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Trends in reproductive health indicators in

Nigeria using demographic and health surveys
(1990–2013)

Chinelo C. Okigbo, Korede K. Adegoke & Comfort Z. Olorunsaiye

To cite this article: Chinelo C. Okigbo, Korede K. Adegoke & Comfort Z. Olorunsaiye (2017)
Trends in reproductive health indicators in Nigeria using demographic and health surveys
(1990–2013), Global Public Health, 12:6, 648-665, DOI: 10.1080/17441692.2016.1245350

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GLOBAL PUBLIC HEALTH, 2017
VOL. 12, NO. 6, 648–665
http://dx.doi.org/10.1080/17441692.2016.1245350

Trends in reproductive health indicators in Nigeria using

demographic and health surveys (1990–2013)
a
Chinelo C. Okigbo , Korede K. Adegokeb and Comfort Z. Olorunsaiyec
a
Department of Maternal and Child Health, Gillings School of Global Public Health, University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA; bDepartment of Epidemiology and Biostatistics, University of
South Florida, Tampa, FL, USA; cDepartment of Health Services Research, College of Health and Human
Services, University of North Carolina at Charlotte, Charlotte, NC, USA

ABSTRACT ARTICLE HISTORY

There is an urgent need to improve reproductive health (RH) in Received 27 November 2015
Nigeria – the most populous country in Africa. In 2015, Nigeria Accepted 26 September 2016
had the highest number of maternal deaths in the world. This
KEYWORDS
study assessed the trends in select RH indicators in Nigeria over Reproductive health
two decades. Data used were from Nigeria Demographic and indicators; trend analysis; at-
Health Surveys (NDHS) conducted between 1990 and 2013. The risk populations; Nigeria;
NDHS uses a two-stage cluster sampling design to select demographic and health
nationally representative samples of reproductive-age women. surveys
The study sample ranged from 7620 to 38,948 women aged 15–
49 across the five surveys. Trends in modern contraceptive
prevalence rate, skilled antenatal care, skilled birth attendance,
and adolescent birth were assessed. The results show increasing
trends in modern contraceptive prevalence rate from 4% in 1990
to 11% in 2013 (p < .001); in skilled antenatal care from 57% in
1990 to 61% in 2013 (p < .001); and in skilled birth attendance
from 31% in 1990 to 40% in 2013 (p < .001). The trend in
adolescent birth decreased from 24% in 1990 to 17% in 2013 (p
< .001). Marked disparities exist as rural, poor, and less educated
women bear the greatest burden. Interventions should target the
at-risk populations to improve their access and use of RH services.

Introduction
Maternal mortality remains a global development challenge; the World Health Organiz-
ation (WHO) estimated that 303,000 women died from pregnancy-related complications
in 2015 (WHO, 2015). To reduce the number of women who die from maternal causes, the
international development community continues to develop and implement policies and
strategies to address this important problem. For example, in the year 2000, the United
Nations member states agreed to achieve eight Millennium Development Goals
(MDGs), one of which was to ‘improve maternal health’ (United Nations, 2015a). This
goal aimed to reduce the global maternal mortality rate (MMR) by 75% from 1990 to
2015 and to achieve universal access to reproductive health (RH) services within the
same time period. By the end of 2015, it was estimated that the global MMR declined
by 44%, falling short of the MDG target; likewise, universal access to RH services was

CONTACT Chinelo C. Okigbo chinelomma@hotmail.com

© 2016 Informa UK Limited, trading as Taylor & Francis Group
 GLOBAL PUBLIC HEALTH 649

not achieved (United Nations, 2015a). To maintain the momentum and success accom-
plished during the MDG-era, 17 new goals – Sustainable Development Goals (SDGs) –
were set to be achieved by 2030 (United Nations, 2015b). The third SDG includes maternal
health targets to further reduce the global MMR and to achieve universal access to RH ser-
vices. These efforts highlight the importance placed on reducing the number of maternal
deaths globally.
Countries in sub-Saharan Africa bear the burden of maternal mortality; it is estimated
that sub-Saharan Africa accounted for 66% of global maternal deaths in 2015 (WHO,
2015). The situation in Nigeria, the most populous country in Africa, is not different.
Although Nigeria saw a 40% decline in the MMR from 1990 to 2015, the current MMR
remains high at 814 maternal deaths per 100,000 live births (WHO, 2015). Approximately
58,000 Nigerian women died from pregnancy-related complications, making Nigeria the
highest contributor to global maternal mortality in 2015 (WHO, 2015). Like many devel-
oping countries, low literacy rates coupled with high levels of poverty constitute significant
barriers to RH services contributing to the high MMR (Ahmed, Creanga, Gillespie, & Tsui,
2010). One way to reduce maternal deaths is through improving access to contraceptive
services, which contributes to reductions in the levels of unwanted pregnancy and
unsafe abortions (Canning & Schultz, 2012; Cleland, Conde-Agudelo, Peterson, Ross, &
Tsui, 2012). Contraceptive use also helps to prevent adolescent pregnancy, thus helping
young girls stay in school to complete their education, further promoting gender equality
and reducing poverty (Shaw, 2009; United Nations Population Fund, 2013). In addition,
antenatal and delivery care improve pregnancy outcomes by ensuring access to trained
health providers who are able to intervene with life-saving care in the event of a compli-
cation during pregnancy and delivery (WHO, 2004). Increasing access to RH services,
such as contraceptive, antenatal, delivery, and postnatal care services, has the potential
to save lives and promote maternal well-being in Nigeria.
In concert with global development goals, the Nigerian government has made several
efforts to provide RH services in diverse ways. Their efforts include, but are not limited
to: (a) provision of free health care services to pregnant women; (b) training and deploy-
ment of midwives to areas of greatest need; and (c) distribution of free modern contracep-
tive methods (Erim, Resch, & Goldie, 2012). In spite of these strategies, access to and use of
RH services remain lower than optimal. Many women who stand to benefit from these RH
services often do not make use of them due to several socio-economic and demographic
factors (Aremu, 2013; Babalola & Fatusi, 2009; Rai, Singh, & Singh, 2012). Despite the
maternal health improvements achieved in the MDG-era, striking disparities in specific
RH indicators are observed across sub-populations. Whereas the proportion of reproduc-
tive-age women in Nigeria using a modern contraceptive method in 2013 was 11%, there
were disparities based on socio-demographic sub-grouping (National Population Com-
mission [Nigeria] and ICF Macro, 2014). For example, only 6% of rural women compared
to 17% of urban women practised modern contraception in 2013. Similarly, adolescent
birth is more prevalent among adolescents with no education compared to their counter-
parts with secondary or higher education (37% vs. 8%). Several other RH indicators vary
among population sub-groups. While 60% of women with a recent livebirth received ante-
natal care from a skilled provider, only 25% of the poorest women, compared to 94% of
their wealthiest counterparts, reported skilled antenatal care (National Population Com-
mission [Nigeria] and ICF Macro, 2014). Similarly, only 6% of births among the
650 C. C. OKIGBO ET AL.

