Contraceptives in sub-Saharan Africa: An unmet need
By Adelia Saunders
13 DECEMBER 2007 [MEDIAGLOBAL]: Family planning may be the most important development strategy hardly any one is talking about.
“It’s a delicate issue and it’s a difficult issue,” Yves Bergevin, Senior Programme Advisor on Reproductive Health for the Africa Division of the United Nations Population Fund (UNFPA), said in an interview with MediaGlobal. “Very few people like discussing sexual and reproductive health. It’s much easier to think ‘child survival’ or ‘basic education for girls and boys’ than it is to talk about sexual and reproductive health and family planning.”
In sub-Saharan Africa, one third of women want to plan their families but lack access to modern methods of birth control. As a result, tens of thousands of women die each year from botched abortions and complications related to unplanned pregnancies. Women’s participation in academic, professional and political spheres is limited by the demands of raising many children, and cycles of poverty continue as parents struggle to feed and educate large families.
“If we meet this unmet need, then we will contribute importantly to achieving the Millennium Development Goals,” Bergevin said. “Not just the health Millennium Development goals, but all the Millennium Development Goals, including poverty reduction.”
As the world’s population hurtles toward seven billion, environmental resources, particularly in the poorest countries, are becoming increasingly strained. Sub-Saharan Africa’s per capita food production has fallen in recent years, while the region’s population growth rates remain the highest in the world. An article published last year in the British medical journal The Lancet identified family planning as “one of the most cost-effective ways to preserve the planet’s environment for the future.”
Women and children in a camp for internally displaced persons in Uganda. (Photo
courtesy of K. Burns/USAID)
Birth control took the spotlight in the 1990s, when the International Conference on Population and Development held in Cairo, Egypt, declared that the ability of individuals and couples to determine when and how often to have children was a basic human right. Since then, universal access to contraceptives has been increasingly marginalized on the development agenda.
Despite the recognition that population growth has outpaced the economies of much of the developing world, so that in the mid-1990s Africans were in fact 22 percent poorer than they had been in 1975, funding for family planning has dropped dramatically over the last ten years. In 2003 international donors spent US$100 million less on contraceptive goods and services than they did in 1995.
“Family planning has fallen way down in terms of priority,” Sandra Krause, Reproductive Health Project Director of the Women’s Commission for Refugee Women and Children, told MediaGlobal. International priorities have shifted, nudged by conservative politics and overwhelmed the devastating impact of HIV/AIDS.
The Millennium Development Goals, launched in 2000, carried no specific mention of family planning, an exclusion that baffled experts and aid workers who saw access to contraceptives as a crucial first step toward poverty reduction, the empowerment of women, healthier children and environmental sustainability, all key tenets of the goals. Earlier this year universal access to reproductive health care was made part of the 2015 targets.
With religious imperatives playing an increasingly important role in the politics of major donor countries such as the United States, support for reproductive health services has waned. “There’s a chilling effect,” Krause said. “HIV is more palatable, certainly safe motherhood programming is more palatable, rape [prevention] is more palatable. People seem to have forgotten the basics of why [family planning] is important, and that it is, in fact, a lifesaving intervention.”
“Family planning has been neglected and more of the partners are focusing on HIV/AIDS,” Dr. Cheick Ouedraogo, Adviser on Access Services for the International Planned Parenthood Federation, told MediaGlobal. “Ten years ago [HIV/AIDS prevention] was part of family planning.”
“There’s been a lot of focus on HIV—as there should have been,” Bergevin said. “HIV is really an emergency and catastrophic for developing countries.” In its scramble to deal with the virus, the international community gave HIV initiatives their own funding and facilities. “We separated HIV too much from family planning, and that separation is really not very good for the client,” Bergevin said. “When you come to a clinic, you want to make sure you decrease your risk of getting a sexually transmitted infection, including HIV, [and] that you are able to choose when you wish to become pregnant.”
The competition for funds and resources has lessened the effectiveness of both family planning and HIV initiatives, with family planning suffering most. While many Westerners are aware that HIV and AIDS have ravaged sub-Saharan Africa, few have any idea that in 2004 more women in Ghana died from unsafe abortions than from AIDS.
Currently about a quarter of African couples use modern contraceptives, although that number varies considerably by region. In much of Western Africa, where family planning institutions are less entrenched, medical infrastructure is sorely lacking and religious resistance is higher, less than ten percent of couples use any form of modern birth control.
