Volume 4, Issue 2, 2019Volume 4, Issue 2, 2019 Enugu State University of Science & Technology Journal of Social Sciences F SO C IY ET NIS CER E AV NI DN U T EE CT HAT N S O U LOG GU YNE Journal of Social Sciences Published by the Faculty of the Social Sciences published by Faculty of Social Sciences Enugu State University of Science & Technology www.esutjss.com Editor-In-Chief Prof. Oby Omeje Managing Editor Barnabas E. Nwankwo, Ph.D Associate Editor Nicholas Attamah, Ph.D EJSS, Volume 4, Issue 2, 2019 399 When Culture plays a Determinant Role in the Adoption of Family Planning amongst Families Ugwu Stella Abel Department of Sociology and Anthropology Enugu State University of Science and Technology stellabel.ugwu@esut.edu.ng Abstract The study explored the influence of cultural factors on the use of family planning services by married women in Nkanu area, Enugu State, South East Nigeria. It focused on married women’s awareness and utilization of family planning services (FPS), factors determining married women’s use of the services, the problems that arise as a result of their not accessing family planning, who decides when to access or not to access these family planning services in marriage? The study adopted a qualitative survey method by reviewing existing literatures and data. The study also adopted the Marxist Feminist perspective which argues that women, as a class, are oppressed by social relations in decision making. The research findings showed that the culture of patriarchy, women illiteracy, financial strain and depressing economic condition of the country amongst others were cultural determinants of access and adoption of family planning services among rural families. This study suggests that door to door sensitization which will involve husbands workshops and conferences should be employed as strategies to increase knowledge of family planning in the research area and by extension all other rural areas of the nation. Keywords: Contraceptives, Culture, African marriage, Family planning, Patriarchy Introduction Family planning (FP) is the purposeful regulation of conception or childbirth or the use of devices, chemicals, abortion or other techniques to prevent or terminate pregnancy or voluntary avoidance or delay of pregnancy (Federal Ministry of Health, Nigeria [FMoH], 2005a; Gavin et al., 2014). According to Olaitan (2011), family planning techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and management and infertility management. These services are defined as educational, comprehensive medical or social activities which enable couples, individuals including sexually active adolescents and minors to determine freely the number and spacing of their children; avoid getting pregnant and/or even avoid sexually transmitted diseases, to select the means by which this may be achieved. Family planning is sometimes used as a synonym for birth control or child spacing, though it often includes more (Olaitan, 2011). Family planning was listed as one of the twelve pillars of reproductive health. Among the objectives of FP is to help women to protect themselves from unwanted pregnancies (FMoH, 2005a). In Nigeria, before the introduction of modern family planning in 1989, there were traditional methods of birth control (Mairiga, Kullima, Bako, & Kolo, 2010; Odimegwu, 1999). These traditional methods which still exist and are convenient for users are natural while mailto:stellabel.ugwu@esut.edu.ng EJSS, Volume 4, Issue 2, 2019 400 the modern types which are new in Nigeria are both natural and artificial (Mairiga et al., 2010). The use of FP implies that the users make concerted efforts to deal with procreation within the context of a sexual relationship. This covers things as varied as when to get pregnant, the number of children that are wanted, how to deal with fertility issues, how to avoid getting pregnant, whether to consider an abortion if an unwanted pregnancy occurs, or adoption, etc. Family planning has also been found to be beneficial to couples such as promotion of gender equality and educational and economic empowerment for women (Kelodjouea, 2015). Despite the known benefits of family planning, globally, more than 120 million women aged 15 to 49 who are married or in a union have an unmet need for family planning (United Nations, 2011) and in Sub-Saharan Africa (SSA) the uptake of the service still remains low (Abdullahi, 2012). An unmet need for FP according to UBOS and IFC International Inc. (2012) as quoted by Sileo (2014) refers to women capable of reproducing who are not using contraception, but wish to postpone their next birth or to stop childbearing all together. In order to curtail the unsustainable population growth, especially through procreation, the Federal Government of Nigeria at the 2012 London Summit on Family Planning made a commitment to scale up promotion of family planning to Nigerians. This was to be done by making contraceptive consumables available to those who need them and when they need them. As part of the efforts, the government launched “Green Dot” to help people identify family planning facilities in the country. Though there is still a huge gap of unmet needs for those willing to use them, many sexually active women are simply reluctant to embrace contraceptives. These includes: Contraceptives are methods, devices or drugs used to reduce or prevent unwanted pregnancy and unsafe abortion. Contraception comes in three broad forms: the long-acting reversible contraception, the short- acting reversible contraception and permanent methods. The long-acting reversible contraceptives (LARC) are methods of birth control that provide effective contraception for an extended period without requiring user action. They include injections, intrauterine devices (IUDs) and subdermal contraceptive implants. On the other hand, the short-acting contraceptives (SARC) have to be used in short time intervals such as in case of condoms, and daily intake of pills. In spite of advocacy by government and development partners on the benefits of family planning, acceptance of modern contraceptives has remained very low in Nigeria. The benefits of family planning are obvious: it allows women to space child birth and replenish vital nutrients lost during the process. It also allows the organs of mothers to return to normal. In spite of these obvious merits, 87 per cent of women in Nigeria or their partners do not use modern or traditional contraceptives. Statistics from the 2016/17 Multiple Indicator Cluster Survey (MICS) indicates that only 11 percent of women of ages 15 to 49 currently married or in union, use the method in the country. The statistics reveals that much needs to be done, especially in the northern part of the country to make Nigerian women embrace modern contraceptives. Cultural factors such as community norms, religious belief and gender roles are the most important factors influencing the choice of family planning among couples. EJSS, Volume 4, Issue 2, 2019 401 In Nigeria like in most developing countries, the utilization of family planning services is not optimal because of a number of factors, such as culture of the people and low status of women (Coleman, 2004; Delano, 2015). Other factors include lack of education and understanding about health related issues, the ability of women to command resources and make independent decisions about their fertility, birth control knowledge (Apanga & Adam, 2015; Nwakeze, 2003; Umoh & Udo, 2014). Location, religion and social class, lack of cooperation from spouse, cost, and perceived difficulties with the methods and lack of knowledge about contraceptive methods, community members’ awareness and understanding about the methods etc. also serve as determinants of use of family planning services (Bakibinga, et al., 2016; Doctor, Findley, Afenyadu, Uzondu & Ashir, 2013; Mairiga et al., 2010; World Bank, 2002). Moreover in Nigeria, the provision of health services is more in the urban areas than in the rural areas (Olaitan, 2011). Where family planning services are located in rural areas, use is low due to lack of proximity, bad road network, and the nearest urban center. Where such clinic is available, it may not provide adequate care because of lack of properly trained staff and equipment (Oluwepo & Okedare, 2006; Quedraogo, 2005). Negative consequences of lack of use of family planning services are enormous as it affects the individual, the family, the community and nation at large. Empirical findings have shown that it leads to increase in maternal illness such as multiple pregnancies, hemorrhage, etc. (Ikpeze, 2010). It sometimes leads to social problems in the family and community such as violence, desertion, accusation of infidelity, fear of violence, on the part of the women, mistrust. On the part of the men, it could lead to having multiple sexual partners with its attendant contraction of STIs and HIV/AIDS, affecting sexual and reproductive lives of women and sometimes it leads to maternal death (Ezumah, 2003). These have socio- economic consequences on the immediate family as the resources meant for the up- keep of the family are diverted to the health care of the parent(s) as the case may be, time wasted and the future and the life of the children truncated (Bowman & Kuenyehia, 2003). Family planning services are aimed at reduction of maternal and child morbidity and mortality, empowering women by alleviating the burden of excessive child bearing, prevention of unwanted and unplanned pregnancies, providing protection against sexually transmitted infections including HIV/AIDS, drop in unsafe abortions, etc (Umoh & Udo, 2014). Family planning services have the function of preventing most maternal/child illnesses and deaths (Smith, Ashford, Gribble & Clifton, 2009) yet it has been recorded that the rate of maternal/child morbidity and mortality is high in developing countries when compared to developed countries (Ikpeze, 2010; FMHN, 2005b). World Bank (2015) estimate shows that maternal mortality ratio in Nigeria is high, about 814/100,000 live births, yet attitude of members of the developing countries to FP services is low and this attitude is attributed to socio-cultural and economic reasons and more in rural areas (Engender Health, 2009; Galadanci, 2009; Smith et al., 2009).With the adverse consequences of non-consent and non-use, and the low understanding of the importance of FP services on the reproductive health of women, concerted efforts must be made economically, socially, politically and otherwise towards ensuring that the negative consequences of lack of use of family planning services are controlled to the barest minimum. This study therefore EJSS, Volume 4, Issue 2, 2019 402 reviewed literatures on cultural determinants of the use of family planning services by married women in Nkanu area of Enugu State and suggests measures that could enhance their effective use of family planning services. Statement of the problem Family planning is a topical issue in Nigeria like most other African countries has high population density because of high maternal fertility of about 5.6 children and above per woman (Abdullahi, 2012; Kelodjouea, 2015). In other African