressure from a mother-in-law not to use an FP method than slightly older women who already have several children. Several young women who had a baby under the age of six months stated that they wanted to get pregnant, and two noted they were being pressured by the mother-in-law to have another baby; none cited their husband as a source of pressure. However, three young women in their 20s reported that their husbands were pressuring them not to use a method, while none mentioned their mothers-in-law. A mother-in-law may pressure her young daughter-in-law early in the marriage to demonstrate her ability to become pregnant and give birth several times. This demonstrates the couples fertility and the daughter-in-laws obedience to the community. Once the young wife has grown older, borne several children and established her position as a wife and mother, the motherin-law may be less able or inclined to advise her daughter-in-law on her childbearing and FP practices. At this point, the husband may become more involved in establishing his preferences over childbearing and spacing. Thus, it is also important to reach husbands and educate them about the benefits of FP as well as address their concerns about methods, such as side effects. Despite these pressures, almost two-thirds of young women interviewed, who had a baby under the age of six months, appeared to be very interested in waiting at least another 12 months before becoming pregnant again, and another one-third stated that they wanted to wait at least 24 months. The majority of young women aged 15 to 20 (67%) without a baby under the age of six months still wanted to wait at least 12 months before becoming pregnant again. This suggests that more attention should be paid to reaching young women and their mothers -in-law with information on the health and social benefits of HTSP prior to her becoming pregnant for the first time (to help her delay) or during the pregnancy/shortly after giving birth to help her space the Page | 15

next pregnancy by at least two years. In particular, young women may want to adequately space their next pregnancies, but in the end succumb to outside pressure to become pregnant; FOMWAN members can play a pivotal role in helping young women achieve their stated desire to space by helping young women, mothers-in-law and/or husbands negotiate and agree upon what is safest and healthiest for young mothers and their babies.

FP Use Both young women and men cited side effects of contraceptives as a reason for not using FP.
Concern about side effects is a perpetual barrier to FP use that is often reinforced by friends and family members. A short interaction with a provider may not be enough to overcome the pervasive fears that many young women may have about side effects, or that they may actually experience on their own. Interactions with providers may be rushed, yet at the same time may be full of important information that even adult clients may find challenging to process. Many adolescents, whether married or unmarried, simply may not yet have the cognitive ability to absorb all this informati on or may not be assertive enough to ask questions of a provider when they do not understand something. This is also an area where groups like FOMWAN can support the efforts of health care providers. FOMWAN members can offer information and education on FP and HTSP in a more relaxed and comfortable environment where young women (and even men) can ask questions and discuss their concerns around issues such as side effects or family pressures. There were some contradictory responses over the relationship between breastfeeding and FP use. Breastfeeding is highly encouraged in Islam and women are expected to breastfeed for at least two years. When asked about their current breastfeeding and spacing practices/FP use, some women responded that they were practicing child spacing through breastfeeding, while others stated they were not using an FP method because they were breastfeeding. When asked about their future plans, over half of the young women said they would use breastfeeding as a means of spacing the next pregnancy, and only around one quarter said they would use an FP method. ESDs experience in Northern Nigeria suggests that many women assume that they will not get pregnant if they are breastfeeding, and most women and men do not adequately understand the mechanism of how breastfeeding works as a contraceptive. Further, many women do not know that a number of FP methods can safely be used by women, even when they are breastfeeding. Since fertility awareness methods are highly acceptable in this part of Nigeria, FOMWAN can easily incorporate the education of men, women, religious leaders and others on the criteria for effective use of the Lactational Amenorrhea Method (LAM), Standard Days Method (SDM) and FP methods that can safely be used by breastfeeding mothers so that women can space for the recommended full two years. Several young women reported having had at least one abortion (abortion is illegal in Nigeria so it is quite possible that these were unsafe abortions). Several FOMWAN members suggested to ESD that abortion is not uncommon among young women, especially if they get pregnant too soon after having given birth. FOMWAN members and several service providers interviewed by ESD also asserted that a young womans decision to seek an abortion is often supported by her husband. Improved understanding of the value of spacing and more effective use of available FP methods can contribute to efforts to decrease the rate of unsafe abortions.

Developing Positive Community Norms A useful predictor of adolescent behavior is that many
adolescents will behave as they perceive their peers are behaving. If young married women perceive that the majority of their peers are using FP to delay and space pregnancy, this can contribute to efforts to increase FP use and spacing behaviors among the community at large.

