Contraceptive practices among nomadic Fulani women in Bade Local Government Area, Yobe State, Nigeria: a cross-sectional study evaluating barriers and predictors

¹Department of Community Medicine, Yobe State University Damaturu, Yobe, Nigeria, ²Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria, ³Department of Community Medicine, Gombe State University/Federal Teaching Hospital, Gombe, Nigeria, ⁴Department of Community Medicine, University of Abuja Teaching Hospital, Abuja, Nigeria, ⁵Department of Community Medicine, Federal Medical Centre Gusau, Zamfara, Nigeria

^&Corresponding author
Nuru Suleiman Muhammad, Department of Community Medicine, Yobe State University Damaturu, Yobe, Nigeria

Introduction    

Contraception is the deliberate use of various methods or devices to prevent pregnancy. It is essential for minimizing the risk of pregnancy and preventing sexually transmitted infections [1,2]. One in 41 women still dies from pregnancy-related maternal causes of death in low and middle-income countries. In contrast, such deaths rarely occur in high-income countries [3]. This has largely been attributed to differences in access to and utilization of effective maternal health services, including contraceptive and skilled service provision [4].

Although the percentage of married Nigerian women aged 15 to 49 years who used contraceptives increased from 6% in 1990 to 20% in 2023 [5], it has been reported that awareness of modern contraceptives among married women in Yobe State remains low [6]. Additionally, among married and unmarried women age 15-49 years in Yobe State, the use of any modern method of contraceptives, the unmet need for contraceptive, the total demand for family planning and the percentage of the demand satisfied by modern contraceptives remain low at 7.6%, 24.6%, 33.7%, and 26.8% respectively [5].

The low awareness of modern contraceptives in Yobe State, despite a national increase in the use of contraceptives, necessitates investigation. The nomadic Fulani were chosen because they may face distinct obstacles in accessing or using contraceptives due to their lifestyle of moving from one place to another. Understanding their practices can inform targeted interventions to improve overall contraceptive use and reproductive health outcomes in the state. Barriers faced by other non-Fulani nomads, such as low education, low knowledge of maternal services, geographic isolation, cultural beliefs, and cost, have been documented [7,8]. Given the similarities in lifestyle with other nomads, it is reasonable to infer that similar obstacles may exist among the Fulani nomads in Yobe State, albeit with slight contextual differences. Understanding these determinants specific to the Fulani community is important for designing culturally sensitive and effective interventions that address their unique needs and circumstances.

Furthermore, studying contraceptive use among nomadic Fulani in Yobe State aligns with broader efforts to improve reproductive health outcomes and achieve Sustainable Development Goals (SDGs Goal 3 and 5) [9]. By addressing the unmet need for contraceptive services within this population, women's empowerment would be ensured, maternal and infant mortality rates reduced, and overall well-being promoted. Additionally, ensuring that contraceptive services are accessible to nomadic Fulani women can contribute to narrowing the existing health disparities and improve equity in healthcare access for all segments of the Nigerian communities.

Lastly, understanding contraceptive practices among nomadic Fulani in Yobe State has broader implications for population dynamics. The Fulani population is one of the largest nomadic groups in West Africa, and their reproductive choices can significantly impact population growth and resource allocation in the region [10]. By promoting informed decision-making regarding family planning, including birth spacing and limiting family size, interventions can help ensure that the well-being of Fulani families is improved while also contributing to sustainable population growth. This will ultimately lead to positive health and economic outcomes for the nomadic Fulani community and the broader West African societies.

Objectives: therefore, the aim of this study was to assess contraception, predictors, and barriers to its use among nomadic Fulani women in Yobe State, Nigeria. The objectives of the study were to determine contraceptive use, the unmet need for contraceptives, the predictors of contraceptive use, and the barriers to contraceptive use among the participants.

Methods     

Study design: this research was a cross-sectional mixed study to assess contraception and barriers to its use among nomadic Fulani women in Yobe State, Nigeria.

Setting: Nigeria, located in West Africa, shares borders with Benin (west), Niger (north), Chad (northeast), and Cameroon (east), with its southern boundary along the Gulf of Guinea in the Atlantic Ocean. It comprises 36 states and 1 Federal Capital Territory, subdivided into 774 Local Government Areas (LGAs). As of 2024, the estimated population is approximately 232.68 million [11,12], and the total land area is about 923,770 km² (356,669 mi²) [13].

This study was conducted in the Bade Local Government Area (LGA) of Yobe State from 5^th to 23^rd June 2022. The LGA has an estimated population of 219,800 [14]. Farming is the main occupation, alongside large-scale livestock rearing by the nomadic Fulani [15].

