CHAPTER TWO

REVIEW OF RELATED LITERATURE

2.1 Concept of family planning
In the olden days when man’s needs were fundamental and was limited to food, shelter, and with little clothing
available, birth control in the form of family planning was not necessarily needed, although birth control then was
done by marring more than one wife and the planning of the family is done by not getting the wives pregnant at the
same time (Bayray, 2016). Birth control was done and achieved by total abstinence from sexual intercourse. Currently,
some facilities are fast becoming a nuisance and perhaps, the inevitable blame of our society, the increasing waves of
abandoned children is now sending ripples to the spine of many concerned mothers. Today, the rate at which husbands
abandoned their families on the excuse of unwanted pregnancies is very alarming, recent studies indicates that the
large percentage of juvenile delinquents came from families which are usually large than the parents are able to care
for properly. This fact calls for the need for family planning (Felix, 2018).
According to the World Health Organization (WHO), family planning is defined as “the ability of individuals and
couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is
achieved through use of contraceptive methods and the treatment of involuntary infertility” (working definition used
by the WHO Department of Reproductive Health and Research [WHO, 2008]). Family planning is usually used as a
synonym for the use of birth control. It is most adopted by couples who wish to limit the number of children they want
to have and control the timing of pregnancy, also known as spacing of children (Hassan, 2019). Melissa (2017) sees
birth control as the method of regulating and taking control of the number of birth couples wanted in their marital life
without producing like fowl. Williams (2012) defined birth control as limitation of child bearing through a modern
means called contraception. In the view of Reynolds et al. 2017, birth control is the volitional limiting of human
multiplication, employing such measures as contraception, sexual abstinence, surgical sterilization and induced
abortion. Bryan, Christine, Barbara and William (2005) view birth control as any way of forestalling birth from
occurring. Family planning is the planning of when to have and use birth the commonly used technique include sexual
education, prevention and management of sexually transmitted diseases, pre-conception counseling, management and
infertility management (Olaitan, 2015). According to Ezugwu and Omeje (2010), family planning means having the
number of children that one can afford to bring up well. The authors affirmed that family planning is birth line by
preference either for the purpose of spacing pregnancy or for limiting family size. This therefore clarities that family
planning is important to individuals, as well as to families, communities, and societies (AGI, 2003) serving three
critical needs such as: helping couples avoid unintended pregnancies, reduces the spread of sexually transmitted
diseases (STDs); and by addressing the problem of STDs, it helps reduce rates of infertility. Family planning provides
protection from Sexually transmitted Diseases (WHO, 2019). Where contraceptive use is widespread fertility is low.
Rajaretnam (2015) has demonstrated that even if there is no reduction in the family size of individual couples,
delaying child bearing will bring about a decline in fertility and population growth rate.

2.2 Types of family planning

When it comes to family planning, there are many options to choose from. As a result, it can be challenging to select
the best approach for your situation. By reviewing the pros and cons of each method, though, you can make an
informed decision. Here is a brief guide to the five main types to get you started (Planned Parenthood Federation of
America, 2023; Stoppler & Balentine, 2023; Bhagat, n.d. 2015)

1. The Barrier Approach

This form of birth control blocks the sperm from reaching the egg, thereby preventing fertilization. Examples include
male and female condoms, diaphragms, cervical caps, and spermicidal foam. These methods are only used during
intercourse. (Planned Parenthood Federation of America, 2023)

2. Hormonal Approach

Hormonal birth control inhibits the ovaries from releasing eggs. When there is no egg for the sperm to fertilize,
pregnancy cannot occur. Common hormonal approaches include the pill, patch, and vaginal ring. Hormonal implants
and injections are also available (Stoppler & Balentine, 2023)
 3. IUDs

There are two kinds of intrauterine devices (IUDs): hormonal and copper. Both are implanted into the uterus and
prevent pregnancy by keeping sperm from reaching the egg. Hormonal IUDs stop the ovaries from releasing eggs and
thicken cervical mucus to impede sperm. Copper IUDs release copper ions into the cervix, making it an
inhospitable environment for sperm (Bhagat, n.d. 2015)

4. The Rhythm Method

Couples who rely on the rhythm method avoid having intercourse when the woman is most likely fertile. An average
woman who menstruates regularly can theoretically only get pregnant for a few days every month. Since many factors
affect ovulation, though, this approach is less reliable than the others.(Bhagat, n.d. 2015)

5. Surgery

Men who want a permanent form of birth control can undergo a vasectomy, which keeps the semen free of sperm.
Likewise, women can opt to undergo a tubal litigation, which prevents eggs from moving through the fallopian tubes
to the uterus. (Stoppler & Balentine, 2023)

2.3 Methods of Family Planning

The methods of birth chosen have to suit the lifestyle, age, state of health, the need to avoid pregnancy and peculiar
relationship in the family. Thus, before choosing a birth control method, there is a need to assess the acceptability,
effectiveness and side effects of the methods. Family planning or birth control methods are the deliberate limit of the
number of children to be born by couples (Olujide et al., 2013). However, scholars (Bryan et al., 2005) identified
modern birth control methods and traditional birth control methods. Modern family planning methods are further
categorised into three subgroups: short-term methods (the pill, condoms, the lactational amenorrhoea method (LAM),
diaphragms, foaming tablets, jelly, and the emergency contraceptive pill), long term methods (injectables, implants
and IUDs) and permanent methods (female and male sterilisation). Traditional methods consist of periodic abstinence,
withdrawal, and various folk methods such as strings and herbs.

