Contraception allows women and couples to plan for their families by spacing or limiting births. Avoiding unintended pregnancies also contributes to improvements in maternal and newborn health outcomes ¹ . In Nigeria, about 15% of all women of reproductive age (15–49) have an unmet need for family planning (FP)- 10% for spacing and 5% for limiting pregnancies ² . Yet as of 2018, 14% of women were using any method and 11% were using a modern contraceptive ² . In addition to the barriers facing women in initiating contraception, discontinuation has been found to contribute to approximately one-third of unmet need globally ³ . About 41% of Nigerian women who begin using a contraceptive method discontinue that method within 12-months ² . The main reasons Nigerian women reported discontinuing their method include desire to become pregnant, side effects/health concerns and infrequent sex ² .

Previous studies have documented factors associated with contractive discontinuation while in need (i.e. wanting to delay or prevent pregnancy). Method-related factors include experience of side effects ^{4– 8} , the type of method selected (for example, short-acting versus long-acting or hormonal versus nonhormonal methods) ^{5, 9, 10} , and women’s satisfaction with the method ¹¹ . Experience of side effects is the most commonly cited reason for method discontinuation while in need ^{4– 8, 11} , although some studies have found that the effect of side effects on discontinuation may be overestimated ^{9, 12, 13} .

Individuals’ characteristics, intimate relationships, and social factors can also influence whether a woman continues to use her method. Non-method related factors associated with contraceptive continuation include: a previous unintended pregnancy, partner support, age, number of desired children, number of living children, number of male children, being in school or working, and discussing FP with a friend ^{8, 9, 11, 13} . Studies have also shown that a woman’s motivation to prevent pregnancy and intent to use contraception are associated with method selection ¹⁴ and contraceptive continuation ^{9, 15} .

Fertility intentions, that is the desire for a certain number of children and the intended timing of a first birth and subsequent spacing between births ¹⁶ , are also associated with contraceptive continuation. A longitudinal study in Indonesia found that women who wanted to wait at least two years before their next pregnancy were more likely to continue using a modern contraceptive than those who wanted a birth within two years ¹⁷ . Fertility intentions also play important roles in women's decision to use contraception and can predict birth outcomes ^{16, 18} . For example, a study in Senegal demonstrated that women who did not want additional children were less likely to become pregnant, especially if they were also using a modern method ¹⁸ . Previous studies have found that factors including age, parity, perception of a partner's desire for additional children, pregnancy attitudes, and a previous negative birth experience are associated with women’s fertility intentions ^{16, 19, 20} . Yet for most women, fertility intentions often fluctuate and can even change within a short period of time ^{18, 19, 21} . For example, Jones et al. found that while 39% of women who were interviewed three times over the course of a year reported being uncertain if they wanted more children, only 9% consistently reported uncertainty at all three interviews. In longitudinal study in India, among women who reported wanting a child in two or more years during an enrollment interview, only 5% of those women consistently reported that preference during subsequent follow-up interviews within a 12 month period ²¹ . Similarly, 14% of those who reported wanting children within two years did so consistently during follow-up interviews ²¹ .

Given that fertility intentions can influence contraceptive use and continuation, and often fluctuate, researchers have highlighted the importance of discussing fertility intentions during FP counseling and general healthcare visits ^{17, 19, 21– 23} . Quality counseling, in itself, has been shown to improve uptake and continuation of FP. For example, higher levels of quality of care received during FP counseling was significantly associated with contraceptive continuation in a study conducted in Indonesia ¹⁷ and in India ²² . Jain et al. found that the method selection domain of quality of care, which includes two items related to the provider’s conversation around their client’s fertility intentions, was significantly associated with contraceptive continuation three months later ²² .

To date, few studies have explored contraceptive continuation of clients who received FP services from private sector pharmacies and drug shops. This paper uses longitudinal data from Nigeria and looks women’s contraceptive continuation approximately nine months after they received FP services from private sector Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs) in Kaduna and Lagos states. Specifically, this paper aimed to assess the fertility intentions of women seeking services from CPs and PPMVs and whether their fertility intentions lead to continued contraceptive use nine months later.

Table 1 presents the demographic profile of women who received FP services from CPs and PPMVs at the enrollment interview. Just under half of the women were 25–34 years of age (47%). Many (75%) had attained at least a secondary education and 72% were employed at the time of the enrollment interview. Most women were married (95%) and had two or more living children (86%). A little over half (56%) had previously used FP in the past and expressed a desire for a/additional children (56%): 18% wanted a child within the next two years, 35% wanted a child in two or more years and 4% were unsure of the timing. Half of the women were from Kaduna and half from Lagos. At follow-up, one-third (33%) reported experiencing side effects and approximately 89% of women continued to use contraception (82% reported using the same method and 7% reported switching to another method, data not shown).

Figure 1 shows the distribution of current method use as reported at the enrollment interview. Two-fifths (40%) of women were using the injectable, 33% were using an implant and 24% were using the pill. Two percent reported using another method such as condoms, cycle beads, and or an IUD (as a results of a referral).

