Parallel 2 - Abstract presentations (Oral-016 - Oral-018)

Background/Objectives:
Fertility desires are high in Nigeria. But research suggests emerging interest in smaller families. This study explored how Nigerian men and women perceived the benefits of smaller (three or fewer children) versus larger (five or more children) families.

Materials and Methods:
Semi-structured in-depth interviews were conducted with 166 adult men and women with diverse characteristics from six states (Akwa Ibom, Anambra, Gombe, Lagos, Nasarawa, and Sokoto) between September and December 2021. Interviews were audio-recorded, transcribed and translated, as appropriate. Transcripts were coded using Dedoose, followed by thematic analysis. 

Results:
The consensus was that smaller families were easier to manage than larger families. However, some felt that those with the means should have as many children as they desired. The benefits and burdens of having few or many children were described under three main themes: responsibilities, relationships and resources. Responsibilities included nurturing and training children (moral socialization and formal education) and were perceived to be easier to achieve with fewer children. Respondents also believed that building relationships and bonding with children individually is easier with fewer children. Building relationships requires time so the parent can be a friend, companion, mentor, and role model to each child. Almost all participants spoke about the need for sufficient economic resources to pay for children's feeding, clothing, education, healthcare, and other needs, noting this was more achievable with fewer children. Many talked about cost savings with fewer children, and less to spend on, allowing parents to save for their own retirement, invest in other things, and reduce their stress levels.

Conclusions:
Increasingly Nigerian men and woman see the value of smaller families over larger ones, especially because their responsibilities, relationships, and resources are easier to manage. Efforts to slow the rate of population growth should include education promoting quality of children over quantity.

Background
Adolescent girls face unique reproductive health challenges like early marriage, early age at first birth, and low contraceptive uptake with a higher unmet need for contraceptives among married adolescents compared to older married women. Anecdotal evidence from A360 project show that adolescent girls discontinue contraceptive use due to side effects, myths and misconceptions, and disapproval from critical influencers. Society for Family Health through her A360 Amplify project implemented an optimal package to support contraceptive continuation for women still in need. 


Methodology
To reduce method failure related to individual level barriers, A360 developed protocols for provider follow-up calls digitized and linked to DHIS2 for tracking and follow-up cards for girls without access to a phone. 
To manage side effects and method related barriers, the counseling for choice (C4C) strategy was introduced targeting woman's unique contraception need. The use of the 3Ws, NORMAL rubric enabled providers to better address girls' concerns around side effects. 
In strengthening enabling environment to address relational and environment barriers, A360 designed a key influencer engagement strategy for husbands of married adolescents and mothers of unmarried adolescent girls. 
While to support sustainable access, community-based distribution agents called Big Sistas work with providers on a two-way referral for initial uptake and resupply of DMPA-SC.


Results
Provider call log; of the 8,441 adolescent girls called, 7,212 returned to the facility for scheduled visits. Specific to continuation, 539 were called and 510 returned for resupply. For sustainable access using Big Sista strategy, of the 658 girls who initiated FP, 450 continuing users representing 68% returned for continuation. Outcome of combined strategies of provider call log and quality counselling using the C4C and 3Ws yielded 88% and 90% of returning unmarried and married adolescent girls respectively who had previously initiated a contraceptive method returning for re-supply. 

Self-care is an effective approach that empowers individuals to take charge of their own health, access information, and utilize health services. Self-care interventions gives agency, autonomy, and choice to individuals to decide if, when, and how frequent to have children which determines significantly to the reproductive health outcomes and the achievement of universal health coverage. Subcutaneous depot medroxyprogesterone acetate contraceptive (DMPA-SC) is the only injectable contraception that fits into the self-care framework. Hence, MSION included DMPA-sc in its demand creation drive, trained providers on quality counseling, choice, product, client training on self-injection, continuum of care through her contact centre, and tracked continuation of use. The intervention was implemented in 130 public health facilities in Abia (19), Ebonyi (5), Enugu (50), and Imo (56) states. Our study compared the trend of self-injection of DMPA-sc with provider administered option.
METHODS: Service statistics for April to September 2022 was extracted from Marie Stopes database. 
RESULTS: 3581 clients received DMPA-SC, of which 23% (816) were self-administered. The trends of the uptake of provider administered option exceeds that of the self-administered option.
CONCLUSION: While more users of DMPA-SC are becoming comfortable with self-injection. Most DPMPA-SC users prefer to be injected by a trained service provider. To accelerate the adoption of self inection, further study is needed to understand the demography of the users and their experience with the self-care approach.