1. Traditional Method of Family Planning

The traditional method of family planning have been in existence before the advent of the modern family planning
programme all over the world. They are non-modern, culturally rooted practices passed down through generations.
It is the congenital method of controlling birth. The traditional methods according to Ebizie (2018) prolonged
breastfeeding, post-partum abstinence, the use of ring, waist band etc. Traditional methods include the following;

i. Abstinence
Abstinence is the act of avoiding sex, whether sexual contact altogether or just intercourse. This method of family
planning is the only one that is 100 percent effective in preventing pregnancy and protecting against sexually
transmitted diseases (STDs). Abstinence can be difficult to maintain and allows for little spontaneity (Afriyie &
Tarkang, 2019).

ii. Birth Control Ring

The small, flexible birth control ring is placed in the vagina, where it releases a steady supply of progestin and
estrogen hormones. The ring stays in the vagina for 3 weeks, after which it is discarded. The ring is over 99 percent
effective when used as prescribed. The ring may cause unwanted side effects such as nausea and weight gain (Bayray,
2016).
Other traditional methods includes:
iii. Herbal remedies: these have to do with the use of local concoctions believed to prevent pregnancy.
iv. Breastfeeding practices (extended lactational amenorrhea, though this overlaps with natural methods).
v. Amulets or charms worn for protection against conception.
vi. Withdrawal (Coitus Interruptus) – in this method, the man withdraws before ejaculation.

2. Modern Family Planning Method

The modern method is the artificial methods of controlling birth. Modern methods include the use of contraceptive
devices (Bryan et al., 2005). The modern family planning methods according to Ebizie (2018) are as follows:
i. Birth Control Pills
This methods of pill control causes temporary menstrual suppression, injectable hormones, a vaginal ring and a patch
(Brayan et al., 2005). Many types of birth control pills are on the market. Pills keep a woman’s ovaries from releasing
eggs, thus preventing fertilization. Birth control pills are 95 percent effective with standard use.
The mini pill contains only progestin, while the combination pill contains both progestin and estrogen. Women who
take these forms of the pill must be sure to take it at the same time each day or risk getting pregnant (Gertner, 2019).
ii. Condoms
Condoms are thin latex coverings that form a barrier between sperm and the vagina. When used as indicated, condoms
are 95 to 97 per cent effective in preventing pregnancy and have the added bonus of protecting against STDs. Female
and male varieties are available, and they come in a wide range of colours and styles (Joseph, 2019).
iii. Fertility Awareness
This is also known as natural family planning. They are scientifically recognized, non-medical methods that rely on
understanding the woman’s fertility cycle. Fertility awareness is the act of abstaining from intercourse on a woman’s
fertile days, when she is most likely to become pregnant. To follow this method, women need to accurately and
precisely chart their fertility, either through basal body temperature changes or changes in cervical mucus, or by
following the calendar (Felix, 2018).
iv. Intrauterine device (IUD)
An intrauterine device (IUD) is a small copper or plastic device inserted into the uterus that creates a hostile
environment for sperm. Some IUDs release small amounts of hormones. IUDs last from 5 to 12 years and are an
effective method of birth control but should only be used by women in monogamous relationships who have already
given birth (Kabagenyi, Reid, Ntozi, & Atuyambe, 2016).
v. Spermicidal cream
Spermicidal cream or tablet kills spermatozoa. A woman applies such a cream or tablet right inside the vagina 5-10
minutes before sexual intercourse. During ejaculation by the man, the spermatozoa discharge is killed by the
spermicide, hence pregnancy is prevented. This method is not very reliable except it is used with a condom (Joseph,
2019).
vi. Surgery
Women and men can be sterilised. In women, tubal ligation is performed to cut off the fallopian tubes so eggs cannot
be released into the uterus for fertilization. Men have a vasectomy, where the tubes that carry sperm are blocked.
Sterilization is nearly 100 per cent effective but should be considered a permanent decision. Once you have decided to
use family planning, you must choose a method. To make a good decision you must first learn about the different
methods, and their advantages and disadvantages (Kabagenyi et al., 2016).
2.4 Cultural belief and health practices
Cultural belief practices encompass many rituals, conventions, and traditions handed down from generation to
generation. these behaviours unite society and shape identity. Religion, art, language, and social
interactions saturate everyday life. These activities also reflect a community's faith, history, and worldview
(Salmorin and Gepty, 2023). Cultural belief is a group's common values, customs, and actions which include:
religion, morality, ethics, and social values. Ogunyemi (2018) noted that many indigenous cultures believe in the
interconnectedness of all living things and the need to cohabit harmoniously with nature.

Additionally, cultural concepts may impact people's self-image and identity. Several indigenous cultures employ
storytelling and oral traditions to preserve and transmit history and knowledge (Bordoloi, 2015). These tales teach life
lessons and build a feeling of ancestral connectedness. These practices often promote continuity and affiliation, which
may vary by culture. Diwali, the Hindu festival of lights, celebrates virtue over evil (Yu, & Stoet,
2019).

Healthcare practice refers to how much people utilize healthcare services to stay healthy. This notion matters
in public health and healthcare systems. Personal traits, healthcare system issues, and socioeconomic variables affect
healthcare service seeking, use, and decision-making. It includes health promotion, maintenance, and repair and
is essential to human civilization. Many activities, services, and systems enhance health and fight disease
(World Health Organization, 2015). Healthcare is an essential human right that benefits individuals and society.

There are scholarly researches that explored factors affecting healthcare utilization. For instance, Moonpanane et al
(2022) conducted a study to understand healthcare service utilization of hill tribe children in underserved communities
in Thailand. The study found that barriers to access was the central theme identified. Other themes included distance
matters, education and socioeconomic deprivation, lack of cultural sensitivity, communication problems, tradition,
beliefs, and differences in cultural practice, lack of child health professionals, and bureaucratic hurdles. Mochache et
al (2020) in their study found that religious and socio-cultural norms as well as gender stereotypes were important
influences on the uptake and utilization of maternal health services, including facility-based delivery and
contraception. Key amongst this was the unspoken deference to the counsel of a prominent matriarchal figure in the
decision-making process.