countries, according to Smith et al, (2009) at least eight in ten women and nine in ten men know at least one method of family planning, yet utilization of family planning is still low; while 13 percent of currently married women use a method of family planning, only eight percent of them use modern methods (Abdullahi, 2012; Apanga & Adam, 2015). This is as a result of several cultural factors. For example, child-bearing and rearing as well as the number and sex of children define a woman’s value and status in her community; these in turn contribute to women’s limited use of family planning services (Engender Health, 2009; Galadanci, 2009). Research carried out in Ilorin by Oluwepo and Okedare (2006) showed that the level of acceptance of family planning is more in the urban areas than in the rural areas. Most Nigerian women do not access it especially those in the rural areas (Nwakeze, 2003) because in relation to contraception, it is a male prerogative (Mairiga et al., 2010). Male control is a major determinant of women’s use of family planning services. Findings have shown that culture of patriarchy is very significant because most women are denied access to education which is expected to help women make informed family planning choices. For instance, Kelodjouea (2015) findings show that education of husband is an important factor particularly in those societies where a woman who is not educated cannot make her reproductive health decision without the consent of her husband. Also, the nature of women’s work in production such as household work (drudgery), to a great extent determines the rate of accessing and using of family planning services (Kelodjouea, 2015). Other factors that affect use of family planning services by married women in Nigeria include poor financing of health care services (Ikpeze, 2010), lack of focus on curative measures and political will by government (Quedraogo, 2005). There is disparity in health care services delivery between the remote and non-remote areas as in Nigeria where access and use is limited in rural areas unlike in urban areas (Engender Health, 2009). Agujiobi (2003) attributed it to ignorance on the part of the rural dwellers and the cause of the ignorance she attributed to lack of presence of Non-Governmental Organisations (NGOs) in the rural areas of Nigeria to educate and enlighten them on the presence and importance of family planning Services. Sometimes the available clinics may not provide decent care because of lack of proper staff and equipment (Engender Health, 2009). The effects of not planning the family cause a large number of women to continue to experience unplanned pregnancies leading to morbidity, mortality and social distress (Ringheim & Gribble, 2010; Smith, et al, 2009). EJSS, Volume 4, Issue 2, 2019 403 In Nkanu area, people’s main source of livelihood is subsistence farming which makes their condition even worse. Social amenities such as quality health care facilities, government presence, etc, are lacking causing increase in high maternal and infant morbidity and mortality. Also prevailing attitude and cultural practices affect women’s knowledge of their reproductive health needs and their willingness and ability to seek appropriate care. Nkanu area is culture bound and therefore could be described as a traditional society even though some of its communities are close to the city. Little or no academic research on family planning has taken place in this study area, even though pregnancy related problems exist here as in other rural communities in Nigeria. Family planning as studies have shown is central to gender equality, women’s empowerment and it is a key factor in reducing poverty. If use of family planning services is not encouraged in this study area, it will become not only a great health problem to married women but also continuous social and economic problem to the community and nation at large. Therefore this study investigated the cultural determinants of use and use of family planning services among the married women of the study area. Objective of the study The main objective of the study is to investigate cultural factors that determine the use of family planning services in some families in Enugu State. These cultural factors refer to the institutions, language, symbols, practices, values, beliefs, norms, folklores, etc of the people and how these affect knowledge and access to family planning services. Theoretical Perspective/Literature Review The Marxist feminist perspective is important for this kind of work. Firestone (1971) for example, argued that women, as a class, are oppressed by social relations in decision making. Ortner (1974) also noted that the other factors that do affect women’s decision making status, power relations/resource allocation in marriage include socio-cultural beliefs, attitudes, values, norms, socialization, which influence social, political and economic realities of societies. This perspective also maintained that subordination of women is further strengthened by encouraging women to develop female culture which involves nurturing and survival thereby affecting their ability to access and use family planning services (Symke, 1991). Offman and Matheson (2004) asserted that sexual inequality is socially constructed and that it is enforced through the social structures of private property and monogamy which contributed to the decline of women’s status (Mills, 1970). This perspective argued that the inequality in decision making is a method men use to secure and maintain their power. Gage in her book “The third person” as reported by