Participants: the quantitative study population comprised nomadic Fulani women aged 15-49 years in Bade LGA who had at least one delivery in the two years preceding the survey. Women with hearing impairment or who were too ill to participate were excluded. The qualitative component included nomadic Fulani women aged 15-49 years in Bade LGA with at least one delivery in the past two years, their spouses, mothers-in-law, household heads, an opinion leader, and the head of a health facility serving nomadic Fulani in Bade LGA. Participants were selected based on their roles and experiences with maternal health service utilization and their willingness and ability to participate in interviews or focus group discussions.

Variables

Outcomes: the study assessed three primary outcomes related to contraceptive use among nomadic Fulani women. The first outcome, "ever used contraceptives", was measured as a binary variable (yes or no), indicating whether a participant had ever used modern contraceptives, such as injectables or pills, at any point before the study. The second outcome, "current contraceptive use", was also binary (yes or no), determined by whether participants were actively using contraceptives at the time of data collection. The third outcome, “future intension” was measured as (yes, no, don´t know). Secondary outcomes include unmet need for contraceptives (for spacing and limiting), met need for contraceptives (for spacing and limiting), total met need, and total demand for contraceptives.

Exposures/predictors: the study investigated predictors of contraceptive use, including sociodemographic factors (age, education, marital status, wealth index), husbands´ characteristics (age, education), antenatal clinic (ANC) attendance, and knowledge of maternal health services. After controlling for confounders, only ANC predicted ever-use of contraceptives.

Potential confounders: confounders identified following binary logistic regression included marital status, parity, husband´s age, husband´s education level, and knowledge of maternal services.

Effect modifiers: none was tested.

Diagnostic criteria: not applicable, as outcomes were self-reported, not clinically diagnosed.

Data sources/measurement

Quantitative data: fifteen research assistants (five Community Health Extension Workers (CHEWs) and ten community volunteers (Fulani informants)) were recruited and trained by the researcher. The training covered an overview of the study and research ethics, basics of quantitative and qualitative methods, and practical sessions on using Focus Group Discussion (FGD) and Key Informant Interview (KII) guides, as well as the Open Data Kit (ODK) software. Community volunteers assisted with settlement entry and participant identification, while CHEWs conducted in-person interviews using a semi-structured, interviewer-administered questionnaire adapted from the 2013 Nigeria Demographic and Health Survey (NDHS) and implemented via ODK/Kobo Toolbox version 2022.1.3 [16]. The questionnaire was pretested among 55 respondents (10% of the minimum sample size) in three nomadic Fulani settlements- Hardo Manu, Lamido Kyau, and Rigan Audu Yahaya- in Jakusko LGA, the closest to Bade. Modifications, including skip logic, were made as needed. The tool captured key outcomes, including contraceptive use (ever, current, future intention) and unmet need (spacing, limiting, total demand). Predictor variables included participants´ sociodemographic factors and their husbands´ characteristics. Barriers to contraceptive use were also assessed. Standardized questions ensured consistency. No structural comparisons between groups were conducted.

Qualitative data: qualitative data were collected using guides adapted from a similar study [17]. All discussions were audio-recorded, transcribed verbatim, and translated into English for analysis.

Comparability: the quantitative data collection employed consistent question phrasing across all participants to ensure uniformity in responses. Qualitative guides were customized to suit the roles of different participants.

Bias: this study faced several potential biases. Selection bias may have arisen from the use of nonprobability convenience sampling in the qualitative arm, possibly favoring more accessible participants and underrepresenting isolated women. Recall bias was a concern, as self-reported contraceptive use relied on memory, which may be inaccurate for events from years past. Social desirability bias was also possible due to cultural sensitivities around contraception. Non-response bias was minimal since all eligible participants took part in the study. To mitigate these biases, the study employed community engagement to broaden recruitment, used recent timeframes (e.g. last pregnancy) for recall, conducted private interviews to reduce social pressure, and facilitated focus groups thoroughly to encourage participation.

Study size: the minimum sample size was determined using the formula [18]:

Where: n= minimum sample size required; z= standard normal deviate = (100-α/2) %=95 and =1.96 at 95% level of confidence; p= utilization of contraceptives from a previous study= 33.9 [1]; q= 1-p = 1-0.339= 0.661; d = type 1 error = 0.05; therefore n= 344. Considering non-response rate of 10%, the minimum sample size = 378; factoring out design effect of 1.433 [19], the minimum sample size = 378 x 1.433 = 541.7 = 542.