Cultural beliefs are deeply embedded in the social fabric of communities and strongly influence health practices,
including reproductive health and family planning. Cultural norms and traditions shape how women perceive fertility,
motherhood, and contraceptive use. These beliefs often determine whether family planning services are accepted,
rejected, or modified to fit local expectations.

1. Fertility as a Cultural Value

In many Nigerian communities, having many children is seen as a sign of wealth, prestige, and continuity of lineage.
Women may face pressure from families and society to avoid contraceptives, as limiting births is perceived as going
against cultural expectations. This belief directly affects the utilization of family planning services at PHCs, as women
may prioritize cultural approval over medical advice.
2. Traditional Health Practices
Some women rely on traditional methods of birth control, such as herbal remedies, charms, or prolonged postpartum
abstinence, believing these are safer or more culturally acceptable. These practices, though culturally significant, are
often less effective compared to modern contraceptives, leading to unintended pregnancies.
3. Religious and Spiritual Beliefs
Religious teachings often strengthen cultural norms by disapproving the use of modern contraceptives, outlining them
as interference with divine will. Women may prefer prayer or spiritual rituals over biomedical family planning
methods, which influences health-seeking behavior.
4. Gender and Social Influence
Men and elders play a dominant role in reproductive decisions. Women may decide not to embark on family planning
services if their husbands or community leaders refuse to approve the idea, even when they personally willing to make
use of contraceptives.
5. Misconceptions and Myths
Cultural narratives often spread myths about contraceptives, such as fears of infertility, cancer, or permanent damage
to the womb. These misconceptions discourage women from utilizing modern methods offered at PHCs, despite
awareness campaigns.

2.5 Influences of culture on family planning decision

Some of the factors influencing the choice of family as highlighted by Ogbozor, N. C. (2024) are explained below:
1. Pronatalist Values
Most of the local communities in Nigeria consider having many children as a sign of prestige, wealth continuity of
family lineage. As a result, women may cease from taking contraception to control birth in order not to go against
the expectation of the society which often regard the use of modern contraceptive as taboos
2. Religious Beliefs

Religious leaders’ opinions strongly influence community attitudes toward family planning. Most of them regard the
the use of contraceptive to control birth as interference to divine directive

3. Gender Dynamics
Cultural and family barriers to family planning may influence women's decision to use contraceptives for example, a
husband may disapprove of the use of contraceptives because he wants more children or the concern about health
effects bothers him, or maybe he is convenience and distrustful to traditional methods such objectives may reflect
information in or access issues or health concern, except for a woman personal opposition to contraceptives (Charles,
2017).
 4. Traditional Health Practices

Dependence on traditional methods contributes to unintended pregnancies because some women rely on herbal
remedies, charms, or prolonged postpartum abstinence as culturally acceptable methods of birth control. These
practices, though culturally significant, are less effective compared to modern contraceptives.

5. Misconceptions

Cultural narratives more often spread misconception about contraceptives which is the effective way of exhibiting
birth control. They are always of the opinion that the use of contraceptives may result to infertility, cancer, or
permanent damage to the womb. This can go a long way in militating against the use of contraceptive in birth control

6. Community Influence
Family members, peers, and community leaders play a major role in shaping women’s decisions on whether to adopt
family planning. Community stigma against contraceptive use often discourages women from accessing PHC services.

2.6 Benefit of family planning

Family planning is a fundamental aspect of public health that enables individuals and couples to anticipate and attain
their desired number of children and the spacing and timing of their births. This is achieved through the use of various
contraceptive methods and the treatment of involuntary infertility (Adeyemi & Ogunleye, 2019).While the term
“family planning” is often used synonymously with birth control, family planning is more than just about using
contraception. From providing sexuality education to reproductive healthcare services, it poses numerous benefits for
the wellbeing of both mother and child, as well as for the family and their community at large. Dr Jen ShekWei (2024)
highlighted some of the benefit of family planning as follows:

1. Family planning promotes maternal health

The Family Planning program plays an important role in efforts to reduce maternal and child mortality by providing
access to various safe and effective contraceptive methods. By using contraception, married couples can plan
pregnancy better, so that the pregnancy that occurs is the desired and planned pregnancy (Memon et al.,
2023). This helps reduce the risk of unwanted pregnancies which often lead to unsafe abortions, which is one of
the main causes of high maternal mortality rates. The Family Planning program is one of the most effective
and multifaceted public health interventions in an effort to reduce maternal and child mortality rates and improve the
quality of life of the family as a whole.(El-Shal et al., 2023).

2. Family planning promotes the long-term health and wellbeing of newborn babies.

Family Planning programs also play a role in improving children's welfare by reducing the rate of unplanned births.
Children born into families who are physically, mentally and financially prepared tend to have better access to
nutrition, health care and education (Hastuti et al., 2022). This is important to reduce child mortality, especially in the
toddler years, where access to good care and nutrition is critical for survival and growth.

3. Family planning is one of the best ways to prevent unplanned pregnancy

Family Planning programs give women complete control over her reproductive health and activities, allowing her to
delay pregnancies for as long as she wishes or when necessary. As a result, family planning reduces the need to
undergo abortion surgery. The ability to time and space children reduces maternal mortality and morbidity by
preventing unintended and high-risk pregnancies (World Bank, 1993; Cleland et al., 2006). Family planning plays a
fundamental role in improving public health by reducing unintended pregnancies, which directly contributes to
lowering maternal and infant mortality rates. Goossens et al. (2018) suggest that well-planned pregnancies allow
women to maintain their health before, during, and after childbirth, minimizing medical complications and increasing
the likelihood of healthy births.