poorest women, compared to 85% among the wealthiest, were attended by a skilled pro-
vider. These demographic disparities suggest the need for targeted interventions to reduce
barriers to accessing RH services.
The purpose of this study was to examine the trends in four RH indicators in Nigeria –
modern contraceptive prevalence rate (CPR), skilled antenatal care, skilled birth attend-
ance, and adolescent birth. These are standard indicators for global RH monitoring and
were used to track the MDGs (WHO, 2004). Unlike MMR and total fertility rate, also
RH indicators, the trends in the indicators assessed in this study, have not been recently
examined in Nigeria. Thus, we assessed the changes in the trends of these indicators
between 1990 and 2013 – the MDG-era – using data from nationally representative house-
hold-based surveys. In addition, we assessed the current key socio-demographic determi-
nants of the four indicators. This study is timely, as our findings will contribute to the
identification of key population sub-groups to consider in establishing national targets
for the achievement of the third SDG in Nigeria.

Conceptual framework
Andersen’s behavioural model of health services use provides a useful lens for examining
patterns and determinants of the use of RH services (Andersen, 1995; Andersen &
Davidson, 2007). The model identifies the interplay of predisposing, enabling, and need
factors and their effect on health service use. The need factors include perceived or eval-
uated health status (e.g. ability to achieve desired fertility), which in turn influence the
need for health service. The predisposing factors include demographic characteristics
such as age and rural/urban residence, which also influence the health service need. For
example, reproductive-age women may need to limit or space childbearing, thus requiring
contraception. The enabling factors include resources such as wealth, which affects the
probability of seeking the health service. Using Andersen’s model, it is proposed that
access to contraceptive services, skilled antenatal care, skilled birth attendance, and pre-
vention of adolescent births will differ among various sub-groups of reproductive-age
women according to their predisposing, enabling, and need factors. In this study, it is
hypothesised that between 1990 and 2013, the trends in these four RH indicators will
change significantly in line with the targets of the development goals. Additionally, this
study hypothesises that the change in trends will differ based on key predisposing and
enabling factors such as wealth, education, and residence.

Methods
Study setting and design
Nigeria is a West African country and currently has the highest population in Africa
(Population Reference Bureau, 2015). With an annual population growth rate of 3%,
Nigeria is projected to be one of the highest populated countries in the world by 2050,
fourth only to India, China, and the United States (Population Reference Bureau, 2015).
Nigeria is divided into six geopolitical zones with 36 states and a federal capital territory
(Central Intelligence Agency, 2014). It is estimated that one-half of Nigeria’s population
currently lives in urban areas and that 70% of the population lives below the poverty
 GLOBAL PUBLIC HEALTH 651

line (<$1.25 per day) (Central Intelligence Agency, 2014). About 50% of Nigeria’s popu-
lation is Muslim while the rest are Christian or belong to other indigenous religions
(Central Intelligence Agency, 2014).
The data for this study are from the available Nigeria Demographic and Health Surveys
(NDHS) (The DHS Program, 2015). The NDHS data are nationally representative cross-
sectional samples of the population residing in non-institutional settings in the country.
The samples were selected using a stratified two-stage cluster design. Each year’s
sample was designed to provide estimates of population and health indicators at the
national, zonal, and state levels. In the first stage of the cluster sampling design, a
random sample of enumeration areas is drawn from the most recent census files prior
to the survey. For the second stage, in each selected enumeration area, a random
sample of households is drawn from an updated list of households. The NDHS is a house-
hold-based survey that collects information from eligible men and women within the
households. In this study, we analysed the NDHS women’s data set files for the years
1990, 1999, 2003, 2008, and 2013. The women’s data include information on a wide
range of RH indicators and offer an advantage for comparative analysis because of the
use of standardised questionnaires and rigorous data collection and processing
procedures.

Sample
The study sample includes women who participated in the women’s surveys. Women were
eligible to participate if they were aged 15–49 years at the time of survey and were residents
of the selected household or visitors who slept in the household the night prior to the
survey. In 1990, 8781 women were interviewed out of 9200 eligible women – a response
rate of 95% (National Population Commission [Nigeria], 1992). In 1999, the response rate
was 92%, as 8199 women out of the 8918 eligible women were interviewed (National
Population Commission [Nigeria], 2000). The response rate in the 2003 survey was
95% as, out of the 7985 eligible women, 7620 women were interviewed (National Popu-
lation Commission [Nigeria] & ORC Macro, 2004). In 2008, out of the 34,596 eligible
women, 33,385 women were interviewed, with a response rate of 96% (National Popu-
lation Commission [Nigeria] & ICF Macro, 2009). While in 2013, 38,948 women out of
the eligible 39,902 women were interviewed, giving a response rate of 98% (National Popu-
lation Commission [Nigeria] & ICF Macro, 2014).

Measures
Four RH indicators were included as the outcome measures – modern CPR, skilled ante-
natal care, skilled birth attendance, and adolescent birth. The first indicator, modern CPR,
was defined as the proportion of reproductive-age women who reported use of any
modern contraceptive method at the time of survey. The modern contraceptive
methods included daily pills, injections, implants, intrauterine devices, male or female
condoms, male or female sterilisation, diaphragms, spermicides (gels or foam), and emer-
gency contraceptive pills. All sampled women irrespective of their marital status, fecundity
or sexual experiences were included in this analysis. This outcome variable is a binary vari-
able: coded ‘1’ for reporting use of a modern contraceptive method and ‘0’ otherwise. The
652 C. C. OKIGBO ET AL.