Quantitative variables

Handling: in the analysis, continuous variables were handled as follows: age, measured in years, was summarized using the mean and standard deviation and was also categorized into groups (e.g. 15-19, 20-24, up to 45-49) to facilitate analyses. Parity was dichotomized into primiparous (one birth) versus multiparous (multiple births) categories. Categorical variables, including marital status, education, income, wealth index, antenatal care (ANC) attendance, and contraceptive use, were treated as either binary or categorical variables to capture distinct groups for statistical comparisons.

Groupings: age categories aligned with reproductive age groups for interpretability. Parity was dichotomized to distinguish low vs. high reproductive experience, relevant to contraceptive needs.

Statistical methods

General methods: data was cleaned and analysed using the International Business Machines Corporation (IBM) Statistical Package for the Social Sciences (SPSS) software version 25. Univariate descriptive statistics included means and standard deviations for participants´ and partners´ ages, and frequencies and proportions for sociodemographic variables like education, shown in tables. Bivariate Chi-square tests assessed contraceptive use associations, with significance at p < 0.05. Variables with p ≤ 0.2 underwent binary logistic regression (enter method) to identify independent predictors (p < 0.05). FGD and KII recordings were transcribed, translated into English, and checked against study notes for completeness. Data was imported into NVivo 11, cleaned for errors, and formatted: main themes as heading 1, questions as heading 2, responses as heading 3. NVivo automatically coded text into main and subcodes. Data mining, including text queries and word searches, was performed. Exported reports were triangulated with quantitative findings.

Subgroups and interactions: no interactions were formally tested.

Missing data: no missing data was reported.

Sampling strategy: for the quantitative arm of the study, a multistage cluster sampling technique was used. First stage: overall, 50 nomadic Fulani settlements were selected using simple random sampling (SRS) by balloting out of the list of 63 nomadic Fulani settlements in Bade LGA. Second stage: within each selected settlement, all households were listed and assigned unique numbers. This listing was done through house numbering and household enumeration in the settlement. All eligible households within each settlement (those with at least one nomadic Fulani woman aged 15-49 years who had a delivery in the past two years) were included. Third stage: participants were selected from a sampling frame of eligible households. In households with one eligible woman, she was automatically selected. In households with multiple eligible women, one was chosen by simple random sampling through balloting.

The qualitative study used convenience sampling to select consenting, eligible participants. Four Focus Group Discussions (FGDs), each with 8-12 household heads, mothers-in-law, and women aged 15-24 and 25-49, were conducted. Three Key Informant Interviews (KIIs) involved the nomadic Fulani leader, district head, and PHC head.

Sensitivity analyses: these were not conducted, as the sample size and data completeness supported robust primary findings.

Ethical consideration: ethical approval was obtained from the Health Research Ethics Committee of Ahmadu Bello University Teaching Hospital with Data Universal Numbering System (D.U.N.S) 954524802. Permission was granted by the Bade Local Government Authority. All participants provided verbally informed consent after being informed of the study´s purpose, assured of confidentiality, and told their participation was voluntary with the right to withdraw anytime without consequences. No personal identifiers were collected, and data were stored on a password-protected computer.

Results     

Participants

Numbers at each stage: a total of 542 nomadic Fulani women were recruited for the study. All eligible participants agreed to participate in the study. All participants completed the initial data collection, and no follow-up was required as the study collected data cross-sectionally via questionnaires, FGDs, and KIIs. A total of 542 participants were analyzed for quantitative data, with additional qualitative data from FGDs and KIIs.

Reasons for non-participation: there was no non-participation. No exclusions occurred due to refusal or other reasons.

Flow diagram consideration: a flow diagram is not necessary due to 100% participation and completion.

Descriptive data

Characteristics of study participants, demographically: the participants had a mean age of 30.6 years, with a standard deviation of 8.31 years. The largest age group, comprising 130 women (24.0%), was between 35 and 39 years old. A significant majority, 493 women (91.0%), were married, and among them, 252 (51.1%) were in monogamous unions. Formal education was notably absent, with 510 women (94.1%) reporting no schooling. Clinically, most participants, 485 women (89.5%), were multiparous. Most had between two and five living children, totaling 335 women (61.8%), with an average of 4.4 children and a standard deviation of 3.0. Socially, more than half of the participants, 336 women (62.0%), had sources of income, reflecting some level of economic engagement within their communities. Considering exposure, the study found low contraceptive use, with only 64 women (11.8%) ever using contraceptives, mainly injectables (32, 50.0%). Current use was minimal, with 16 women (2.6%) using injectables (5, 35.7%) or pills (6, 42.9%). However, 173 women (31.9%) intended future use. Cultural and religious barriers, noted by 26.9%, were primary obstacles. Potential confounders included marital status, parity, maternal health knowledge, and ANC attendance.