4. Family planning is beneficial for families financially and assist in the improvement in economic activities:
Family Planning program takes into consideration the parents’ capability to provide for their children’s present and
future needs, including the medical costs of pregnancy and delivery, up to the child’s education, food, clothing,
shelter, etc. Couples can then make an informed decision on how many children they can have based on their current
income and lifestyle. Family planning is crucial in reducing poverty and enhancing social mobility by providing
families with more significant economic opportunities (Banks, 2024). Research suggests that families with controlled
birth rates can allocate resources more effectively, leading to improved financial outcomes. Additionally, a study by
Dang & Rogers (2016) in Vietnam demonstrated that smaller family sizes allow for increased investment in each
child's education, thereby enhancing human capital development. The ability of a family to maintain financial security
directly affects its capacity to provide for children's education, healthcare, and future economic opportunities
(Friedline et al., 2021). Couples who are able to plan their families experience less physical, emotional, and financial
strain; have more time and energy for personal and family development; and have more economic opportunities
(Cleland et al., 2006). Family planning is crucial in enhancing household economic stability by enabling families to
allocate resources more efficiently. Studies indicate that smaller family sizes contribute to higher per capita income,
allowing parents to invest more in their children's education and future opportunities (Laszlo et al., 2024).

5. Family planning is beneficial for women with career prospect

Studies show that women who practice family planning can invest in their .careers and contribute significantly to the
national economy (Vladislav et al., 2024). This empowerment, in turn, enhances family welfare and can have long-
term benefits for communities, reducing economic disparities.

6. Family planning prevents the spread of HIV/AIDS and other sexually transmitted diseases (STDs) through the
use of contraceptives such as male and female condoms.

Family planning program provides men and women living with HIV/AIDS and STDs with the healthcare services they
need to prevent unplanned pregnancies. Family planning counseling for women living with HIV prevents mother-to-
child transmission and reduces HIV spread by promoting contraceptive use (BMC Public Health, 2013). Also, Family
planning empowers women and plays a significant role in HIV prevention in low-income countries (World Journal of
Pharmaceutical and Medical Research (2025)

7. Family planning fosters good relationships between members of the family.

A manageable family size ensures that parents are able to give adequate time and attention for each child and each
other. At the same time, the individual needs of the children will be met accordingly and timely. Families with strong
financial foundations and effective family planning strategies tend to experience lower levels of financial anxiety,
leading to improved mental health and stronger familial bonds (Price et al., 2010).

8. Family planning aids in population planning and control.

Family planning contributes to pollution control by stabilizing population growth, which reduces the strain on natural
resources and lowers the volume of waste generated by households and industries. When families are smaller, there is
less demand for energy, housing, transportation, and food production, all of which are major sources of air, water, and
land pollution. By preventing rapid population expansion, family planning helps governments and communities
manage urban growth more effectively, ensuring that sanitation systems, waste management facilities, and
environmental protections are not overwhelmed. It also supports conservation efforts, since fewer people competing
for land, forests, and water reduces deforestation, soil erosion, and water contamination. In the long run, family
planning indirectly lowers greenhouse gas emissions, mitigates climate change, and promotes sustainable development
by aligning human population size with the earth’s carrying capacity. The United Nations Population Fund (2002)
explained that family planning and population stabilization are essential for sustaining ecosystems and reducing
human-driven pollution, whereas Sage Journals (2023) highlighted that empowered, smaller families contribute
positively to environmental sustainability. More recently, Lee (2025) argued that family planning supports sustainable
community development by reducing population pressure and environmental degradation. These perspectives show
that family planning is not only a health intervention but also a critical environmental strategy for pollution control
and sustainable growth ;which leads to positive community development, effective conservation and distribution of
natural resources, more jobs, sufficient number of schools and healthcare and sanitation facilities, and other economic
and environmental benefits.

2.7 Hindrances of family planning

Despite growing awareness of contraceptive methods, the actual utilization of family planning services remains low in
many Nigerian communities, especially among women of reproductive age. Several studies attribute this discrepancy
to a variety of factors, including cultural beliefs, religious opposition, limited access to health facilities, and low levels
of education (Adepoju, 2018; Mba, 2020). Ikogho (2022) further emphasized that sociocultural resistance,
misinformation, and gender norms continue to undermine reproductive health interventions in numerous regions as
witness in Afaha-Offong. Religious norms also play a pivotal role in shaping attitudes toward family planning.
Odimayomi and Ikogho (2025) reported that religious ideologies significantly influence the perceptions of educators,
leading to both passive and active resistance to the implementation of family planning programs. Moreover, the
societal expectation of large family sizes, especially in rural communities, often discourages contraceptive use. Ikogho
and Onoharigho (2025) observed that issues such as the culture of silence surrounding reproductive health and
menstruation contribute to the lack of open dialogue, which in turn affects decision-making regarding family planning

Additionally, economic and infrastructural limitations have been identified as major barriers to the uptake of family
planning services. Adebayo et al. (2017), Ikogho and Igbudu (2013) noted that the cost of contraceptives, coupled
with the unavailability of trained personnel and facilities, particularly in underserved areas, remains a persistent
challenge. This is supported by the findings of Ikogho and Onoharigho (2025) who revealed that inadequate hygiene
infrastructure and poor access to health education in primary schools reflect broader systemic issues that hinder
reproductive health service delivery.