second indicator, skilled antenatal care, was defined as women who reported receiving at
least one antenatal care during their most recent birth from doctors, nurses, or midwives.
Women who did not receive at least one antenatal care from the aforementioned health
professionals were coded as not having skilled antenatal care. This analysis used a sub-
sample of only women with a recent birth in the five years preceding the survey. The
reason for using this sub-sample is to reduce the potential of recall bias, as it is easier
for a woman with a recent birth to remember whether she had skilled antenatal care
than those whose last birth were more than five years prior to survey (The DHS
Program, 2015). The outcome variable for this sub-analysis is also a binary variable:
coded ‘1’ for skilled antenatal care and ‘0’ otherwise.
The third indicator, skilled birth attendance, was defined as child deliveries assisted by
doctors, nurses, or midwives. Women whose deliveries were assisted by other individuals
not listed above (example, traditional birth attendants, relatives, or no one) were coded as
having unskilled birth attendance. This analysis used a sub-sample of only women with a
recent birth in the five years preceding the survey for the same reason as for skilled ante-
natal care. The outcome variable for this sub-analysis is also a binary variable: coded ‘1’ for
skilled birth attendance and ‘0’ otherwise. The fourth indicator, adolescent birth, was
defined as the proportion of adolescents who have had a birth. This sub-analysis was
restricted to women aged 15–19 years and the binary outcome variable coded as ‘1’ for
any live birth and ‘0’ otherwise.
Other variables used in these analyses include socio-demographic variables such as
age, education, religion, marital status, parity, fertility intention, household wealth, resi-
dence, and region. The woman’s age was included as a categorical variable: 15–19, 20–
24, 25–29, 30–34, 35–39, 40–44, and 45–49 years. Education was categorised as no
formal education, primary, secondary, or tertiary education. The religious affiliation,
which included Catholicism, Protestantism, other Christianity, Islam, Traditionalism,
and other religion, was recoded as ‘1’ if Islam and ‘0’ if Christian/Others. Marital/
union status, which included never married, married, living together, widowed,
divorced, and not living together, was recoded into a binary variable coded ‘1’ if cur-
rently married/cohabiting and ‘0’ otherwise. For the adolescents sub-sample, the
marital status variable was recoded to reflect whether they had early marriage or not.
The early marriage was defined as being 15 years or younger at first union (mar-
riage/cohabitation). The woman’s parity was defined as the number of children ever
born and was recoded as ‘0’, ‘1–4’, or ‘5 or more’ children. The fertility intention vari-
able was created using the question that asked the women whether they wanted to have
a/another child. The women who said that they wanted ‘no more children’ were coded
as ‘1’ while those who said they wanted more children or were undecided were coded
‘0’. The woman’s residence was categorised as either residing in an urban or rural area.
The household wealth index was calculated based on principal component analysis of
household ownership of various assets and on housing characteristics. This method
of calculating household wealth has been validated in several settings including
Nigeria (Rutstein & Johnson, 2004). The household wealth index was divided into quin-
tiles: poorest, poor, middle, rich, and richest. The region variable reflected the six geo-
political zones in Nigeria: north-central, north-east, north-west, south-east, south-west,
and south-south zones. These factors have been found to be associated with RH out-
comes in Nigeria (Babalola & Fatusi, 2009; Rai et al., 2012).
 GLOBAL PUBLIC HEALTH 653

Statistical analysis
All statistical analyses were weighted to control for clustering of women within house-
holds, using the ‘svy’ command in Stata (StataCorp, 2013). Descriptive statistics were con-
ducted by year of survey and shown in Table 1. In addition, the four RH indicators were
described for the sample and trend analyses were conducted (Table 2). The age distri-
bution of the sampled women was similar across all time points; hence, it was not necess-
ary to calculate age-adjusted rates. The four indicators were further evaluated based on
stratification by residence (urban vs. rural), household wealth (poorest vs. richest), and
education (none, primary, or secondary or tertiary). The stratified analyses were con-
ducted to assess disparities in the trends of the indicators in order to identify at-risk

Table 1. Socio-demographic characteristics of reproductive-age women, NDHS 1990–2013.

1990 1999 2003 2008 2013
N (%) N (%) N (%) N (%) N (%)
Age
15–19 1612 (18.3) 1775 (21.6) 1716 (22.5) 6493 (19.4) 7820 (20.1)
20–24 1676 (19.1) 1521 (18.5) 1494 (19.6) 6133 (18.4) 6757 (17.4)
25–29 1669 (19.0) 1516 (18.5) 1382 (18.1) 6309 (18.9) 7145 (18.3)
30–34 1409 (16.1) 1137 (13.9) 941 (12.4) 4634 (13.9) 5467 (14.0)
35–39 954 (10.9) 992 (12.1) 816 (10.7) 3912 (1.7) 4718 (12.1)
40–44 836 (9.5) 696 (8.5) 688 (9.0) 3032 (9.1) 3620 (9.3)
45–49 625 (7.1) 569 (6.9) 583 (7.7) 2872 (8.6) 3421 (8.8)
Marital Status
Never married/cohabiting 1513 (17.2) 2130 (25.9) 1926 (25.3) 8397 (25.2) 9326 (23.9)
Currently married/cohabiting 6880 (78.4) 5757 (70.2) 5336 (70.0) 23,576 (70.6) 27,829 (71.5)
Formerly married/cohabiting 388 (4.4) 319 (3.9) 358 (4.7) 1410 (4.2) 1793 (4.6)
Religion
Christian 4186 (47.7) 4432 (54.0) 3654 (48.0) 17,907 (53.6) 18,239 (46.8)
Muslim 4174 (47.5) 3587 (43.7) 3862 (50.7) 14,826 (44.4) 20,148 (51.7)
Others/Traditional/None 421 (4.8) 187 (2.3) 104 (1.3) 652 (2.0) 561 (1.5)
Education
No formal 5020 (57.2) 3324 (40.5) 3171 (41.6) 11,942 (35.8) 14,730 (37.8)
Primary 2099 (23.9) 1868 (22.8) 1628 (21.4) 6566 (19.7) 6734 (17.3)
Secondary 1499 (17.1) 2506 (30.5) 2370 (31.1) 11,903 (35.6) 13,926 (35.8)
Tertiary 163 (1.8) 508 (6.2) 451 (5.9) 2974 (8.9) 3558 (9.1)
Parity
0 child 2128 (24.2) 2580 (31.5) 2363 (31.0) 9981 (29.9) 11,333 (29.1)
1–2 children 2069 (23.6) 1822 (22.2) 1699 (22.3) 7181 (21.5) 8538 (21.9)
3–4 children 1756 (20.0) 1609 (19.6) 1290 (16.9) 6508 (19.5) 7670 (19.7)
5+ children 2828 (32.2) 2195 (26.7) 2268 (39.8) 9714 (29.1) 11,407 (29.3)
Household wealth
Poorest 1742 (19.8) 1812 (22.1) 1414 (18.6) 6194 (18.5) 7132 (18.3)
Poor 1790 (20.4) 1629 (19.9) 1439 (18.9) 6234 (18.7) 7428 (19.1)
Middle 1752 (20.0) 1592 (19.4) 1513 (19.8) 6341 (19.0) 7486 (19.2)
Rich 1727 (19.7) 1612 (19.6) 1526 (20.0) 6938 (20.8) 7992 (20.5)
Richest 1770 (20.1) 1561 (19.0) 1728 (22.7) 7678 (23.0) 8910 (22.9)
Residence
Rural 6594 (75.1) 5666 (69.1) 4991 (65.5) 21,450 (64.3) 22,535 (57.9)
Urban 2187 (24.9) 2540 (30.9) 2629 (34.5) 11,935 (35.7) 16,413 (42.1)
Region
North-Central na 1861 (22.7) 1121 (14.7) 4748 (14.2) 5572 (14.3)
North-East 1999 (22.8) 1292 (15.7) 1368 (17.9) 4262 (12.8) 5766 (14.8)
North-West 2098 (23.9) 1087 (13.3) 2095 (27.5) 8022 (24.0) 11,878 (30.5)
South-East 2768 (31.5) 1886 (23.0) 734 (9.7) 4091 (12.3) 4476 (11.5)
South-South na na 1342 (17.6) 5473 (16.4) 4942 (12.7)
South-West 1915 (21.8) 2080 (25.3) 958 (12.6) 6789 (20.3) 6314 (16.2)
Weighted total 8781 8206 7620 33,385 38,948
Note: NDHS: Nigeria Demographic and Health Surveys; na: not available.
654 C. C. OKIGBO ET AL.