Outcome data

Outcome events and summary measures: the primary outcome was contraceptive use (ever used, current use, and future intention). Of the 542 participants, less than a quarter (64,11.8%) had ever used contraceptives. The type commonly used was injectables, 32 (50%). Very few 16 (2.6%) were using contraceptives as at the time of data collection, and the types being used were injectables and pills, 5 (35.7%) and 6 (42.9%) respectively. More than a quarter of 173 (31.9%) of the participants had the intention of using contraceptives in the future. Cultural/religious reasons were the commonest (26.9%) reasons for not using contraceptives (Table 1). The total unmet need for contraceptive use among the participants was 76.5%, of which 61.3% was for spacing and 15.2% for limiting family size. Of these, only 2.6% were met. Overall total demand for contraceptives was high at 79.1%. Qualitative outcomes included barriers to contraceptive use, such as lack of healthcare access, cost, traditional beliefs, and transportation issues, identified through FGDs and KIIs.

Main results

Unadjusted estimates: at the bivariate analysis level, participants who were widowed (27.3%) (p=0.021), multiparous (13.0%) (p=0.023), who had good knowledge of maternal health services (25.8%) (p<0.001), and attended ANC in their last pregnancy (30.4%) (p<0.001) had significantly the highest proportions of those that ever-used family planning (Table 2).

Confounder-adjusted estimates: after adjusting for confounders at the multivariate level, ANC attendance was the only significant predictor of contraceptive use. Women who attended ANC during their last pregnancy were 5.5 times more likely to use contraceptives ( aOR = 5.5, 95% CI 2.56-11.91, P <0.001) compared to those who did not attend ANC (Table 3). The confounders were included due to their significant associations in bivariate analysis and potential influence on contraceptive uptake.

Category boundaries: in addition to age (e.g. 35-39 years) and parity (multiparous vs. primiparous), other variables were also categorized: marital status (e.g. married, widowed), education (no formal to tertiary), income source (yes/no), ANC attendance (yes/no), and knowledge of maternal health services (yes/no).

Absolute risk translation: absolute risk translation was not calculated.

Other analyses

Results of focus group discussions and key informant interviews

Contraceptive use among the participants: the use of contraceptives among the participants was poor; however, some intended to use them in the future. A participant in the husband's focus group said “......we don't allow them (i.e. their wives) to use contraceptives here".

According to a participant in the women's FGD, "I don't believe there is any family that is using contraceptives in this community......” “Even though I haven't used any before, I may do so in the future, but I'm not sure yet. I can't say when I'll know for sure", said another participant in the women's FGD.

Barriers to the utilization of contraceptive services: many nomadic Fulani settlements had no healthcare facilities. They had to travel a long distance to access healthcare. There were inadequate means of transportation. A participant among the women FGD said, “we don't have any medical services here. We normally take patients to the General Hospital Gashua when there are major difficulties. From here, it will take you up to two or three hours. It's a long way from here". Other important barriers to contraceptive use included cost, traditional beliefs, and lack of means of transportation to health care facilities.

The district head said, “you know most of them are very poor. They don´t even have what to eat. So, when they bring a woman to the hospital, they will have to go and source money elsewhere to settle the hospital bills”. The nomadic Fulani leader said, “there are those that use charm in the form of a string of beads that is worn around the waist of a woman. They believe it serves as a contraceptive”. The head of the healthcare facility said, “there is also a delay caused by a lack of means of transportation”.

Discussion     

Key results: this study offers valuable insights into four key objectives: contraceptive use, unmet need, predictors, and barriers among participants. While over a quarter intended future contraceptive use, only 2.6% were current users, well below rural (10.2%) and northeast regional (12.9%) rates reported in the 2023-2024 NDHS [5]. The dominance of injectables and pills aligns with broader sub-Saharan African trends favoring these methods for their convenience and effectiveness [19,20]. The high total unmet need highlights significant gaps in family planning access and utilization in nomadic communities.

Antenatal clinic (ANC) attendance emerged as a significant predictor of contraceptive use, reinforcing its role in counselling and raising awareness of contraceptive options. Key barriers included cultural and religious beliefs, cost, traditional perceptions, and transportation issues. These were further explored through qualitative findings, offering deeper insights into the social and economic constraints faced by participants.

Limitations: the cross-sectional study design limits establishing causality. Self-reported data may introduce social desirability bias, especially for past contraceptive use and intentions. Unlike studies on male partners´ influence in patriarchal societies [21,22]. This study did not explore these dynamics extensively. It also excluded mass media and community-based health education impacts, known to boost contraceptive knowledge and uptake [19,23].