From the forgoing some of the barriers of family planning are explained as follows:

Cultural influences: One significant challenge is socio-cultural resistance. In many cultures, particularly in traditional
and religious communities, the use of contraception is viewed as contrary to social or spiritual beliefs, which can
result in a low adoption rate of family planning methods. Community beliefs and norms relating to health care seeking
behaviour are reflected in individuals’ decisions which are based, to some extent, on how the community views their
actions (Rutenberg & Watkins, 1997). Community beliefs concerning childbearing preferences and sexual and
reproductive health behaviour are a strong influence on individual attitudes towards family planning and fertility
preferences (Greenwell, 1996). In addition, Goodburn and her colleagues (1995) note that in many cultures, the use of
reproductive health services is an alien concept, because services are perceived as existing solely for curative
purposes.

Cost of accessing the service: cost has been shown to be a barrier in service use (Bloom et al., 1999; Griffiths &
Stephenson, 2001) and it also influences the choice of source from which care is sought. In a study of the use of
antenatal care in India, Griffiths and Stephenson (2001) show that although women perceive private services to offer
greater quality care, the cost of such services often makes them unaffordable.

Socio-economic: Socio-economic indicators such as urban residence (Addai, 1998), household living conditions
(Bloom et al., 1999; Magadi et al., 2000) and employment status have also proven to be strong predictors of a
woman’s likelihood of using reproductive health services.

Lack of personnel: The absence of trained healthcare professionals and inadequate supply chains also hinders the
effectiveness of family planning programs (Atuhaire et al., 2023).

Additional barriers for adolescents may include community disapproval of their use of family planning, stigma related
to obtaining contraceptives, lack of knowledge about the existence of publicly funded clinics, a perceived lack of
affordable services, ambivalence, a history of sexual abuse, and fears of side effects (Frost and Kaeser, 1995; Brindis
et al., 2003). Other hindrances may include Lack of awareness of the availability of services, and perceived or real
cost barriers can constitute a major barrier to family planning utilization (Bertrand et al., 1995; Brindis et al., 2003).
Women in rural areas may have particular difficulty finding and obtaining family planning services (Frost et al.,
2001). Some special populations, such as homeless women (Wenzel et al., 2001) and those who are incarcerated, may
be especially likely to face access and cost barriers.

2.8 Strategies for Family Planning Methods Utilization

The strategies to improve the practice of family planning include; linking community members and removing
unnecessary cultural values that affect the utilization of family planning services, informing couples about the
importance of family planning choices to improve their reproductive health behaviour, as the community accepts the
preaching of religious leaders, the health extension works should make good communication with them, provision of
adequate health education by caregivers to clients and family in the community to expand their knowledge of family
planning to ensure adequate child spacing and reproductive health (Kelechi, & Catherine, 2016).
Counselling in religious institutions to propagate the knowledge of family planning and encourage the utilization of
the services by their members to enhance their reproductive health. Men play an active part in their family’s decision-
making, therefore healthcare providers should educate men on the benefits of family planning services to enhance its
acceptance and utilization among women of reproductive age. Lastly, the public enlightenment on family planning
services through the mass media, as it is the largest means of dissemination of information.

The main strategies for family planning going forward should be to:
(a) Expand the basket of contraceptives: this has to do with; giving choice to couples of contraceptive methods,
informing the users, making available competent instructors, maintaining client/provider relationship (Kentos, 2019).
(b) Expand the access, both financial and physical acceptance of contraceptives: this has to do with; providing cost-
effective contraceptive, more sales outlets for easy accessibility, re-contacting and follow-up mechanisms, an
appropriate constellation of services with proper Information Education and Communication (IEC) and Interpersonal
Communication Programs (IPC) programmes, and encouraging new acceptors, retaining current users and increasing
contraceptive use should increase couple years of protection and contraceptive prevalence (Ndiritu, 2021).
(c) Increase knowledge and awareness of providers and acceptors: this relates to; effective IEC and IPC programmes,
giving out methods for free access or at a reduced price, or giving incentives could encourage more people to become
new acceptors, getting men involved, it would be important to emphasize the “healthy family” aspect of family
planning, and that spacing between children is good for the whole family, economically speaking and also in terms of
health, and training providers in counselling and technical procedures should increase the level of knowledge around
family planning. This knowledge, in turn, should translate into increased contraceptive use (Otieno, 2016).

2.9 Empirical Framework

There are scholarly researches that explored cultural factors affecting family planning and healthcare utilization. For
instance, Mochache et al (2020) in their study found that religious and socio-cultural norms as well as gender
stereotypes were important influences on the uptake and utilization of maternal health services, including facility-
based delivery and contraception. Key amongst this was the unspoken deference to the counsel of a prominent
matriarchal figure in the decision-making process. Also, Ugochukwu T. Ugwu1* & Chiemerie O. Okpala (2024)
conducted a study on cultural beliefs and healthcare utilization in anambra state, nigeria The study adopted a mixed-
methods research design. And it involves the collection and analysis of data via quantitative and qualitative methods.
The study found a connection between cultural beliefs and healthcare utilization, often leading to delayed treatment,
reduced access to preventive services, and poorer health outcomes. The reliance on traditional medicine, coupled with
religious practices and gender norms, creates significant barriers to the effective use of modern healthcare services.

Felix (2018) evaluated socio-cultural strategies to improve the practice of family planning in Nigeria. The study
utilized secondary data. The data was sourced using interviews and online surveys. The study employed correlation as
a method of data analysis. The study revealed that there is a positive relationship between socio-cultural factors such
as attitudes, childbearing practices, cross-cultural differences, cultural deprivation, cultural identity, culture change,
language, level of education and family planning in Nigeria.