Table 2. Proportion of women who reported current use of modern contraceptive methods, NDHS
1990–2013.
p-value for
Indicators Category 1990 1999 2003 2008 2013 trend
All women aged 15–49 years (%) Total 3.7 8.9 8.9 10.5 11.1 <.001
Residence
Urban 9.1 14.0 13.6 16.2 16.7 <.001
Rural 2.0 6.6 6.4 7.3 7.1 <.001
Household
wealth
Poorest 0.5 2.1 4.2 2.5 0.9 0.497
quintile
Richest quintile 11.0 19.0 18.5 20.1 22.2 <.001
Education
None 1.3 3.2 2.4 2.6 1.7 .614
Primary 4.5 8.7 9.3 10.6 12.8 <.001
Secondary 9.3 12.6 14.5 14.6 16.5 <.001
Tertiary 19.3 28.1 23.8 25.4 26.0 .269
Weighted n 8781 8206 7620 33,385 38,948
Adolescent women aged 15–19 Total 1.9 3.2 4.7 4.7 4.8 <.001
years (%) Residence
Urban 4.6 4.2 6.2 6.0 6.5 .006
Rural 0.7 2.8 3.9 4.0 3.6 <.001
Household
wealth
Poorest 0.2 1.8 3.0 2.4 0.3 .163
quintile
Richest quintile 4.7 3.8 8.3 6.4 8.1 .001
Education
None 0.2 0.7 1.2 0.7 0.1 .363
Primary 1.3 2.4 3.7 2.4 2.7 .341
Secondary 4.2 4.4 6.9 6.7 7.1 <.001
Tertiary 10.2 26.4 15.7 16.8 18.2 .881
Weighted n 1612 1775 1716 6493 7820
Notes: Modern contraceptive methods included daily pills, injections, implants, intrauterine device, diaphragm, spermi-
cides, female or male sterilisation, female or male condoms, and emergency pills. NDHS: Nigeria Demographic and
Health Surveys.

populations. To analyse the trends across the survey years, trend tests were conducted
using the ‘nptrend’ command in Stata. A two-tailed p value <.05 was considered statisti-
cally significant. Finally, we used logistic regression analyses to assess the socio-demo-
graphic factors associated with the outcomes in the 2013 NDHS. The rationale was that
the logistic regression results might identify current at-risk populations to be targeted
in the SDG-era. An interaction term between residence and wealth was also included in
the logistic regression models to test whether the effects of these two factors interact to
have differential effects on the outcomes. The goodness-of-fit tests of the regression
models were conducted; only the results of the models with the best fit are described.

Ethical approval
All survey procedures were approved by the National Health Research Ethics Committee
in Nigeria. The women’s surveys were conducted by trained female interviewers who
sought informed consent from the eligible women prior to conducting the interviews
using paper-and-pencil questionnaires. Access to the data sets was obtained from the
DHS Program.
 GLOBAL PUBLIC HEALTH 655

Results
Table 1 shows the distribution of our sample by survey year. Across all surveys, women
were mostly aged 15–29 years (>50%) and greater proportions of them were married/coha-
biting at the time of surveys (≥70%). The women had predominantly Christian and Muslim
religious affiliations with less than 5% of the women reporting traditional or no religion
across all surveys. Having secondary or tertiary education increased over the years from
19% in 1990 to 45% in 2013. Across the years, about one-quarter to one-third of the
women reported having no children while the proportion that reported having five or
more children ranged from 27% to 40%. The household wealth was equally distributed
across all quintiles as expected, given the method of calculation. Additionally, the pro-
portion of the women living in urban areas increased from 25% in 1990 to 42% in 2013.
Nigeria had four geopolitical zones (regions) in 1990, five by 1999, and six by 2003
onwards. The proportion of women living in these regions is shown in Table 1.
The four RH indicators are described in Figure 1 and Tables 2–5. The modern CPR had a
consistent increase across the years from 3.7% in 1990 to 11.1% in 2013 (Table 2). This
positive trend was statistically significant at p < .001. The trends in urban and rural areas
were also positive though the proportions in urban areas were consistently higher than
those in the rural areas across all years. The trend among the richest women increased over-
time (p < .001) but that in the poorest women did not (p = .497). The trend among those
with no formal education did not change overtime (p = .614); likewise, those with tertiary
education (p < .269). However, the trends among those with primary and secondary edu-
cation increased across surveys (p < .001). A sub-analysis of the trends in modern CPR
among adolescent women was conducted and also shown in Table 2. The trends were
similar to those of all reproductive-age women except for the fact it was only those with
secondary education that saw a significant positive trend in modern CPR across the surveys.

Figure 1. Trends in four reproductive health indicators in Nigeria, 1990–2013. (a) Proportion using
modern CPR at time of survey; (b) proportion who received skilled antenatal care at time of survey;
(c) proportion who received skilled birth attendance during most recent birth and (d) proportion of
adolescent women with a livebirth at the time of survey.
656 C. C. OKIGBO ET AL.