Spender in her book, “Women of ideas and what men have done to them” (1990) noted that Christianity helps to reduce women to subordination and also perpetuates it. Boserup (1970) was of the opinion that the division between the private (female) sphere and public (male) sphere entrenched women subordination to men. Western materialist feminists like Kate Millet (1970), noted that women were socialized to be dependent on men. Reproductive health has been a major concern to man. Family planning was listed as one of the twelve pillars of reproductive health and one of its objectives is to help women to protect EJSS, Volume 4, Issue 2, 2019 404 themselves from unwanted pregnancies, ill-health, etc (FMHN, 2005). This has not been effective in some African societies Nigeria inclusive, because there are factors that militate against the ability of women of all levels to seek and use family planning services (Bowman & Kuenyehia, 2003; Olaitan, 2011). The literature identifies a number of ways that norms influence the general uptake of contraception and preferred methods. The traditional norm of not using modern contraception is sometimes deeply embedded and can take a long time to change, despite interventions. In a heavily cited journal article based on analysis of longitudinal data of uptake of contraception, Munshi and Myaux (2006) explain how in rural Bangladesh, the traditional norm to regulate fertility was early and universal marriage, as a precedent for immediate and continuous childbearing. This norm was legitimized through religious belief and authority. Although the government started to promote contraception from 1978 onwards, take up was very slow. The authors found that as the institution of ‘purdah’(veiling and segregation) limits women’s social interactions to other women within their religious groupin Bangladesh, shifts in attitudes about fertility occurred at the level of these religious groups rather than across villages, despite common family planning inputs across villages (Munshi & Myaux, 2006). The World Bank’s (2015, p.54) World Development Report suggests therefore that ‘fertility transitions may be better viewed as a norm-driven process than as the aggregate outcome of autonomous decisions’. In Uganda, contradictory messages about whether to use contraceptives from partners, parents, clergy, teachers, cultural leaders and health workers were identified as key obstacles to uptake (Nalwadda, et al., 2010). Negative stereotypes, stigma, misconceptions and fear limit uptake of contraception. Social stigma, fear and embarrassment were identified as one of the most common barriers to young people accessing contraception services –including the attitude of the service providers. Research in Tanzania by Shattuck, et al. (2011) found that sexual jealousy discouraged contraceptive use, as men worried that women’s use of contraception might allow them to be promiscuous and unfaithful without fear of conceiving. In Uganda, focus groups with young people found that they believed and were afraid that contraceptives could harm their fertility (Nalwadda, et al., 2010). It is considered critical to intervene early, when adolescents are forming their identities, developing their understanding of social norms around sexuality and gender, and making choices (including whether/when to have sex or use contraception) that will affect the rest of their lives(expert comments). In all countries, community attitudes, such as those of parents, faith leaders, teachers, providers, and others, play a critical role in how impactful youth programmes can be. Working with parents, families, and community leaders is imperative to ensuring that young people have access to the information and services they need. Methodology The paper, as a theoretical study, made use of secondary sources of data collection. Relevant data were extracted from reports, textbooks, academic journals, magazines, and from other secondary sources such as the internet and library. Factors that influence the use of family planning services EJSS, Volume 4, Issue 2, 2019 405 In Nigeria like in most developing countries, the extent of the acceptance and usage of family planning services are affected by the social, economic and culture of the societies in it. Omeje (2000) in his findings noted that poor access (both in logistics and financial terms) to modern health care clinic increase maternal and child morbidity and mortality. Culturally, child-bearing and rearing are very important to mankind and in particular women as it defines a woman’s value and status in her community alongside the number and sex of children (Mairiga et al., 2012; Nnorom, 2003). Ringheim and Gribble’s (2010) research findings show that in Nigeria, most pregnancies were reported as intended reflecting early marriage and social norms that support early child bearing. Onyeneho and Okeibunor (2003) in the study they carried out in Mbaise, Imo State noted that their respondents had an average of 5.6 children and above, which is comparatively high. In the same study they found out that those respondents with more female children wanted more children than those with more male children or equal sexes. The status of women as wives and mothers add to pregnancy related problems (Ezumah, 2004). Okeibunor’s (2000) findings from a qualitative study in Nsukka on the Sociological Context of Sexuality and family planning showed that the low status of women was socially constructed and hinders women from exercising their health rights as newly young married girls lose independence and mobility when they move into their in-laws