Chinenye Ifeoma Ogidi1, et al (2019) investigated the knowledge level and use of birth control methods by married
people for family planning in Nsukka Education Zone of Enugu state. descriptive survey design was used in the study
since the researchers were interested in investigating a large number of people and it provided the researchers with the
opportunity of gathering data from a significant number of the population to enable favourable generalization about
the entire [Link] population of this study comprised 4450 married people who registered for marriage from
2010 to 2017 in Nsukka Education Zone of Enugu State. Based on the data presented and analyzed it was discovered
that married people have knowledge of birth control. The result also, established that both males and females married
people make use of birth control methods of family planning with condom being the most common method for males.
It was also established that a few family planning agencies cause problem in the use of birth control methods for
family planning methods.

Daniel (2019) assessed the socio-cultural factors influencing the practice of family planning in Nigeria. The study
utilized descriptive statistics as a method of data analysis on secondary data. The study revealed that religious
believers or observers might choose to avoid certain methods of family planning, such as birth control pills, in an
effort to live their lives according to the teachings of their religion Some religions, such as Catholicism, have
restrictions on contraception based on the belief that it is God’s will to bring children into the world. The larger the
differences in reproductive intentions within a community, the more likely the community norms support individual
choices.
Research by Ogbozor (2024) revealed that pronatalist values and religious doctrines remain powerful determinants of
contraceptive use, with many women perceiving fertility as a source of prestige and family continuity. Using a
descriptive survey design and structured questionnaires, the study found that despite high awareness of contraceptive
methods, cultural opposition significantly reduced uptake.

Similarly, Ugbede, Owoyemi, Gomment, and Yunusa (2024), through a cross-sectional survey that employed both
interviews and questionnaires, highlighted the role of male dominance in reproductive decision-making and the
persistence of myths about contraceptives as barriers to family planning among women. Their findings underscore the
importance of gender dynamics and community narratives in shaping reproductive health behavior.

Other studies have emphasized the reliance on traditional health practices as a culturally acceptable alternative to
modern contraceptives. For example, Samphina Academy (2023), using a case study approach with questionnaires and
focus group discussions, documented that women often resort to herbal remedies, charms, or prolonged postpartum
abstinence, which are deeply rooted in cultural traditions but less effective in preventing unintended pregnancies.
Akinyemi and Adedokun (2019), using a mixed-methods approach that combined structured questionnaires with
in-depth interviews, found that cultural taboos and male partner disapproval were major barriers to contraceptive
uptake among women in Southwestern Nigeria. Their findings highlight how cultural expectations around fertility and
gender roles directly shape reproductive health behavior. Similarly, Isiugo-Abanihe (1994), through survey research
involving married couples, revealed that male dominance in reproductive decision-making significantly reduced
women’s autonomy in family planning choices, a pattern that continues to resonate in contemporary Nigerian society.

Ezeh (1993) also contributed to this body of evidence by examining fertility preferences and contraceptive use in
Nigeria through quantitative surveys. His findings showed that cultural preference for large families and male
authority were key barriers to contraceptive adoption. International evidence from the World Health Organization
(2020), based on secondary data analysis of demographic health surveys, reinforced these observations by identifying
cultural opposition, gender roles, and misinformation as consistent barriers to contraceptive uptake across sub-Saharan
Africa. Also, Ozumba (2018) examined the socio-cultural strategies affecting the practice of family planning in
Nigeria. The study employed secondary data. The data was sourced from an online survey. The study utilized
descriptive statistics for data analysis. The result showed that a low rate of contraceptive use, such as withdrawal
methods, pills, abstinence and sterilization particularly in the northern and rural areas of Nigeria was a key cause of
high fertility rates.

Taken together, these empirical studies demonstrate that cultural beliefs, religious norms, gender dynamics, traditional
practices, and misconceptions are persistent determinants of family planning utilization. They provide a strong
foundation for the present study, which seeks to explore how these factors manifest among women attending
Afaha-Offong PHC in Nsit Ibom LGA. By situating the research within this empirical framework, the study builds on
existing evidence while addressing a specific local context where cultural norms continue to shape reproductive health
practices.

2.10 Theoretical framework

Health Belief Model (HBM)

The health belief model (HBM) is a psychological health behavior change model developed to explain and predict
health-related behaviors, particularly in regard to the uptake of health services. The health belief model suggests that
people’s beliefs about health problems, perceived benefits of action and barriers to action, and self-efficacy explain
engagement (or lack of engagement) in health-promoting behavior. A stimulus, or cue to action, must also be present
in order to trigger the health-promoting behavior. The health belief model (HBM) is a theoretical and foundational
framework in health behavior research. It was conceptualized in the 1950s by Urwin Rosenstock, Hochbauim,
Stephen, and Howard and was amplified by Rosenstock (1990). This theory can be used to explain and predict
individual changes in health behaviors. It is one of the most widely used models for understanding health behaviors.
Key elements of the Health Belief Model focus on individual beliefs about health conditions, which predict individual
health-related behaviors. The model defines the key factors that influence health behaviors as an individual's perceived
threat to sickness or disease (perceived susceptibility), belief of consequence (perceived severity), potential positive
benefits of action (perceived benefits), potential barriers to action (perceived barriers), exposure to factors that prompt
action (cues to action), and confidence in ability to succeed (self-efficacy). This study applied the Health Belief Model
(HBM) to contraceptive behavior in Nigeria, showing how perceptions of risk, benefits, and barriers influence
willingness to use family planning. Rosenstock (1990) observed that the health belief model identified four categories
of beliefs which are essential determinants of health behaviour. They include perceived susceptibility, perceived
severity, perceived benefits and perceived barriers.