Table 3. Proportion of women who reported skilled antenatal care during recent pregnancy, NDHS
1990–2013.
p-value for
Indicators Category 1990 1999 2003 2008 2013 trend
All women aged 15–49 years Total 57.2 49.8 58.0 57.7 60.6 <.001
(%) Residence
Urban 84.2 65.6 82.8 83.8 86.0 <.001
Rural 49.8 43.7 47.8 46.4 46.5 <.001a
Household
wealth
Poorest 31.6 25.0 33.9 23.5 24.6 <.001a
quintile
Richest quintile 91.0 71.6 95.8 93.8 94.5 <.001
Education
None 44.2 3.5 35.9 30.8 36.2 <.001 a
Primary 73.3 64.8 72.0 69.0 71.5 <.001 a
Secondary 91.2 74.1 87.5 86.0 87.6 .595
Tertiary 98.5 67.6 98.1 97.4 97.3 <.001 a
Weighted n 8781 8206 7620 33,385 38,948
Adolescent women aged 15–19 Total 45.5 39.4 50.0 40.9 46.8 .316
years (%) Residence
Urban 84.7 68.3 77.8 72.7 77.5 .565
Rural 36.8 34.0 42.2 34.3 40.0 .003
Household
wealth
Poorest 23.2 20.7 28.8 19.9 26.5 .049
quintile
Richest quintile 87.4 90.3 96.6 79.2 94.2 .805
Education
None 30.0 25.8 37.4 25.8 29.3 .275
Primary 60.9 65.3 65.8 54.4 63.0 .106
Secondary 94.9 79.8 77.1 70.8 80.6 .012 a
Tertiary 0.0 0.0 0.0 100.0b 100.0b –
Weighted n 1612 1775 1716 6493 7820
Notes: Skilled antenatal care defined as receiving antenatal care from a doctor, nurse, or midwife at least once during a
pregnancy in the last five years. NDHS: Nigeria Demographic and Health Surveys.
a
Statistically significant negative trend.
b
Only two adolescents and one adolescent with tertiary education had a recent birth in 2008 and 2013, respectively.

Table 3 shows the trends in the second indicator, skilled antenatal care. A statistically
significant positive trend was observed across all surveys (p < .001). The trend increased
from 57.2% in 1990 to 60.6% in 2013; the positive trend was not linear, as there was a
decrease in 1999. Among urban women, there was a statistically significant positive
trend from 84.2% in 1990 to 86% in 2013 (p < .001). However, there was a negative
trend among rural women decreasing from 49.8% in 1990 to 46.5% in 2013 (p < .001).
In assessing wealth disparity, there was a non-linear negative trend in skilled antenatal
care among the poorest women decreasing from 31.6% in 1990 to 24.6% in 2013 (p < .001).
This represents a 22% reduction in the proportion of poorest women who received skilled
antenatal care during their most recent childbirth. On the contrary, there was a positive
trend among the richest women, increasing from 91% in 1990 to 94.5% in 2013 (p < .001).
The trends decreased across surveys for those with no formal education (44.2–36.2%),
primary education (73.3–71.5%), and tertiary education (98.5–97.3%); however, the
trend for those with secondary education, though negative, did not reach statistical signifi-
cance (p = .595). For adolescent women, only trends for rural areas (36.8–40%), poorest
women (23.2–26.5%), and secondary education (94.9–80.6%) reached statistical signifi-
cance (p < .05).
 GLOBAL PUBLIC HEALTH 657

Table 4. Proportion of women who reported skilled birth attendance during recent pregnancy, NDHS
1990–2013.
p-value for
Indicators Category 1990 1999 2003 2008 2013 trend
All women aged 15–49 years Total 30.8 32.0 37.1 40.6 40.0 <.001
(%) Residence
Urban 60.2 45.6 61.0 67.5 69.1 <.001
Rural 22.7 26.7 27.2 28.9 23.9 .129
Household
wealth
Poorest 10.6 12.6 13.0 8.9 6.1 <.001a
quintile
Richest quintile 70.9 60.4 85.0 86.6 87.0 <.001
Education
None 15.6 12.0 13.4 12.7 12.6 <.001a
Primary 47.6 43.3 46.3 45.3 45.8 <.001a
Secondary 74.1 59.2 72.9 73.1 72.2 .039a
Tertiary 94.8 63.3 90.3 94.0 93.7 <.001a
Weighted n 8781 8206 7620 33,385 38,948
Adolescent women aged 15–19 Total 24.2 19.6 28.0 27.1 26.0 .414
years (%) Residence
Urban 42.5 38.2 56.6 52.5 57.0 .036
Rural 20.2 16.1 19.9 21.8 19.1 .274
Household
wealth
Poorest 7.4 10.1 4.7 11.1 9.8 .362
quintile
Richest quintile 50.3 66.6 71.0 64.9 72.7 .263
Education
None 12.0 8.0 15.0 13.7 11.0 .413
Primary 34.4 39.2 43.6 34.5 33.8 .239
Secondary 67.4 58.2 56.5 56.7 58.8 .007a
Tertiary 0.0 0.0 0.0 100.0b 100.0b –
Weighted n 1612 1775 1716 6493 7820
Notes: Skilled birth attendance defined as birth in the last five years assisted by a doctor, nurse, or midwife. NDHS: Nigeria
Demographic and Health Surveys.
a
Statistically significant negative trend.
b
Only two adolescents and one adolescent with tertiary education had a recent birth in 2008 and 2013, respectively.

Table 4 shows the trends in the third indicator, skilled birth attendance. A statisti-
cally significant positive trend was observed across all surveys (p < .001). The trend
increased from 30.8% in 1990 to 40% in 2013; the trend stalled between 2008 and
2013. Among urban women, there was a statistically significant positive trend from
60.2% in 1990 to 69.1% in 2013 (p < .001). The trend among rural women, which
was about 1% increase from 1990 to 2013, was not statistically significant. The trend
for the poorest women increased from 1990 to 2003 (10.6–13%) but declined
between 2003 and 2013 (13–6.1%) – a 53% reduction in the proportion of poorest
women who received skilled birth attendance during their most recent childbirth in
a 10-year period. On the contrary, there was a positive trend among the richest
women, increasing from 70.9% in 1990 to 87% in 2013 (p < .001). There were statisti-
cally significant negative trends for all education groups (p < .001). For the adolescent
women, there were positive trends in skilled birth attendance for those in urban areas
and a negative trend for those with secondary education (p < .05). All the other groups
were not statistically significant.
The trend in adolescent birth is shown in Table 5. The proportion of adolescent women
who had ever had a birth decreased from 23.5% in 1990 to 17.1% in 2013 (p < .001),
658 C. C. OKIGBO ET AL.