home after marriage (Umoh & Udo, 2014). This is epitomized in Alumanah’s (2003) findings that women had no decision making power with regard to their reproductive health as most of her female respondents (ruralite, uneducated and poor, etc) reported that they would have to inform their spouses or relatives of complications before seeking care and 1/3 of them said they would have to seek permission to seek care. NDHS (2014) reports indicate that only 6 percent of currently married women make decisions themselves on their own health care while 3/5 (60%) women report that their husbands make such decisions. Children are highly valued and desired irrespective of their gender as both sexes fill a very crucial gap in the social and cultural life of the family (Mairiga et al., 2010). Nwakeze’s (2003) findings from her study in Anambra State showed that infertility was of great consequences for the couple and the woman in particular. Similarly, Ezumah’s (2003) findings of a research she undertook on Sexuality and Gender Relations in Anambra State using qualitative methods, showed the importance attached to procreation as emphasized on the extent a barren woman goes to get a wife for her husband to bear children on her behalf or a wife goes outside her matrimonial home (with or without the consent of her husband in the case of infertility on the man’s side) to get children in order to maintain the family’s existence and value in the community. These socio-cultural attitudes towards the importance of marriage and family made many Nigerians react negatively to the programme of family planning services (Ringheim & Griggle, 2010). Alumanah (2003) and Kelodjouea (2015) noted from their findings in Nigeria and Cameroon respectively that the ability of women to command resources and make independent decisions about their fertility has an impact on choice of use or non-use of family planning services. Their findings also showed that women who were economically independent sought health care more compared to those without education. EJSS, Volume 4, Issue 2, 2019 406 In agreement to their findings, Ugwu’s (2007) research findings showed that educational achievement of wives does not translate directly to exercise of authority as no matter the educational level of a wife, she still needs her husbands’ approval or at least that of his kins to seek health care and in particular family planning services. The social strength of power relations between married couples and extended family to a large extent affect the rate of access and use of family planning services by women in relation to contraception. Empirical studies in Nigeria like in other African countries have shown that even with urbanisation and westernization men are still the main decision makers when it comes to fertility control with no class difference and to a less degree the kins and in-laws (Bowman & Kuenyehia, 2003; Kelodjouea, 2015; Mairiga et al., 2010). There are social consequences of use of family planning services in areas where it is not socially accepted especially in traditional areas and these consequences could be fatal and the actions range from violence, desertion, accusation of infidelity, fear of violence, etc. On the part of the woman, she ceases to trust the man. On the part of the man, it could lead to having multiple sexual partners with its attendant contraction of STIs and HIV/AIDs affecting sexual and reproductive lives of women, to death sometimes (Ezumah, 2003; Gavin et al.,2014; Oluwepo & Okedare, 2006; & Sonfield, 2013). Traditional family planning methods The findings of Ringheim and Gribble (2010) and Mairiga et al. (2010) show that traditional methods of birth control though old and natural are still being used in Nigeria. The findings show that long lactation combined with post-partum sexual abstinence, fertility awareness methods (that is, use of basal body temperature, cervical position, cervical mucus method), withdrawal, waist band, rings, charms, jumping ropes, horseback riding, and having abortions are used to space birth (Delano, 2015). These traditional and natural family planning methods are persisting because the fertility patterns observed in developing countries are attributed to the traditional attitudes and cultural values held by communities and the tradition of communities to favour having many children (Mairiga et al., 2010). The research findings of Obasi and Umoh (2000) showed that 9.8% of 20.4% of their total respondents who were currently using any type of family planning methods were those using traditional family planning methods. Recently, the result of the research findings by Mairiga et al. (2010) on the practice of traditional family planning among the rural Kanuri community shows that 63% of the female respondents practice traditional family planning. Ringheim and Gribble’s (2010) research findings showed that rural respondents were more aware of traditional family planning methods than the urban respondents and vice versa. Research findings in Ibadan by Bowman and Kuenyehia (2003) show that women in polygynous marriages were very happy with traditional abstinence because it helps them preserve their health with advancement in age, avoid ridicule from others, maintain a happy home since older wives do not want babies and so do not vie to become pregnant like younger EJSS, Volume 4, Issue 2, 2019 407 wives. Among the younger wives, long lactation and use of traditional contraceptives were also found to be the main methods of family planning in Ghana from the study that was carried out by Abu as cited in the works of Bowman and