Perceived susceptibility, according to Rosenstock (1990) assesses the probability of acquiring an illness or
encountering an undesirable outcome. For instance, the individual susceptibility to viral infection increases if in a
crowded public space during a respiratory pandemic. Individuals vary widely in their feelings of personal vulnerability
to a condition (in the case of medically-established illness, this dimension has been reformulated to include such
questions as estimates of susceptibility, belief in the diagnosis, and susceptibility to illness in general’). Thus, this
dimension refers to one’s subjective perception of the risk of contracting a condition. If women believe they are not at
risk of pregnancy (e.g., due to cultural myths like “breastfeeding prevents pregnancy”), they may avoid family
planning on the other hand, women who recognize their susceptibility are more likely to seek contraceptives.

Janz and Becker (1994) referred to perceived severity as the severity of the illness, condition, or unfavorable outcome
and what could happen if no additional action is taken. There is a considerable range in how people perceive the
severity of an illness, and they often consider both the medical and social implications when assessing its severity. The
COVID-19 pandemic is an excellent example, with a wide range of behaviors based on differing perceptions of the
consequences of becoming infected. Feelings concerning the seriousness of contracting an illness (or of leaving it
untreated) also vary from person to person. This dimension includes evaluations of both medical/clinical
consequences (e.g., death, disability, and pain) and possible social consequences (e.g., effects of the conditions on
work, family life, and social relations). Some women may see frequent childbirth as a blessing or cultural expectation,
reducing perceived severity, whereas, many may recognize health risks (maternal mortality, economic strain) and
decides to opt for the service of family planning.

Perceived benefits according to Janz and Becker (1994) refer to the benefits from projects like the provision of
adequate water supply and sanitation which reduce the risk of diseases associated with water supply and sanitation.
They argued that people are more likely to participate in programmes such as the provision of portable water supply
and sanitation if they believe that such programme will enhance their health. While acceptance of personal
susceptibility to a condition also believed to be serious was held to produce a force leading to behavior, it did not
define the particular course of action that was likely to be taken; this was hypothesized to depend upon beliefs
regarding the effectiveness of the various actions available in reducing the disease threat. Thus, a “sufficiently
threatened” individual would not be expected to accept the recommended health action unless it was perceived as
feasible and efficacious. Women, in most cases who believe contraceptives can improve maternal health, reduce
financial burden, and allow better child spacing are more likely to seek for the service. But when cultural belief such
as “the use of contraceptives cause infertility” sets in the distortion of perceived benefits becomes sure thereby
lowering its acceptance.

Perceived barriers are the obstacles to performing a recommended health action that may stop one from doing what is
recommended. Examples include the availability, perceived social implications, or discomfort associated with wearing
a respirator during a respiratory infectious disease outbreak. The potential negative aspects of a particular health
action may act as impediments to undertaking the recommended behavior. A kind of cost benefit analysis is thought to
occur wherein the individual weighs the action’s effectiveness against perceptions that it may be expensive, dangerous
(e.g., side effects, iatrogenic outcomes), unpleasant (e.g., painful, difficult, upsetting), inconvenient, time-consuming,
and so forth. Cultural taboos, religious opposition, fear of side effects, and lack of spousal approval are common
barriers that can hamper women decisions towards contraceptive usage

Social Cognitive Theory (SCT)

The Social Cognitive Theory (SCT) was propounded by Albert Bandura in 1986, a Canadian-born American
psychologist, when he published his book Social Foundations of Thought and Action. The theory is a general theory
that stresses learning from the social environment from its early focus on observational learning through modeling,
social cognitive theory has expanded in scope to address such processes as motivation and self-regulation. Bandura's
social cognitive theory postulates reciprocal interactions among personal, behavioral, and social/environmental
factors. Researchers in this tradition have investigated the operation of vicarious, symbolic, and self-regulatory
processes, in the various ways that individuals interact with their environments and one another. A key point is that
persons seek to develop a sense of agency for being able to exert a large degree of control over important events in
their lives. Among the influential variables affecting one's sense of agency are self-efficacy, outcome expectations,
goals, and self-evaluations of progress. The theory postulated that current behaviors, thoughts and emotions, and
environment all interact to affect new behavior. The SCT can be applied as a theoretical framework in different
settings and populations. It is frequently used to guide behavior change interventions. It may be particularly useful in
rural communities for examining how individuals interact with their surroundings. The Social Cognitive Theory can
be used to understand the influence of social determinants of health and a person's past experiences on behavior
change. Social Cognitive Theory (SCT) describes the influence of individual experiences, the actions of others, and
environmental factors on individual health behaviors. In communities where family planning is stigmatized, women
may observe peers avoiding contraceptives and internalize similar behaviors. Conversely, if respected community
leaders or peers endorse family planning, women may feel more confident in adopting it. SCT highlights the
importance of role models and community narratives in shaping reproductive health practices.

The Social Cognitive Theory, provides a crucial lens for understanding family planning conduct. The theory
emphasizes reciprocal determinism, meaning that personal factors, environmental influences, and behavior interact to
shape decisions. In the context of family planning among women in Affaha-Offong, this means that cultural beliefs
and religious norms (environment) influence women’s awareness, attitudes, and confidence (personal factors), which
in turn affect whether they will opt in for contraceptive methods (behavior). For instance, if a woman perceives peers
or respected community members effectively using family planning, she may be motivated and feel more confident in
the utilization as well. On the other hand, if cultural narratives interpret contraceptives as hazardous or immoral, those
environmental cues reduce self-efficacy and discourage adoption. Social Cognitive Theory also highlights outcome
expectations, where women weigh the perceived benefits of family planning, such as child spacing and improved
health, against perceived risks like infertility or stigma. In this way, the theory explains how cultural beliefs, social
pressures, and individual confidence interact to determine family planning practices, making it highly relevant to your
study.