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The majority of young women interviewed stated that they discussed child spacing with their friends and that they were talking more about FP and HTSP than in the past. Since the movement of young women can be somewhat restricted in this community, it is quite likely that much of this peer -topeer discussion is occurring in the Islamiyya schools that many young women attend. In addition to support from their peers to adopt healthy behaviors, the open approval they receive from res pected members of the community (such as FOMWAN members and religious leaders) may also have an effect on the ability of young women to discuss and adopt these new behaviors. Young women are also influenced by older women in the community, whether their own mothers or their mothers-in-law. Fewer older women reported having heard about HTSP from a FOMWAN outreach worker. Future efforts should further explore mechanisms to reach these influential matriarchs, perhaps through female scholars and teachers.

7. CONCLUSION
This activity in Kano was a small-scale intervention conducted with limited resources from ESD. However, the survey findings indicate a positive reception to the information on HTSP and FP and its benefits for both women and children. We speculate that this is due to the following factors: A very clear focus on the importance and benefits of HTSP and FP, especially for young married women where rates of mortality and morbidity are high; The dissemination of the information in multiple, targeted venues to key stakeholders; The engagement of respected members of the community, such as imams and FOMWAN members; and An effort to build on existing opportunities and programs (for example, the implementation of the COMPASS project by Pathfinder and FOMWAN). While ESD cannot directly support further activities for FOMWAN and the religious leaders to promote FP and HTSP in Kano State under the present scope of the project, there are several opportunities to maintain this initial momentum and respond to the health and information needs of men and women. 1. An initial training of 30 Islamic religious leaders quickly spread across the state to reach approximately 1000 religious leaders, using resources provided by the Sharia Commission and Council of Ulama. Since religious leaders are often the arbiter of community norms and practices, they are clearly an important pathway to reach men and women both directly and indirectly. Most religious leaders want to be good community leaders, and helping them to promote the health and wellbeing of their followers is one way to build their credibility as compassionate and supportive leaders. ESD believes its approach of orienting religious leaders to the health and social benefits of HTSP and its link to Islams recommendation for women to breastfeed for two years can easily and inexpensively be rolled out to Islamic religious leaders across the country. Future projects may also want to more clearly understand which religious leader activities are most effective in influencing individual behaviors. 2. FOMWAN is a national organization with chapters in nearly every state of Nigeria, and FOMWAN members are well-respected community leaders who understand the issues of Page | 17

women and can be an important catalyst for positive change. The experience and model introduced in Kano can be disseminated to other state chapters, and the national leadership can encourage its members to focus on reaching young married women, in concert with their ongoing efforts to eliminate child and early marriage. 3. While the HTSP information is being positively received, there are still information gaps. FOMWAN can begin to revise the information that they provide to young women, men and mothers-in-law in the compounds to address some of the concerns revealed in the interviews. Importantly, FOMWAN members should address the expressed concerns about the side effects of FP, and should improve womens and mens knowledge about the correct use of LAM (or other fertility-awareness methods) for pregnancy prevention/spacing. FOMWAN members provide an integral service by bringing discussions on FP and HTSP to the compound level, so that young women and the members of the family who influence decision-making can learn about the benefits of FP and HTSP in a more relaxed and comfortable environment. FOMWAN can also explore partnering with other womens groups to better reach older women, mothers, and mothers-in-law. 4. Community education efforts must be supported by targeted and improved services that better reach young women. Under the COMPASS project, Pathfinder International worked to establish youth-friendly clinics in Kano. This can be most easily addressed by providing training and guidance to clinical providers to improve their ability to educate and counsel adolescent clients, whether married or unmarried. Married adolescents have often been overlooked by adolescent sexual and reproductive health programs, most of which are targeted to unmarried adolescents to help them prevent pregnancy or HIV. Married adolescents may have even less control over their sexual activity than unmarried adolescents, because they are expected to become pregnant soon after marrying, and may be expected to have several closely spaced pregnancies. Given the high rates of adolescent maternal mortality and morbidity, clinic-based providers and outreach workers need to be better prepared to deal with the pregnancy- and childbirth-related problems and risks of young mothers and be able to help them decide if FP use is right for them. This small community survey, while providing interesting insights, leaves several unanswered questions. Most specifically, does this kind of community outreach model involving religiou s leaders, husbands and mothers-in-law contribute to an increase in FP use among young married women to both delay and space their pregnancies? Will these changes in community norms contribute to reducing maternal and infant mortality and morbidity among a dolescent mothers? Regrettably, these questions cannot be completely answered without an additional investment of resources into a comprehensive intervention with a rigorous evaluation component.