Table 5. Proportion of adolescent women in Nigeria who had ever given birth, DHS 1990–2013.
Indicators Category 1990 1999 2003 2008 2013 p-value for trend
Adolescent birth (%) Total 23.5 18.4 21.0 18.0 17.1 <.001a
Residence
Urban 14.6 9.5 13.6 8.9 7.5 <.001a
Rural 27.0 22.3 24.8 22.9 24.1 .002a
Household wealth
Poorest quintile 44.6 39.1 27.4 35.7 34.1 .025a
Richest quintile 9.1 3.4 10.1 3.1 3.5 <.001a
Education
None 43.4 50.1 44.5 44.0 37.0 <.001a
Primary 18.4 16.2 20.5 21.0 22.7 .006
Secondary 8.4 3.9 7.6 6.8 6.9 .131
Tertiary 0.0 0.0 0.0 2.7 0.7 .789
Weighted n 1612 1775 1716 6493 7820
Note: NDHS: Nigeria Demographic and Health Surveys.
a
Statistically significant negative trend.

though there was a slight increase in 2003. This non-linear negative trend was observed
among urban and rural women, the poorest and richest women, and among those with
no formal education (p < .01). Among those with primary education, the trend in adoles-
cent birth increased across surveys from 18.4% in 1990 to 22.7% in 2013 (p = .006).
However, there was no statistically significant trends observed among those with second-
ary or tertiary education (p > .05).
The results of the multivariate logistic regression analyses assessing the associations
between key socio-demographic factors and the indicators using the 2013 NDHS are as
follows:

. Modern CPR: Compared to women aged 15–19, those aged 20 years and older had
higher odds of reporting modern contraceptive use (aOR: 1.2–3.6; p < .001). Women
who had formal education had higher odds of reporting modern contraceptive use
compared to those with no formal education (aOR: 2.7–4.8; p < .001). Muslim
women were 40% less likely to report modern contraceptive use compared to Chris-
tians/Others (aOR: 0.6; 95% CI: 0.5–0.7). Likewise, women who were married/cohabit-
ing had lower odds of reporting modern contraceptive use compared to those who were
not married/cohabiting (aOR: 0.6; 95% CI: 0.5–0.7). Compared to women with no chil-
dren, those who had three or more children had higher odds of modern contraceptive
use (aOR: 1.5–2.0; p < .001); however, there was no statistical difference between
women with no children and those with one to two children (p > .05). Women who
reported not wanting any more children had higher odds of modern contraceptive
use compared to those who reported wanting more children (aOR: 1.7; 95% CI: 1.5–
1.9). Compared to women in north-central region, women in north-east, north-west,
and south-east had lower odds of modern contraceptive use (aOR: 0.5–0.7; p < .05),
while women in south-west had higher odds of modern contraceptive use (aOR: 1.3;
95% CI: 1.1–1.4). Compared to women living in the poorest households in rural
areas, those living in all the other wealth groups in rural areas had higher odds of
reporting modern contraceptive use (aOR: 1.9–3.7; p < .001). Women living in the
poorest households in urban areas were not statistically different from women living
in the poorest households in rural areas in their modern contraceptive use (p > .05);
however, women living in all the other wealth groups in urban areas had higher
 GLOBAL PUBLIC HEALTH 659

odds of reporting modern contraceptive use compared to the poorest women in rural
areas (aOR: 1.7–4.4; p < .05).
. Skilled antenatal care: Compared to women aged 15–19, those aged 30 and older had
higher odds of receiving skilled antenatal care during their most recent birth (aOR:
1.3–1.4; p < .05). There was no statistical difference in skilled antenatal care between
women aged 15–19 and those aged 20–29 (p > .05). Women with primary, secondary,
or tertiary education also had higher odds of reporting skilled antenatal care compared
to those with no formal education (aOR: 2.2–9.0; p < .001). There was no association
between religious affiliation and skilled antenatal care and between current union
status and skilled antenatal care (p > .05). Compared to women with 1–2 children,
those with five or more children had lower odds skilled antenatal care (aOR: 0.8;
95% CI: 0.7–0.9). Compared to women living in north-central region, women in
north-west and south-south regions had lower odds of skilled antenatal care, while
women in south-east region had higher odds of skilled antennal care (p < .001).
Women in the poorest households in rural areas were the least likely to report
skilled antenatal care as women in all the other wealth groups in the rural areas
(aOR: 1.8–9.2; p < .001) and all the wealth groups in urban areas (aOR: 1.6–15.6; p
< .05) had higher odds of skilled antenatal care.
. Skilled birth attendance: Women who were aged 30 and older had higher odds of skilled
birth attendance compared to women aged 15–19 years (aOR: 1.3–1.6; p < .05). There
was a positive association between education and skilled birth attendance, as women
with primary, secondary, or tertiary education had higher odds of skilled birth attend-
ance compared to those with no formal education (aOR: 1.7–8.6; p < .001). There was
no association between religion and skilled birth attendance (p > .05); however,
married/cohabiting women were 30% more likely to report skilled birth attendance
compared to those who were not married/cohabiting (aOR: 1.3; 95% CI: 1.1–1.5).
On the other hand, women with three or more children had lower odds of reporting
skilled birth attendance compared to those with one to two children (aOR: 0.6–0.7;
p < .001). Compared to women living in the north-central region, those in north-
east, north-west, and south-south had lower odds of skilled birth attendance while
those in south-east and south-west regions had higher odds of skilled birth attendance
(p < .001). Just like in skilled antenatal care, women in the poorest households in rural
areas were the least likely to report skilled birth attendance, as women in all the other
wealth groups in the rural areas (aOR: 2.1–9.0; p < .001) and all the wealth groups in
urban areas (aOR: 2.3–22.6; p < .001) had higher odds of skilled birth attendance.
. Adolescent birth: Compared to adolescent women with no formal education, those with
secondary or tertiary education had lower odds of reporting adolescent birth (aOR: 0.1–
0.5; p < .05). There was no statistical difference in adolescent birth between those with
no formal education and those with primary education (p > .05). There was also no
association between religion and adolescent birth (p > .05). However, adolescent
women who got into a marital union at 15 years or younger had 14.7 times the odds
of adolescent birth compared to those who did not have such an early marital union
(aOR: 14.7; 95% CI: 11.5–18.7). Compared to adolescent women living in the north-
central region, those in the south-south region had higher odds of reporting adolescent
birth (aOR: 1.6; 95% CI: 1.1–2.2). There were no statistically significant associations for
the other regions (p > .05). Compared to adolescent women in the poorest households
660 C. C. OKIGBO ET AL.

in rural areas, those in richest households in the rural areas and those in the richest
households in the urban areas had lower odds of reporting adolescent births (aOR:
0.4 each; p < .05). The other groups were not statistically different from the reference
category (p > .05) (Table 6).