Kuenyehia and among the Kanuri in northern Nigeria as noted by Mairiga et al. (2010). These studies showed that women who experienced difficulties in achieving the desired birth spacing tried to overcome the problems of these methods and space births as well as satisfy their husbands sexually using traditional contraceptives. This helped them ensure that they do not incur the wrath of their husbands as a result of negotiating especially modern family planning services. Such wraths include their husbands seeking sexual satisfaction outside their matrimonial homes, refusing their wives’ food, sending them home to their parents, physical violence, etc (Bawa et al., 2014; Ezumah, 2003) with its attendant consequences of jeopardizing the women’s physical and psychological health. Modern family planning methods Modern family planning methods include barrier methods that prevent sperm from meeting eggs, hormonal contraceptives that affect a woman’s hormones, altering her reproductive cycle. Another modern birth control method is Fertility Awareness Methods (FAM). It is a collection of practices that helps a woman know which days of the month she is likely to get pregnant using natural family planning methods such as abstinence. Sometimes using FAM like abstinence is not for the purpose of limiting the size of their families but to give their bodies’ time to rest and replenish their resources before embarking upon another pregnancy. This corresponds with the findings of Bowman and Kuenyehia, (2003) among rural Gambian women, mainly with women who have had one reproductive mishap or another. Modern family planning methods can also be grouped according to prescription. (1) Prescription contraceptives refer to those contraceptives that are by law provided by licensed pharmacists such as injectibles, IUDS, diaphragms, and Nor-plants, and (2) Non prescription contraceptives. These can be provided both by pharmacists and chemists. Examples are oral contraceptives, foaming tablets, creams and jellies and condoms. Though contraceptive knowledge and use have risen minimally in Africa from 23.6% in 2008 to 27.6% in 2014 (Umoh & Udo, 2014), for instance Ugwu (2007) noted that more than half of the respondents who had contraceptive knowledge had made use of one type or the other (the type of contraceptives was not indicated). Abdullahi (2012) noted that the use of modern family planning in Nigeria is very low as only 10% of married women used a modern contraceptive in 2008 and it has led to an increase in abortion rate of 25/1000 women aged 15-44 years. Empirical findings of Ringheim and Gribble (2010) also show that among their respondents especially among the unmarried sexually active women, condom was the best known and used but very much unpopular with the young married women. This attitude they attributed to the inability of women to negotiate condom use especially in marriage but rhythm was the most commonly used among the married women. Nwakeze (2003) from her study noted that out of the 64.5% of her respondents who have used contraceptives, only 18.6% used the modern methods such as condom, pills, injectibles. IUD was rarely used. Douche, tubal ligation and EJSS, Volume 4, Issue 2, 2019 408 hysterectomy were used even to a lesser degree. The reverse was the case in a studies conducted by Ozumba and Ibekwe (2001) at UNTH and Umoh and Udo’s (2014) conference finding show that IUCD was the most preferred method among the users. From Nwakaeze’s (2003) and Mairiga et al.(2010) reports, those who were non users had reasons like fear of side effect, husband’s disapproval and religion as major reasons. Reasons for and not using family planning services According to Sonfield (2013) women and men who experience unplanned pregnancy are particularly likely to experience depression, anxiety and a decreased perception of happiness espousing empowerment feminists’ perspective that involvement of men in family planning services programmes will help avert the consequences of non-use on all. The reasons most of the male respondents who allow wife to use family planning services gave are that they want to maintain good health of the family and that their wives are their responsibilities. According to the research findings of Bawah et al. (2014), Oluwepo and Okedare (2006),Smith et al, (2009) and Sonfield (2013) the consequences of not using family planning by married women could be detrimental to the couple and family at large and the actions range from violence, desertion, accusation of infidelity, fear of violence on the part of the woman and mistrust which are culturally justified. On the part of the men, it could lead to having multiple sexual partners with its attendant contraction of STIs and HIV/AIDs affecting sexual and reproductive lives of women, tension that wife will seek sex outside marriage and to death sometimes. The issue of women secretly using family planning services (a coping strategy) is general in all Nkanu communities. This finding is consistent with the findings of Bawa, et al, (2014) in Ghana. Most of the female qualitative respondents agreed that a wife who is tired of giving birth for health reason(s) might use family planning without her husband’s consent especially when he refuses her the right to use the service. Because of the stress the married woman faces at home trying to manage the home as a wife, mother and financial aide to the husband, she might decide to use family planning without her husbands’ knowledge to avoid the tension that comes with refusal to have conjugal relationship between her and her husband yet if her husband