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APPENDIX 1
Nigeria Community Survey 2010
Good morning/afternoon/evening. Thank you for agreeing to speak with me today. My name is ____________________, and I am working with FOMWAN. We are interviewing a sample of women in this and other communities to get a better understanding of mothers health. The answers you provide will be kept private and you can refuse to answer any question. The interview should take about X minutes of your time and you may stop at any time. Your participation in this survey is completely voluntary. However, we hope that you will participate in this survey since your views are important. Do you agree to participate in this survey? Yes No

I certify that this woman has received the full information above and has verbally agreed to participate. _______________________________________ Signature of Interviewer Name of LGA/Ward ID Code of Respondent Date (Day/Month/Year) Name of Interviewer Date

Instructions: Please circle the answer in the response column or write in response under written answers column.

Q. #
1.

Questions
How old were you at your last birthday?

Responses

Skip to

Written answers

_____Years

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Q. #
2.

Questions
How many times have you been pregnant?

Responses
_______ pregnant 1. ___ total # of children born to respondent 2. 3. 4. 5. ___ total # of children now living ___ total # of stillbirths ___ total # died ___ any abortions? 1. 2. Yes No

Skip to

Written answers

3.

Have you heard of Healthy Timing and Spacing of Pregnancy (HTSP)?

If no, go to Q#7

Interviewer: For questions 4, 5 and 6 below, mark all that they mention!
4. If Yes, where did you hear about HTSP? 1. 2. 3. 4. 5. 6. 1. 2. Imam FOMWAN outreach worker Friends/Peers Islamiyya School Husband Mother-in-law Wait 2 years before next pregnancy Wait 6 months before next pregnancy, after a miscarriage or abortion For young woman, wait until 18 years before having first child Not sure Gave incorrect HTSP message(s) Healthier babies Healthier mothers Better nutrition for the babies Economic benefits Other (specify) Yes No Soon

5.

Can you tell me what HTSP advises you to do?

3. 4. 5. 1. 2. 3. 4. 5. 1. 2. 1.

6.

What are the benefits of HTSP?

7.

Do you currently have a baby younger than 6 months? When do you want to get pregnant again?

8.

Want to wait: 1. 2. 3. For 6 months For 12-24 months More than 24 months Breastfeeding Abstinence

9.

What would you do to space your

1. 2.

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Q. #

Questions
next pregnancy?

Responses
1. 1. 2. FP/Contraceptives Yes No

Skip to

Written answers

10.

Are you using any method (modern/traditional) to delay your next pregnancy? If yes, can you tell me which method or methods you are using?

If no, go to Q#12

11.

12.

If no, why arent you using any method of FP?

1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. 5. 6. 7. 8. 9. 1. 2. 1. 2. 3.

13

Do you and your friends/peers discuss or child spacing with each other? Is there a change in how often your friends are talking about FP/HTSP messages?

Pill Condom Injection IUD Abstinence Calendar method SDM Other (specify) Pregnant already Want to get pregnant Religious beliefs Pressure from husband Pressure from mother-in-law Side effects of contraceptives Distance/transportation for FP services Finances/cost Other (specify) Yes No Yes, more Yes, less No change

14

This concludes the survey. Do you have any questions or comments? Thank you very much for your time.

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The Extending Service Delivery (ESD) Project, funded by the United States Agency for International Development (USAID) Bureau for Global Health, is designed to address unmet need for family planning (FP)and increase the use of reproductive health /family planning (RH/FP) services at the community level, especially among underserved populations, in order to improve health and socioeconomic development. To accomplish its mission, ESD strengthens global learning and application of best practices; increases access to community-level RH/FP services; and improves capacity for supporting and sustaining RH/FP services. ESD works closely with USAID missions to devise tailored strategies that meet the RH/FP service delivery needs of specific countries. A five-year Leader with Associates Cooperative Agreement, ESD is managed by Pathfinder International in partnership with IntraHealth International, Management Sciences for Health, and Meridian Group International, Inc. Additional technical assistance is provided by Adventist Development and Relief Agency International, the Georgetown University Institute for Reproductive Health, and Save the Children. Contact information: Extending Service Delivery Project 1201 Connecticut Avenue, NW, Suite 700 Washington, D.C. 20036 Tel. 202-775-1977 Fax 202-775-1988

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