Table 6. Adjusted logistic regression models of the reproductive health indicators in Nigeria, DHS 2013.
Modern CPR Skilled ANC SBA Adolescent Birth
AOR (95% C.I.) AOR (95% C.I.) AOR (95% C.I.) AOR (95% C.I.)
Age
15–19 ref ref ref –
20–24 3.6 (3.1–4.1)*** 1.1 (0.9–1.3) 0.9 (0.8–1.1) –
25–29 3.3 (2.8–3.8)*** 1.2 (1.0–1.4) 1.0 (0.8–1.2) –
30–34 2.8 (2.3–3.3)*** 1.3 (1.1–1.6)* 1.3 (1.1–1.6)* –
35–39 2.6 (2.2–3.1)*** 1.4 (1.1–1.7)** 1.5 (1.2–1.9)** –
40–44 2.3 (1.9–2.8)*** 1.3 (1.1–1.7)* 1.6 (1.2–2.0)*** –
45–49 1.2 (0.9–1.4) 1.3 (1.1–1.7)* 1.6 (1.2–2.1)** –
Education
None ref ref ref ref
Primary 2.7 (2.2–3.3)*** 2.2 (2.0–2.5)*** 1.7 (1.5–1.9)*** 1.1 (0.9–1.5)
Secondary 3.7 (3.1–4.5)*** 3.9 (3.4–4.6)*** 3.0 (2.6–3.5)*** 0.5 (0.4–0.7)***
Tertiary 4.8 (3.9–5.9)*** 9.0 (6.2–13.0)*** 8.6 (6.5–11.5)*** 0.1 (0.1–0.6)*
Religion
Christian/Others ref ref ref ref
Muslim 0.6 (0.5–0.7)*** 1.2 (1.0–1.5) 0.8 (0.7–1.0) 0.9 (0.7–1.1)
Current union status
Not married/cohabiting ref ref ref –
Married/cohabiting 0.6 (0.5–0.7)*** 1.0 (0.8–1.2) 1.3 (1.1–1.5)** –
Early marriage
No – – – ref
Yes – – – 14.7 (11.5–18.7)***
Parity
0 child ref – – –
1–2 children 1.0 (0.9–1.1) ref ref –
3–4 children 1.5 (1.3–1.7)*** 0.9 (0.8–1.0) 0.7 (0.6–0.8)*** –
5+ children 2.0 (1.7–2.4)*** 0.8 (0.7–0.9)* 0.6 (0.5–0.7)*** –
Fertility intention
Want more children ref – – –
No more children 1.7 (1.5–1.9)*** – – –
Geopolitical zones
North-Central ref ref ref Ref
North-East 0.5 (0.4–0.6)*** 0.9 (0.7–1.2) 0.5 (0.4–0.6)*** 1.0 (0.7–1.4)
North-West 0.6 (0.4–0.9)* 0.6 (0.4–0.7)*** 0.2 (0.2–0.3)*** 0.8 (0.6–1.1)
South-East 0.7 (0.6–0.8)*** 2.1 (1.5–2.9)*** 2.3 (1.7–3.2)*** 0.9 (0.6–1.3)
South-South 1.0 (0.8–1.1) 0.4 (0.3–0.5)*** 0.4 (0.3–0.5)*** 1.6 (1.1–2.2)**
South-West 1.3 (1.1–1.4)** 1.2 (0.8–1.7) 1.7 (1.3–2.3)*** 1.0 (0.7–1.5)
Wealth*Residence
Rural Poorest ref ref ref Ref
Rural Poor 1.9 (1.3–2.8)*** 1.8 (1.5–2.2)*** 2.1 (1.7–2.6)*** 1.0 (0.8–1.2)
Rural Middle 2.9 (2.0–4.2)*** 3.4 (2.7–4.2)*** 4.0 (3.1–5.0)*** 1.3 (1.0–1.7)
Rural Rich 3.4 (2.3–4.9)*** 4.8 (3.7–6.3)*** 5.5 (4.2–7.2)*** 1.0 (0.7–1.4)
Rural Richest 3.7 (2.5–5.5)*** 9.2 (6.5–13.0)*** 9.0 (6.3–12.9)*** 0.4 (0.3–0.9)*
Urban Poorest 0.8 (0.4–1.9) 1.6 (1.1–2.4)* 2.3 (1.4–3.7)*** 1.0 (0.5–2.1)
Urban Poor 1.7 (1.1–2.8)* 3.4 (2.3–5.0)*** 3.4 (3.1–5.0)*** 0.8 (0.5–1.3)
Urban Middle 2.8 (1.9–4.2)*** 4.8 (3.6–6.3)*** 5.9 (4.5–7.8)*** 0.8 (0.6–1.3)
Urban Rich 3.7 (2.5–5.5)*** 9.8 (7.5–13.0)*** 11.3 (8.9–14.4)*** 0.8 (0.6–1.1)
Urban Richest 4.4 (3.0–6.4)*** 15.6 (11.9–20.4)*** 22.6 (17.3–29.4)*** 0.4 (0.2–0.6)***
Note: NDHS: Nigeria Demographic and Health Surveys; AOR: Adjusted Odds Ratio; CPR: Contraceptive Prevalence Rate;
ANC: Antenatal Care; SBA: Skilled Birth Attendance; ref: reference category.
*p < .05.
**p < .01.
***p < .001.
 GLOBAL PUBLIC HEALTH 661

Discussion and conclusions

These results indicate that Nigeria has made some progress in improving RH in the last
two decades, though marked disparities exist across sub-populations. Considering the
MDG policy shock that occurred in 2000, the surveys included in our analyses provide
appropriate pre-policy and post-policy rates for the RH indicators. The 1990 and 1999
rates serve as the pre-policy rates while the 2003, 2008, and 2013 rates serve as the
post-policy rates.
The modern CPR increased by 7.4 percentage points from 1990 to 2013. This increasing
trend, though encouraging, falls short of the national target of 2 percentage points increase
annually (National Population Commission, 2004). Although the trend in modern contra-
ceptive use among adolescents was similar to the general population, they had even lower
rates. The at-risk populations for low modern CPR are those who live in rural areas, the
poorest households, and those with no formal education. Younger age, being married, and
being Muslim were also associated with reduced odds of modern contraceptive use. Pre-
vious studies found similar results and suggested that limited access to RH services,
including contraceptive services, is the main reason for the lower modern CPR observed
in these populations (Babalola & Fatusi, 2009; Fotso et al., 2011; Rai et al., 2012). This
result is further supported by the Andersen’s behavioural model of health services use,
which proposed that the balance between the need for health services and the predisposing
and enabling factors predicts the probability of using health services (Andersen, 1995;
Andersen & Davidson, 2007). In this study, we assumed that the need for RH services
is constant for reproductive-age women; however, the differences in the predisposing
and enabling factors created disparities in access and use of available RH services. The
rural residents may have disproportionately faced limited access to RH services due to geo-
graphic inaccessibility such as far distance to health facilities and/or difficult geographic
terrain. Economic accessibility may have led to the limited access to RH services seen
among the poor and the young. Non-supportive gender and religious norms may have
led to social inaccessibility among married and Muslims women, respectively. The high
levels of desired fertility and/or misconceptions about contraceptive methods may be con-
tributing to the low use of RH services, especially among the non-educated women as
reported in previous studies (Bertrand, Hardee, Magnani, & Angle, 1995).
Between 1990 and 2013, the proportion of women with recent livebirths who received
skilled antenatal care increased by 3 percentage points. Although this result was statisti-
cally significant, it falls short of the MDG 5 target of ensuring universal access to RH
care (Who, 2015). We found increasing trends in skilled antenatal care among women
living in urban areas and in the wealthiest households. On the contrary, among women
with no formal education and primary education, and those living in rural areas and in
the poorest households, the trends were negative. Among adolescents, there was no
change in access to skilled antenatal care between 1990 and 2013. These results highlight
socio-economic inequities in access to skilled antenatal care. All women, regardless of pre-
disposing and enabling factors, should receive skilled antenatal care during pregnancy.
However, from our findings, women who did not receive skilled antenatal care, may
have had limited access to skilled antenatal care, and were at increased risk for adverse
pregnancy outcomes. Women living in rural areas may have limited physical access to
healthcare resources due to the poor spatial distribution of these health facilities. Similarly,
662 C. C. OKIGBO ET AL.