Figure 2 shows the distribution of continuers and discontinuers at follow-up by their fertility intentions as reported at enrollment. Among women who wanted to have a child within two years, 81% continued using contraception approximately nine months later compared to 93% of women who reported wanting a child in more than two years and 91% of women who did not want any more children. Only 74% of women who were unsure when they wanted their next child continued using their contraceptive method approximately nine months later.

Unadjusted and adjusted odds ratios of contraceptive continuation are presented in Table 2. Women who wanted their next child more than two years after enrollment were three times more likely to continue using contraception compared to those who wanted a child within two years (OR=3.0; 95% CI 1.4-6.7). Women who did not want any/more children were two times more likely to continue using contraception compared to those who wanted a child within two years (OR=2.3; 95% CI 1.1-4.6). When accounting for covariates in the multivariate model, women who intended to have a child in more than two years remained significantly more likely to continue using contraception compared to women who intended to have a child within two-years, although the odds ratio decreased slightly (AOR 2.6; 95% CI 1.1-6.1). Not wanting any/more children was no longer significant in the multivariate model but the OR remained in the expected direction.

Women who had no children were 80% less likely to be using contraception compared to women with 4 or more child (OR 0.20; 95% CI 0.06-0.65) and this association remained significant in the multivariate model (AOR 0.16; 95% CI 0.03-0.97). Women who reported that they did not experience side effects at follow-up were two times more likely to be using contraception compared to women who did in both the univariate model (OR 2.1; 95% CI 1.2-4.0) and multivariate model (AOR 2.1; 95% CI 1.1-4.0).

Figure 3 presents the proportion women who were asked about their fertility intentions by the CP and PPMV at enrollment. Of the 411 women who were asked about the quality of care received from the CP or PPMV that they saw, 93% were asked whether they wanted to have a or another child in the future and 85% were asked when they would like to have a or another child.

Results from this analysis suggest that among women who received services from CPs and PPMVs in Nigeria, fertility intentions are associated with their contraceptive continuation. Specifically, the respondents in this study were more likely to continue using contraception if they reported wanting a child in two or more years compared to women who wanted a child within two years. These results are consistent with previous studies that have found associations between fertility intentions and contraceptive use and continuation ^{17, 37, 38} . We also found that experience side effects and number of living children were also associated with contraceptive continuation for the women in this study, consistent with existing literature ^{4– 8, 11, 20} .

As FP services are task shared to CPs and PPMVs, the results from this study underscore the importance of discussing fertility intentions during FP counseling between CPs/PPMVs and their clients in order to help women choose a method that best suits their needs and to continue using FP. As stronger or more precise fertility intentions have been shown to be associated with the actualization of those intentions ³⁹ and that fertility intentions change over time ^{15, 19} , CPs and PPMVs should also discuss fertility intentions with their clients often, consistent with recommendations from studies in Sweden ²³ , and the U.S. ¹⁹ .

The association between fertility intentions and continuation remained significant even when accounting for experience of side effects. This suggests that understanding a woman’s fertility intentions, in addition to providing information about side effects, is essential for comprehensive FP counseling and quality of care ^{17, 22} . Many of the women interviewed in this study reported that the CP or PPMV asked about their fertility intentions, suggesting that when CPs and PPMVs are trained in FP counseling, they can provide quality counseling and facilitate a dialogue around fertility intentions with their clients. As the method selection domain of quality of care has also been shown to be significantly associated with continuation ²² , emphasizing the importance of comprehensive FP counseling when task sharing FP service provision to CPs and PPMVs will be essential. Understanding other aspects in a woman’s life, such as number of living children, will also be important for these new FP providers in aiding their clients in choosing an appropriate method.

Another important finding from this study is that 89% of women in need who received a FP method as a result of a visit from CPs and PPMVs continued to use their method about nine months later. These results suggest that when CPs and PPMVs are properly trained, many of their clients continue to use contraception, even though about two-thirds of the women interviewed were using short acting methods such as the pill, injectable, or condom. Previous studies have documented proximity and flexible operating hours as reasons why women prefer PPMVs for FP and other primary health care services ^{40, 41} . Therefore, the accessibility of CPs and PPMVs may also facilitate women’s continued use FP.

The fertility intentions of women who seek FP services from private sector pharmacies and drug shops (PPMVs) in Nigeria can predict contraceptive continuation. With training, CPs and PPMVs can discuss fertility intentions with their clients and many women who seek services from these providers continue using FP, even short acting methods like the pill or injectable. As task sharing FP services to these private sector cadres is scaled in Nigeria and in similar settings, supporting CPs and PPMVs to provide comprehensive FP counseling, emphasizing the importance of discussing fertility intentions with women often, will be essential.

SCD managed the overall preparation of the manuscript including conceptualizing and drafting the manuscript and conducting the analysis and contributed the development of the overall study’s metholodgy. SB supervised the implementation of the research activities and contributed to drafting the manuscript. EO led the funding acquisition for the Integrate project, including the study, and reviewed drafts of the manuscript. UO and DBO managed the coordination of data collection and data management. AJ was the principal investigator and led the development of the overall study’s methodology, and also guided the conceptualization of the manuscript and analysis. All authors have read and approved this version of the manuscript.