Finding the Path: Increasing Contraceptive Choice in Africa’s Most Populous Countries

More than 225 million women in developing countries want to avoid or delay pregnancy but are not using safe, modern, and effective contraceptive methods. Such a gap between women’s contraceptive behavior and reproductive goals is called an unmet need for family planning, and no region has more unmet need than sub-Saharan Africa.

Unmet need for family planning can lead to unintended pregnancies that pose severe health risks and cause higher maternal and child mortality rates. Adolescents, marginalized groups, and women in the post-partum period are generally more affected by unmet need than others.

In sub-Saharan Africa, 183,000 women die each year from pregnancy-related causes. Accelerating access to family planning is essential for ensuring reproductive health care for women and girls, said representatives of the U.S. Agency for International Development’s Evidence to Action Program (E2A) from four of sub-Saharan Africa’s five most populous countries, at the Wilson Center on October 5.

E2A, a flagship USAID project led by the NGO Pathfinder International, works to strengthen family planning and reproductive health services by “taking evidence-based practices and putting them in action at the country level,” said Ann Hirschey, chief of USAID’s Service Delivery Improvement Division.

Improving Post-Partum Health in Ethiopia

One of Africa’s most dire family planning situations is fast becoming a success story. Contraceptive use in Ethiopia has increased from 8 percent to 42 percent over the past decade, said Dr. Mengistu Asnake, Pathfinder’s Ethiopia country representative.

While this is a promising change reflecting much greater access to health services, the overall popularity of long-acting and reversible contraceptive methods (LARCs), such as intrauterine devices and birth control implants is still low, said Mengistu. These methods are important because they are both easy to use and require little medical effort after the initial appointment, making them ideal for inaccessible areas.

Unmet need also remains high for women who have recently given birth – up to 76 percent, three times that of women who are not in the post-partum period, said Mengistu.

With Ethiopian government support, E2A has created the Integrated Family Health Program Plus to train more than 150 community-level health workers on the insertion of intrauterine contraceptive devices, a popular LARC, and other comprehensive family planning services. By supplying equipment and resources to each trainee and collecting personal preferences of women to improve the quality of care, the program produced a significant uptick in the number of women using IUCDs in the post-partum period in its first year.

Community Agents Key in Nigeria and the DRC

Nigeria, Africa’s most populous country, has very high fertility and maternal mortality rates. The United Nations projects its 182 million people will likely swell to almost 400 million in 2050. There is an unmet need for contraception as well, at 16 percent in 2013, said Dr. Farouk Jega, Pathfinder’s Nigeria representative.

As in Ethiopia, the use of long-acting and reversible contraceptive methods is particularly low. One reason is the lack of qualified doctors and nurses, who are the only ones allowed to implement LARCs; another is the high cost of private health care providers.

"Where were you when we were of reproductive age?"

Supporting government community health extension workers, or CHEWs, has helped increase the uptake and prevalence of LARCs, specifically implants and injectables, said Jega. A new initiative by the government and Pathfinder is training CHEWs to provide implants in order to expand access to LARCs at the community level. CHEWs in Nigeria now go through 18 months of training after high school where they learn about modern reproductive health and family planning services and receive mentoring and support.

Similarly, in the Democratic Republic of Congo, community engagement is very important to the success of reproductive health efforts, said Pathfinder Country Representative Dr. Aben Ngay.

The DRC has the one of the highest rates of unmet need for family planning, ranging from44 percent to 67 percent. E2A is working to erode these numbers through community-based distribution and outreach. Pathfinder-trained staff regularly visit communities to consult with people face-to-face and give out pills and cyclebeads, said Ngay.

One community member was impressed by the effort, but not by its timing. “Where were you when we were of reproductive age?” she asked a field representative. “I am going to talk to my daughter-in-law so that my son doesn’t have to go through all this.” She now works with Pathfinder to educate other young women on family planning and reproductive health options available to them.

“Involving men, especially, really makes a big difference,” said Ngay. “A woman will not go for family planning services if she doesn’t get permission from her husband.” He also emphasized the inclusion of religious, community, and youth leaders.

Counting Days in Tanzania

Among the most populous countries in sub-Saharan Africa, only the DRC is growing at a faster rate than Tanzania. According to Pathfinder Country Representative Mustafa Kudrati, women in Tanzania have been increasing their uptake of family planning services, but there are huge disparities throughout the country.

Working in the largely Catholic Shinyanga region where the use of modern methods is exceedingly low and fertility is exceedingly high, the government and Pathfinder are focusing on simple methods, Kudrati said. The standard days method and cyclebeads help women keep track of their menstrual cycle and know when they are most likely to get pregnant. Women can also access a calendar on their phones.

“Because it’s a big item, it lends itself to couple engagement,” Kudrati said of cyclebeads. “Couples engage with each other a lot more than other methods which women have to often hide from their husbands or partners when using family planning methods.”

Though not considered a modern contraceptive, the standard days method works in Tanzania because many communities are resistant to other methods and want to avoid side effects, Kudrati said. They’ve received testimonials from many women who say it helps them understand their body better and brings them closer to their husbands.

As of data collected in 2015, Kudrati said only three percent of women participating have discontinued out of fear of becoming pregnant or wanting to become pregnant and two percent have switched to other methods.

E2A staff have also trained more than 250 community health workers through a mobile app that simplifies and condenses important information regarding family planning and the standard days method. The app has been an essential and effective tool for increasing awareness, said Kudrati.

A Community-Based Future?

While the programs in Ethiopia, Nigeria, the Democratic Republic of Congo, and Tanzania are at different stages, each of the Pathfinder country representatives echoed the importance of closely engaging community members.

Discussing results from the DRC, the newest participant in the E2A program, Ngay said community-based distribution and outreach – as opposed to requiring women to come to a central hub – is helping to dispel misconceptions and rumors about family planning.

More important still is the cooperation of the government. Without government support and investment, these initiatives may only produce temporary gains, said Kudrati. “We are learning from countries such as Ethiopia and Nigeria that there needs to be a move towards formalization of the community health worker cadre.”

Written by Deepshri Mathur, edited by Schuyler Null.