younger women and those living in the poorest households may face financial barriers to
receiving skilled antenatal care. These at-risk populations will benefit from focused inter-
ventions to increase their awareness of the importance of skilled antenatal care and to sur-
mount their barriers to accessing these services.
Over the last two decades, the proportion of women who received skilled assistance at
their most recent childbirth increased by 9.2 percentage points. This minimal increase in
trend falls short of the MDG target to provide universal access to RH services (Who, 2015).
Our results suggest that the skilled birth attendance increased significantly among urban
women, but not among rural women, indicating that programmatic efforts may be focus-
ing only on urban areas that are usually easier to access compared to rural areas. We found
that, although the trend in receipt of skilled birth attendance increased for the richest
women (16 percentage point increase), the trend decreased for the poorest women by
4.5 percentage points. The declining trends observed for the poorest women, the non-for-
mally educated, and those with only primary education could be as a result of economic
and social inaccessibility. Hence, the government should target these at-risk women to
improve their: (a) knowledge of maternal and child health benefits of skilled delivery;
and (b) physical and economic access to services. Meeting the needs of these women
will contribute to the reduction of maternal and infant mortality in Nigeria.
Adolescent birth decreased by more than a quarter (27%) from 1990 to 2013. The
majority of the decrease was observed among urban residents (∼50% vs. 11% among
rural residents) and richest households (61% vs. 24% among poorest households). Our
finding that, between 1990 and 2013, young women with no formal education had a
15% decline in adolescent birth while those with primary education had a 23% increase
in adolescent birth is puzzling. However, similar findings were observed in Latin
America and the Caribbean. Rodríguez-Vignoli and Cavenaghi (2014) found a decline
in adolescent fertility and motherhood in Latin America and the Caribbean, which they
attributed to increased enrolment in secondary education. Their finding suggests a
rising threshold of the protective effect of education on adolescent birth – secondary
rather than primary education is protective. Another reason for the puzzling result
could be that those who have no formal education may be aware of and are using tra-
ditional contraceptive methods compared to those with primary education who may
not be using either traditional or modern contraceptive methods. Magadi and Curtis
(2003) found similar results in Kenya where women with no formal education had
higher probability of using traditional contraceptive methods compared to those with
primary or higher education. The traditional contraceptive methods, such as standard
days method, when used appropriately prevents conception though with proven lower
effectiveness. Despite the increase in trend of adolescent birth among those with
primary education, the birth rate among those with no formal education is almost twice
as high as the rate for those with primary education. Therefore, programmes focused
on reducing adolescent birth in Nigeria should target the rural residents, the very poor,
and those with little or no education where the prevalence of births among adolescents
remains high at more than 20%. Further research on the predictors of contraceptive
method choice based on educational level is needed. The results of such a study may
inform interventions tailored to women based on their educational attainment.
Consistent with previous studies, education, religion, marital status, residence, and
wealth were significant predictors of the RH indicators (Babalola & Fatusi, 2009; Fotso
 GLOBAL PUBLIC HEALTH 663

et al., 2011; Rai et al., 2012). Of interest is that the greatest determinant of adolescent birth
is marital/union status. Addressing the issue of early child marriage will help reduce ado-
lescent pregnancy and birth, and reduce maternal mortality in this population. The effects
of residence on all the indicators were modified by household wealth in Nigeria. The
marked disparities observed may signify lack of access to RH services among rural
poorest and urban poorest women. Lack of or limited access to these RH services could
be due to geographic or economic inaccessibility (Bertrand et al., 1995). Building health
centres close to rural residents, providing free/affordable health care and transportation
to health facilities especially for pregnant women may help improve the proportion of
women who receive skilled antenatal and delivery care.
Despite these important findings, this study is not without limitations. Though we
could ascertain associations between the socio-demographic factors and the RH indi-
cators, we could not establish causality. This was because of the use of cross-sectional
data; thus, we could not establish the temporality of the covariates in relation to the indi-
cators. Additionally, there is a potential for recall bias as women were asked about past RH
behaviours and outcomes. This recall bias, if present, may have affected the estimates for
skilled antenatal care and skilled birth attendance, but not those of modern CPR and ado-
lescent birth. This is because the modern CPR assessed current use while adolescent birth
assessed childbirth, which is a life-altering event that is difficult to forget. The effect of the
recall bias, however, is likely minimal because of the restriction to only women with a
recent birth. In spite of these limitations, the study findings are relevant, as they
provide up-to-date information on the RH status in Nigeria using nationally representa-
tive samples. The results of this analysis may inform planning and implementation of RH
programmes in the SDG-era, inform a focus on at-risk/high-priority populations, and
encourage stakeholders to intensify their efforts towards improving maternal health in
Nigeria.

Acknowledgement
The authors thank the Demographic and Health Surveys (DHS) Program for the access to the data
used in this study. We also thank Dr. Ngozichukwuka Agu who read and provided insights to the
final version of this manuscript.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
The authors also thank the funders of the DHS surveys in Nigeria – the United States Agency for
International Development (USAID) and the Nigerian Government.

ORCID
Chinelo C. Okigbo http://orcid.org/0000-0002-4983-9339
664 C. C. OKIGBO ET AL.

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