finds out she faces problems. Therefore such married women try as much as they can to hide it. A family planning provider also noted that wives who use the service(s) without their husbands’ consent insist that their husbands are not informed and the providers’ advice on method to use accordingly. Religion Religion is a strong factor that negatively affects use to family planning services by married women in the research area. According to the research findings of Bowman and Kuenyehia (2003) and Apanga et al. (2015) religion poses strong limitations to the use of family planning services because they perceive it as increasing infidelity in women and fighting the will of God for procreation. Yet it does not compare favourably with the findings of Bakibinga et al. (2016) in Kenya that religion has no effect on access and usage of family planning among their married women. Many services like abortion, etc are being provided by the family planning services EJSS, Volume 4, Issue 2, 2019 409 clinic in the area but the Christians do not utilize them because of their doctrine which is tinted with tradition of fatalism as noted from family planning providers. The implication is that this nascent religion has a negative teaching on family planning services on the reproductive health of married women therefore it has given root to culture of male superiority and undermined the right of women to reproductive issues that concern them. Religion has gone deep into the culture of the research area that when issues of family planning arise the case is preferably reported to the religious leader than to the kinsmen especially by women faithful which is not really acceptable by the men folk. Education and knowledge of family planning by husbands and useof family planning by wives There is a general agreement that knowledge of family planning services by husbands will increase their support of wives use of family planning services. This assertion is supported by the report of International Planned Parenthood Federation (IPPF) that if more accurate information and affordable services were easily available, that as many as 20 million more women would be using family planning services more, than are currently using. Since the governments have the intention of reducing maternal morbidity and mortality, and also achieve universal access to reproductive health, it is then expected that the government should not only empower the people generally with education but with access to family planning services information especially in rural areas by introducing enlightenment programmes. Also the programmes to achieve this have to be all encompassing that is involving men and every other target group such as married women, to give them value re-orientation. Men being involved in the processes of family planning services have positive consequences for the couple and the family in general. Culture of Patriarchy Findings show that husbands are the ones in the position to permit wives before they use family planning services. For those who would not permit their wives to use family planning services, greater percentage said it is because of the side effects. This is to show that lack of proper knowledge of family planning services is evident among husbands in the study area. Another major reason given is that it is not their tradition. Because tradition is beneficial to the males, they would want to maintain the status quo of male superiority. Yet there was an agreement that where the woman’s life is threatened that she can use the service without her husband’s permission. They also agreed that if such is found out by her husband that serious trouble usually resulted. It was also found that in spite of the consequences of using family planning in secret that married women still use the services and in certain cases such women are helped by their female folks to keep it secret because for them, some men can be terrible and might make such women who use family planning services without their approval to face some repercussions. Losing their homes means losing their children which customarily are in the husband’s custody in case of separation or divorce and these children are supposed to be the promoters of the woman’s prestige and status in the society. This agrees with the findings ofBawah, et al. (2014), Ezumah, (2003) and NISER (2001) that child-bearing and rearing EJSS, Volume 4, Issue 2, 2019 410 defines a woman’s value and status in her community. Therefore the implication of using family planning services in secret might be to retain their homes or status as married women. According to studies carried out among the Yoruba people and Nsukka people in Ekiti and Enugu States in Nigeria, as reported by Bowman and Kuenyehia (2003) and Okeibunor (2000) respectively show that men are the main decision makers when it comes to fertility control with no class difference and to a less degree the kins and in-laws. The little or no involvement of in- laws and others in the research area especially in marriage issues might be attributed to the fact that it is considered exposure of family issues as qualitative respondents noted. This is in line with the arguments of empowerment theorists that women’s subordination and oppression had its root in culture especially patriarchy and socialization which are gender biased. They noted that women were socialized to be dependent on men. Therefore the inequality in decision making is a method men used to secure and maintain their power. To avert this, they advocated effective communication among couples and literacy for men and restructuring