Interpretation: the study highlights a critical gap in contraceptive access and utilization, as evidenced by the low contraceptive prevalence (2.6%) despite a substantial proportion of participants expressing future intent to use contraception. The study aligns with findings from other studies in sub-Saharan Africa, which have also identified low contraceptive use among rural populations due to cultural, religious, and logistical barriers [24,25]. However, the study´s focus on a nomadic population highlights unique barriers, such as the lack of health facilities and transportation, which are less emphasized in studies of sedentary rural populations [21,26]. The low prevalence of contraceptive use among the respondents reveals significant challenges faced in accessing and utilizing reproductive health services.

This finding of high unmet need for contraceptives aligns with a systematic review in Ethiopia, which found similarly high levels of unmet need for contraceptives [21]. The low met need for contraception, with only 2.6% of the unmet need being addressed, stressed the inadequate provision of family planning services and limited access to a range of contraceptive methods tailored to the needs and preferences of nomadic populations. Additionally, the high overall total demand for contraceptives at 79.1% indicates a strong desire for family planning services among nomadic communities in Bade, highlighting the importance of strengthening healthcare systems and implementing targeted interventions to address their unmet need for contraception.

The identification of ANC attendance as a predictor of contraceptive use aligns with findings from another study highlighting ANC´s role in promoting contraception uptake [27]. This underscores the need to integrate family planning into routine ANC and maternal health services, even in transient, hard-to-reach populations. The study also reaffirms the strong impact of cultural and religious norms, financial barriers, traditional beliefs, and transportation challenges on contraceptive behavior among nomadic Fulani. These findings call for context-specific interventions, including community-based education, contraceptive subsidies, and improved healthcare access in underserved areas.

Generalizability: the generalizability of this study relies on the sample´s representativeness and Bade, Yobe State´s sociocultural and healthcare context in Northern Nigeria. Multistage cluster sampling selected 542 women who delivered within two years, ensuring representativeness for recent mothers and reproductive-age women in similar Northern Nigerian settings. However, focusing on recent childbirth excludes contraceptive behaviors of women without recent births, adolescents, unmarried, or childless women, who face unique contraceptive challenges.

Regional variations in policies, socioeconomic conditions, and healthcare availability within Nigeria will restrict generalization beyond its Northern region. Nevertheless, the methodology provides valuable insights for rural Northern Nigerian communities and similar settings.

The study´s focus on ANC attendance as a predictor of contraceptive use highlights healthcare engagement´s role, relevant in low- and middle-income countries (LMICs) where ANC is a key healthcare contact point, but less so in high-income countries with broader contraceptive access. Despite generalizability constraints, the findings will guide policymakers in high-unmet-need regions, emphasizing ANC-based family planning counselling and addressing cost, transportation, and cultural barriers to enhance contraceptive access among nomadic Fulani and comparable populations.

Conclusion     

This study shows a low contraceptive use rate (2.6%) among nomadic Fulani women in Yobe State, Nigeria, despite high unmet need and intention to use contraception. Barriers like cultural beliefs, costs, and poor transportation limit access. Contraceptive use was higher among widowed, multiparous women with maternal health knowledge and antenatal care attendance. These findings highlight the need for culturally sensitive, community-focused strategies to overcome barriers, dispel myths, and enhance contraceptive awareness and access. Integrating family planning into maternal health services, especially antenatal care, and strengthening healthcare systems are crucial. Tailored interventions should involve community leaders, healthcare providers, and stakeholders to address nomadic populations. Future longitudinal studies should examine causal relationships and intervention effectiveness, while expanding research to other nomadic groups will enhance findings´ applicability, improving reproductive health outcomes.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Nuru Suleiman Muhammad and Tukur Dahiru designed the research, methodology, and data collection. Nuru Suleiman Muhammad, Tukur Dahiru, Abdulhakeem Abayomi Olorukooba, Danimoh Mustapha Abdulsalam, Aishatu Attahiru, and Abdullahi Shehu contributed to drafting, reviewing, and editing the manuscript. All the authors read and approved the final version of this manuscript.

Acknowledgments     

This research relied on the invaluable contributions of many. We sincerely thank our dedicated research assistants for their critical role in data collection. We are grateful to the Bade Local Government Area and opinion leaders for enabling access to participants and navigating the community. We also appreciate all others who supported or guided us throughout the process.

Tables     

Table 1: utilization of contraceptives among participants, Bade, Yobe State, Nigeria, 2022

Table 2: bivariate analysis of contraceptive use among participants, Bade, Yobe State, Nigeria, 2022

Table 3: logistic regression analysis of contraceptive use among participants, Bade, Yobe State, Nigeria, 2022

References