These theories make available a concise framework for getting acquainted on how cultural beliefs impact the
fundamental practice of family planning. The Health Belief Model explains the role of perceptions and barriers, and
Social Cognitive Theory underscores the importance of learning by experience and from the environment. By
application of these theoretical perspectives, it offers a structured explanation of how they affect the utilization of
family planning among women in Afaha-Offong PHC. For instance, women who successfully use family planning and
share positive experiences can influence peers. Also, confidence in one’s ability to negotiate with a husband or visit
the health centre alone is critical. Low self-efficacy due to cultural restrictions reduces uptake. Furthermore, when
women expect positive outcomes (better child spacing, improved health), they are more likely to adopt family
planning whereas Negative expectations (infertility, stigma) reduce adoption.

2.11 Summary of Literature Review

This chapter examined the concept of family planning. Family planning here which is synonymous to birth control is
mostly adopted by couples who wish to limit the number of children they want to have and control the timing of
pregnancy, also known as spacing of children (Hassan, 2019). According to Ezugwu and Omeje (2010), family
planning means having the number of children that one can afford to bring up well. Going forward, some of the types
of family planning were discussed as; The Barrier Approach – used to avoid fertilization by preventing the sperms
from getting to the egg, Hormonal Methods- in this type of family planning, the ovaries are prevented from releasing
the egg, Copper IUDs- release copper ions into the cervix, making it an inhospitable environment for sperm, Rhythm
approach- Couples who rely on the rhythm method avoid having intercourse when the woman is most likely fertile,
and Surgery –use for permanent birth control by undergoing a vasectomy, which keeps the semen free of sperm.
(Bryan et al., 2005) identified modern birth control methods and traditional birth control methods: Traditional
methods - consist of periodic abstinence, withdrawal, and various folk methods such as strings and herbs. And the
modern method – consist of the use of contraceptive pills, surgery, IUDs, condoms etc.

Cultural beliefs influencing health practices and family planning were also examined. Cultural belief is a group's
common values, customs, and actions which include: religion, morality, ethics, and social values and traditional
practices handed down from generation to generation. Healthcare practice refers to how much people utilize
healthcare services to stay healthy. Some of these cultural beliefs influences health and family planning practices
include: Religious leaders- their opinions strongly influence community attitudes toward family planning. Most of
them regard the use of contraceptive to control birth as interference to divine directive, gender dynamics- a husband
disapproving the use of contraceptives because he wants more children, traditional health practices - women relying
on herbal remedies, charms, or prolonged postpartum abstinence as culturally acceptable methods of birth control
which may be culturally significant but less effective, misconception- most communities spread misconception about
contraceptives which is the effective way of exhibiting birth control; for instance the opinion that the use of
contraceptives may result to infertility, cancer, or permanent damage to the womb, Community influence- community
stigma against contraceptive use often discourages women from accessing PHC services.
Benefit for the utilization of family planning were highlighted as: promoting of maternal health, promoting of the
long-term health and wellbeing of newborn babies, prevention of unplanned pregnancy, beneficial for families
financially and assist in the improvement in economic activities, beneficial for women with career prospect,
prevention of the spread of HIV/AIDS and other sexually transmitted diseases (STDs) through the use of
contraceptives such as male and female condoms, fostering good relationships between members of the family and
population planning and control. Some of the barriers to effective or successful family planning as explained in the
study includes: Cultural influences, cost of accessing the service (Bloom et al., 1999; Griffiths & Stephenson, 2001),
socio-economic (Addai, 1998), Lack of personnel (Atuhaire et al., 2023). Other barriers such as community
disapproval, stigma related to obtaining contraceptives, lack of knowledge about the existence of publicly funded
clinics, a perceived lack of affordable services, and fears of side effects (Frost and Kaeser, 1995; Brindis et al., 2003),
Women in rural areas may have particular difficulty finding and obtaining family planning services (Frost et al.,
2001), and so on.

Some of the strategies for family planning were highlighted: The strategies to improve the practice of family planning
include; linking community members and removing unnecessary cultural values that affect the utilization of family
planning services, informing couples about the importance of family planning choices to improve their reproductive
health behaviour, as the community accepts the preaching of religious leaders, the health extension works should
make good communication with them, provision of adequate health education by caregivers to clients and family in
the community to expand their knowledge of family planning to ensure adequate child spacing and reproductive health
as highlighted by (Kelechi, & Catherine, 2016).
Furthermore, some empirical findings related to the research were also examined among them are: Isiugo-Abanihe
(1994), through survey research involving married couples, revealed that male dominance in reproductive
decision-making significantly reduced women’s autonomy in family planning choices, a pattern that continues to
resonate in contemporary Nigerian society. Samphina Academy (2023), using a case study approach with
questionnaires and focus group discussions, documented that women often resort to herbal remedies, charms, or
prolonged postpartum abstinence, which are deeply rooted in cultural traditions but less effective in preventing
unintended pregnancies. Also, Ozumba (2018) examined the socio-cultural strategies affecting the practice of family
planning in Nigeria. The study employed secondary data. The data was sourced from an online survey. The study
utilized descriptive statistics for data analysis. The result showed that a low rate of contraceptive use, such as
withdrawal methods, pills, abstinence and sterilization particularly in the northern and rural areas of Nigeria was a key
cause of high fertility rates, and so on.

Finally, theoretical framework relevant to the study was also explained; these theories make available a concise
framework for getting acquainted on how cultural beliefs impact the fundamental practice of family planning. The
Health Belief Model (HBM) which explains the role of perceptions and barriers, and Social Cognitive Theory (SCT)
which examine the environmental and learning by experience factor. These theoretical perspectives, offers a structured
explanation of how they affect the utilization of family planning among women.