of the cultural framework of power to the ones that no sex will feel inferior. Sexuality communication There is a general belief that proper sexuality communication between spouses encourages increase use of family planning services by married women. According to a study on socialization by Boserup (1970) it was found that women are taught to be shy, subtle and non- vocal while men are taught to be arrogant, out spoken and aggressive. In the research area, women are taught to repress their feelings even in marriage. Contraceptive effect In as much as there are negative consequences for women that do not use family planning, there are also consequences for use which could be attributed to be inherent in family planning methods and also to the fact that the users are not properly enlightened on family planning which produces contrary desire in the users in the research area. It’s been found that oral pills interfere with the hormones in the body, therefore if the blood pressure of a woman is very high, she cannot be administered with this hormonal drug. Most of these injectible, oral pills are hormonal but IUCD is not hormonal, you may even decide to advice the prospective user on IUCD, it does not interfere with the hormones in the system. But those methods that interfere with the hormones may cause high blood pressure. So if somebody’s blood pressure is very high we advice against use of hormonals. With IUCD, if somebody has pelvic inflammatory disease (PID) or any other STI, we do not advise such prospective user on it, unless you give her treatment prior to that, you may ask her to go on injectible while she is being treated of the infection and then after the treatment she can go on this barrier since that is her choice. If she is inserted with IUCD while still infected it might lead to ascending infection. Married women could be empowered to use family planning services in the research area if there is proper family planning enlightenment and advocacy. For instance, when they understand that health histories are requirements for efficacious family planning use especially for hormonal and insertions, the notion that it can be accessed anywhere like with quacks and EJSS, Volume 4, Issue 2, 2019 411 the effect of wrong application that occasion negative side effect(s) would be reduced to the minimum. Some of the FGD respondents who experienced health hazards in the services noted that they accessed and used the services from unregistered clinics that are found in their localities. Family planning providers noted that to have a side effect free use of family planning methods that counseling must be done that is to say that before any method is offered to a prospective user that the client has to be counseled before administering any method to avoid negative side effects. The counseling will enable them choose correctly. Summary and Conclusion One of the findings of this research is that decisions in marriage are the prerogative of the husband among married people in Nkanu area and this also impacts negatively on the reproductive choices and health of married women in the area. The theoretical implication of this finding is that married women’s use of family planning in the research area is contingent on male control as well as the level of their husbands’ education and knowledge of family planning. The theoretical implication of this finding is that married women are not seen as personalities who have their needs, aspirations and limitations. If they are empowered through effective sensitization to make rational reproductive health choices and decisions, they will be in a position to meet their family planning needs. This study shows that empowering women through education and skills will enhance their use of family planning more. This tallies with the definition of women empowerment as having sense of self worth, access to opportunities and resources, choices and the ability to exercise them, have control over their own lives and influence over the direction of social change (NDHS, 2013). But if they are stretched beyond their natural limits by male control which constrains them from accessing family planning services, they will face challenges of maternal morbidity and mortality and marital stress, as the case may be. These may in turn, affect negatively the home, community and nation at large. These were highlighted in the findings of the study as likely consequences of non use of family planning in the research area. The study found that women who do not communicate with their husbands before accessing modern family planning services do so to avert marital conflict. This agrees with the consequences of use of family planning without the consent of the husband as enumerated by Ezumah (2003) in her research findings in Anambra state. This portrays the tradition of male supremacy in marriage. According to empowerment theorists, women in all cultures face the same subordination from societies they belong to. Liberal feminists maintain that in marriage, women do not achieve equality with men. They advocated learning through collective action which serves the function of successfully challenging individuals and institutions opposed to their self interests and enable women to collectively take control of their own lives, to set their own agenda, to organize to help each other and make demands on society for change. Hooks (1984) advocates effective communication among couples and literacy for the female and involvement of men in feminist movements if sex inequality is to be averted. 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