An additional 34 percent would like to. “In West Africa, and even in more religiously conservative parts of countries in West Africa, demand for contraceptives surfaces,” Bergevin said.
Throughout sub-Saharan Africa, aid workers have found that when services are provided, women are eager to control their family’s size. “Communities, when they are informed, will ask and demand,” said Krause, who conducted a study of the unmet need for contraceptives in camps for Ugandans displaced by civil war.
A well-stocked clinic is not enough, she said. There must be outreach and follow-up campaigns staffed by well-trained health workers. “These women would be asking for [contraceptives], saying ‘we really need it,’ and not be aware that it was available ten meters away in the health center, because no one’s promoting it,” she said.
The average African woman gives birth five or six times during her lifetime and stands a one in 16 chance of dying during pregnancy or childbirth. For women in North America, the risk is one in 3,700.
“Family planning is very, very important for reducing maternal mortality. That is something that is often forgotten,” Bergevin said.
The World Health Organization estimates that contraceptives could prevent nearly a third of all maternal deaths, most of them in Africa and Asia. “In an environment where maternity may not be safe, it is very important to make sure that couples can decide on the number of children they want,” Bergevin added.
Men are integral to the success of family planning initiatives. “We encourage ownership, responsibility by men of their duties as partners and husband and fathers,” he said.
To a woman interviewed for the Ugandan study, the need for male support was simple. “I have six children and I pray that my husband will understand that I want no more,” she said.
Women sometimes ask for injectable forms of birth control that their husbands won’t know about, but this is hardly encouraged. Neighbors spy, and distrust builds among men, leading to family discord and potential domestic abuse.
On the other hand, the subject of family planning can act as a starting point for other conversations, creating an “open dialogue between couples and in their communities,” Bergevin said. “That dialogue then fosters gender equality. When you have socially responsible and religiously sensitive social marketing, you have tremendous uptake of family planning.”
It’s important to involve local leaders in the process of educating communities, Sandra Jordan, Director of Communications for the United States Agency for International Development (USAID), told MediaGlobal. “We have a lot of very strong programs with faith-based and community groups, and find that just talking with the leaders, the opinion-makers in the community, and working with them, they did it very quickly.”
A sign for a prenatal and family planning clinic in Senegal. (Photo
courtesy of R. Nyberg/USAID)
Religion plays an active, and not always limiting, role in success of family planning programs. After being banned for nearly a decade, Iran’s political and religious leaders recognized the health benefits of contraceptive use. They issued a fatwa encouraging family planning in 1989, and today nearly three quarters of Iranian women use some form of birth control.
Yet while millions of people rely on religious charities to deliver crucial health services, many faith-based groups do not provide contraceptives. Referring to the program to reduce the spread HIV/AIDS based on “Abstinence, Being faithful, using Condoms,” Hilary Roxe, Catholic Relief Services’ Communications Officer for Sub-Saharan Africa, told MediaGlobal, “We do the A and the B portion of the ABC program.”
Catholic Relief Services (CRS) provides abstinence education and marital fidelity programs, and is one of the world’s leading providers of anti-retroviral drugs, said Elizabeth Griffin, CRS’s Director of Communications. As far as contraceptives are concerned, “We don’t distribute them ourselves, but we know where to get them,” she said.
Beyond limitations imposed by religious charities and competition for healthcare funds, poor infrastructure presents one of the greatest challenges to family planning, particularly in West Africa, where roads to remote villages are often flooded, facilities are under-stocked and qualified medical staff are hard to come by.
“We’ve found in West Africa motorcycles work better for taking [supplies] in because they can get through the bad roads better during the rainy seasons,” Jordan said. “A lot of our programs provide generators, because then we can keep the electricity going. So if you have any pills and such that need to be kept cold, you can do it with all the electrical outages.”
As the world’s population grows, its natural resources shrink and the disparities between rich and poor become ever more entrenched, an immediate effort to make contraceptives available to everyone could have profound effects. A study of 45 countries found that lowering birthrates by five births per 1000 in the 1980s would have reduced the number of people currently living in poverty by a third.
“Family planning is a precondition for economic take-off and sustainable development,” Bergevin said. “It’s very important and it’s a neglected area internationally. It requires much more funding, much more energy by governments, both developing country governments and governments from the North, and it requires much more focus by international agencies.”
“There’s always so much demand,” Bergevin said. “Wherever one has provided commodities and services, family planning really takes off very fast.”