Demographic dividend-favorable policy environment in two pre-dividend African nations: review of national policies and prospects for policy amendments in Nigeria and Tanzania.

BACKGROUND: In collaboration with local partners, we reviewed 18 national policy documents across two sub-Saharan African countries identified as pre-dividend nations by the World Bank in 2017: Nigeria and Tanzania. Our aim was to assess national policies in pre-dividend countries and to determine whether national strategies were primed to capitalize on changing demographic structures, maximally attain the demographic dividend, and augment socio-economic growth. METHODS: We conducted policy reviews by focusing on five key sectors of the Gates Institute Demographic Dividend Framework: Family Planning, Maternal and Child Health, Education, Women's Empowerment, and Labor Market. This framework was developed as a tool for countries to apply targeted policies for accelerating the demographic dividend based on their demographic structure. For each component we used a comprehensive list of indicators, defined via a systematic literature review, through which we assessed national policies aimed at maximizing the demographic dividend. RESULTS: Between the two countries, we observed persistent gaps in policies targeting family planning. Although more comprehensive, policies addressing maternal and child health, education, women's empowerment, and labor market still lagged in their specificity and measurability. We identified specific policy amendments and alternatives that Nigeria and Tanzania could consider to mitigate these gaps. We also stress the importance of designing measurable policy initiatives across sectors. CONCLUSIONS: Based on these recommendations, as Nigeria, Tanzania, and other pre-dividend nations start experiencing rapid demographic changes, they may consider implementing routine policy reviews to strengthen policies across the five key sectors and harness the benefits of a demographic dividend.

Government stakeholders' perspectives on the family planning environment in three Nigerian cities: qualitative findings from the Nigerian Urban Reproductive Health Initiative (NURHI) Sustainability Study.

Background: The Nigerian government has made numerous commitments to expanding access to family planning services for its population yet has faced many challenges in implementing these commitments. Foreign donors provide support for expanding access to family planning in key populations. Objective: This study examines the family planning environment after donor funding has ended, including how government stakeholders perceive family planning services and their role in providing them post donor funding. Methods: The NURHI Sustainability Study used qualitative data to evaluate the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI), which focused on increasing the use of modern contraceptive methods, particularly among the urban poor. This study presents results from in-depth interviews with 16 key government stakeholders, selected using purposive sampling methods, in three cities: Ilorin (where NURHI Phase 1 programming discontinued in 2015), Kaduna (where programming continued under NURHI Phase 2), and Jos (a comparison city). A thematic analysis was employed to identify key themes related to government stakeholders' perspectives on the family planning environment and sustainability of NURHI programming. Results: Respondents from all three cities highlighted local political leaders' positive perceptions about family planning. All respondents were open to continued foreign donor support for family planning services while respondents in Kaduna and Jos emphasized the need for governments to lead efforts among all family planning actors. Stakeholders highlighted the benefits of a dedicated and implemented family planning budget line and encouraged continued state financial support. Respondents in Kaduna and Ilorin praised the positive influence of NURHI programming while those from Ilorin reflected on the need for future programs to gradually close-out their efforts to support sustainability. Conclusions: As donors look to transition to government ownership of family planning efforts, it is important for family planning programs to understand and incorporate government stakeholders' perspectives into their sustainability planning efforts.

Role of Religious Leaders in Promoting Contraceptive Use in Nigeria: Evidence From the Nigerian Urban Reproductive Health Initiative.

BACKGROUND: Despite the many supply- and demand-side interventions aimed at increasing contraceptive uptake, the modern contraceptive prevalence rate in Nigeria has remained very low (9.8%). Religion is an important part of the sociocultural fabric of many communities. As such, religious leaders have the power to inhibit or facilitate effective adoption of contraceptive methods to support family health. We assess the association of exposure to religious leaders' tailored scriptural family planning messages with contraceptive use in Nigeria. METHODS: This cross-sectional study used data from a Measurement, Learning and Evaluation Project survey conducted in 2015 in 4 Nigerian states-Federal Capital Territory, Kaduna, Kwara, and Oyo. The final study sample was restricted to 9,725 non-pregnant women aged 15 to 49 years. Data analysis included descriptive statistics and binary logistic regression analysis to explore significant relationships between current use of a modern contraceptive method, exposure to family planning messages from religious leaders, and selected background characteristics. RESULTS: About 2 in 5 women reported being exposed to family planning messages from religious leaders in the past year. Bivariate results revealed a higher uptake of modern contraceptives among women with high exposure to different NURHI interventions (35.5%) compared with respondents in the low or medium exposure categories (14.5% and 24.5%, respectively). The multivariable analysis revealed significantly higher contraceptive uptake among women who had exposure to family planning messages from religious leaders relative to those with no exposure (odds ratio=1.70; 95% confidence interval, 1.54 to 1.87; P<.001). This association remained significant after adjustment for background characteristics and other selected variables. CONCLUSION: Interventions that engage clerics of different faiths as change agents for shaping norms and informing behaviors about family planning and contraceptive use are crucial for increasing contraceptive uptake in Nigeria.

Factors affecting the achievement of fertility intentions in urban Nigeria: analysis of longitudinal data.

BACKGROUND: Maternal mortality ratio in Nigeria is among the highest in the world with an estimated 160 women dying every day of complications related to pregnancy and childbirth. In addition to appropriate management of complications related to pregnancy and childbirth, preventing unwanted pregnancies is an effective way to reduce maternal deaths. Identifying potentially modifiable factors associated with the achievement of fertility intentions is critical for developing behavior change interventions that will contribute to reducing maternal mortality. METHODS: The data analyzed came from a longitudinal design with data collected in 2010/2011 and 2014 from the same group of women of reproductive age in six Nigerian cities. The data were collected as part of efforts to evaluate the effects of the Nigerian Urban Reproductive Health Initiative (NURHI). A total of 10,672 women were interviewed at the two points in time but the analyses in this manuscript were limited to 1921 in-union women who reported that they desired no more children at baseline in 2010/2011. The principal analytic method was multivariable regression adjusted for clustering at the enumeration area level. The analysis controlled for socio-demographic and household variables, ideational characteristics, and contraceptive use at baseline. RESULTS: About two thirds of the women who desired no more children at baseline have neither had any children nor were pregnant at endline. The strongest predictors of the achievement of fertility intentions include parity, age, religion, residence, spousal communication about family size, perceived severity of another pregnancy, and spousal agreement about family size. CONCLUSION: A comprehensive strategy to help women avoid unwanted pregnancies should include efforts to increase women's understanding about effective ways to prevent unplanned pregnancies and strengthen self-efficacy for contraceptive use. Promoting spousal communication about reproductive issues, engaging men, promoting smaller family sizes and changing pronatalist attitudes should also be part of such a strategy.

Inadequate birth spacing is perceived as riskier than all family planning methods, except sterilization and abortion, in a qualitative study among urban Nigerians.

BACKGROUND: Fertility is high in Nigeria and contraceptive use is low. Little is known about how urban Nigerians perceive the risk of contraceptive use in relation to pregnancy and birth. This study examines and compares the risk perception of family planning methods and pregnancy related scenarios among urban Nigerians. METHODS: A total of 26 focus group discussions with 243 participants were conducted in September and October 2010 in Ibadan and Kaduna. The groups were stratified by sex, age, family planning use, and city. Study participants were asked to identify the risk associated with six different family planning methods and four pregnancy related risks. The data were coded in ATLAS.ti 6 and analyzed using the thematic content analysis approach. RESULTS: The ten family planning and pregnancy related items ranked as follows from most to least risky: sterilization, abortion, getting pregnant soon after having a baby (no birth spacing), pill, IUD, injectable, having a birth under 18 years of age (teenage motherhood), condom use, having six children, and fertility awareness methods. Risk of family planning methods was often categorized in terms of side effects and complications. Positive perceptions of teenage motherhood and having many children influenced the low ranking of these items. CONCLUSION: Inadequate birth spacing was rated as more risky than all contraceptive methods and pregnancy related events except for sterilization and abortion. Some of the participants' risk perceptions of contraceptives and pregnancy related scenarios does not correspond to actual risk of methods and practices. Instead, the items' perceived riskiness largely correspond with prevailing social norms. However, there was a high level of understanding of the risks of inadequate birth spacing. TRIAL REGISTRATION NUMBER: This study is not a randomized control trial so the study has not been registered as such.

Using behavior change communication to lead a comprehensive family planning program: the Nigerian Urban Reproductive Health Initiative.

BACKGROUND: The Nigerian Urban Reproductive Health Initiative (NURHI), a 6-year comprehensive family planning program (2009-2015) in 4 cities, intentionally applies communication theories to all program elements, not just the demand generation ones, relying mainly on a theory called ideation-the concept that contraceptive use is influenced by people's beliefs, ideas, and feelings and that changing these ideational factors can change people's behavior. PROGRAM DESCRIPTION: The project used multiple communication channels to foster dialogue about family planning, increase social approval for it, and improve accurate knowledge about contraceptives. Mobile service delivery was started in the third year to improve access to clinical methods in slums. METHODS: Data from representative baseline (2010-11) and midterm (2012) surveys of women of reproductive age in the project cities were analyzed. We also used propensity score matching to create a statistically equivalent control group of women not exposed to project activities, and we examined service delivery data from NURHI-supported clinics (January 2011-May 2013) to determine the contribution of mobile services to total family planning services. RESULTS: Three years into the initiative, analysis of longitudinal data shows that use of modern contraceptives has increased in each city, varying from 2.3 to 15.5 percentage points, and that the observed increases were predicted by exposure to NURHI activities. Of note is that modern method use increased substantially among the poorest wealth quintiles in project cities, on average, by 8.4 percentage points. The more project activities women were exposed to, the greater their contraceptive use. For example, among women not using a modern method at baseline, contraceptive prevalence among those with no exposure by midterm was 19.1% vs. 43.4% among those with high exposure. Project exposure had a positive dose-response relationship with ideation, as did ideation and contraceptive use. By the end of the observation period, mobile services were contributing nearly 50% of total family planning services provided through NURHI-supported clinics. Propensity score matching found that the increase in contraceptive use in the 4 cities attributable to project exposure was 9.9 percentage points. Intention to use family planning in the next 12 months also increased by 7.5 to 10.2 percentage points across the 4 cities. CONCLUSION: Demand-led family planning programs, in which demand generation is the driving force behind the design rather than the conventional, service delivery-oriented approach, may be more suitable in places where expressed demand for contraceptives is low.