Silence! Frustration etched on the surgeons’ faces. ‘ Time of death.. 9.05 pm’.
In the end the bleeding had been too much for Funmi. Indeed the nature of the presentation made her prognosis poor. A magical night out with her village heartthrob had resulted in an abdominal pregnancy that had been slowly eating her intestines for weeks until this end. She had felt the condom burst inside her back then in the heat of passion but what could she do? Little was said when she collected the pack at a hastily arranged health outreach. It had seemed as though the nurses were more interested in registering large swathes than attending to her questions. John had reassured her that she wouldn’t conceive if she took an tablet of Ampiclox™ . It had felt better to listen to him than go back where she wasn’t welcome. You aren’t even 18 and you collected a pack she swore she had heard those eyes say. Now she’s 18 and no more.
Family planning involves all methods used to decide the number and spacing of children and to postpone conception as to a time that is personally desirable. Family planning is a concept older than Nigeria itself and coincidentally was introduced during the nation’s inception with the Family Planning Council of Nigeria now Planned Parenthood Federation of Nigeria (PPFN). However a fertility rate of approximately 6 children per woman and contraceptive prevalence of about 13% with still high levels of abortions annually suggest that there is still a large unmet need for family planning methods in the country1. The role of family planning in preventing maternal mortality can’t be overemphasized and with Nigeria already contributing the second highest levels to global maternal deaths with maternal mortality rate currently at 814/100000 women of reproductive age, we have an emergency!2 Problems of family planning in Nigeria are far reaching and have some roots in the prevalent culture and attitudes towards sex, women, religion. I will try to highlight some of the most pertinent from where I work.
To begin, there are serious deficiencies in the understanding and knowledge of the different types of contraceptives and what they do to the body. A stark example of this was in the uproar created by some civil societies and religious groups in response to the plan by the present minister of health to increase contraceptive prevalence to 36% to combat rising populations in the midst of economic downturn3 (Nigeria’s Population increases at a rate of 3% per year)1.They likened contraceptives to abortifacients. This can’t be further from the truth. Contraceptives work to prevent conception and implantation. By law, the requisite for defining abortion is that implantation has occurred. The different types of contraceptives available in Nigeria include; condoms, oral contraceptive pills, emergency contraceptive pills, intrauterine devices, implants, sterilization procedures for male and females, natural methods such as prolonged breast feeding and periodic abstinence. These could be subdivided into Hormonal and Non-hormonal methods. Hormonal methods tend to be the fulcrum of modern methods used widely in developed countries as they provide long lasting means of contraception that is freely reversible once conception is desired. Problems associated with them include high costs most especially in third world countries like Nigeria and side effects. All contraceptive methods have their specific efficacies, possible side effects and their mode of preventing pregnancies and it is for this reason that health personnel and family planning volunteers must be adequately trained so that each client(as receivers of contraceptive methods are called) make fully informed choices.
In Nigeria, Condoms are by far the most widely known contraceptive4. Condoms, however, have been associated with higher failure rates as a result of less than optimal usage and poor storage. Condoms also have the problem of male-dependent use especially considering relatively low awareness and usage of female condoms. Few have knowledge of longer acting contraceptive method and even fewer have knowledge of availability of emergency contraception5. The burden of educating the populace rests with the health professionals and those trained accordingly. More must be done to ensure that information is dispersed freely and at all levels especially in the rural communities where the fertility rate is at its highest. Family planning and sex education should be included in school curriculum with the risks involved with unsafe sexual practices laid bare for adolescents to assimilate especially in the Government schools which carry a significant proportion of the nation’s school age youths. There is no such program presently. Such programs must also be administered by trained health professionals. A recent community strategy by Center for Development and Population Activities(CEDPA) in a village in Northern Nigeria between 2006-2008 to improve contraceptive acceptance recorded improved attitudes towards family planning among the inhabitants6. This proves that with the right education, preconceived fallacies can be corrected.
The perception that family planning is meant for married women even among health professionals and trained personnel has led to decreased utilization of these services by those young ladies who fall in the reproductive age group and who are in need of these services the most. Nigeria’s society is one in which discussions about sex and contraception with young people is still considered inappropriate even among health professionals despite increasing levels of sexual activity among teens evidenced by increased percentages of women between ages of 21-24 having had prior sexual encounters from 27% in 1990 to 32% in 20037. Girls who access contraceptive methods are regarded as loose in many settings. It is such attitudes that contribute significantly to the unmet need for contraception and increased rates of abortions annually. We must ensure that those charged with administering family planning services are trained to do away with prejudices and attend to all potential clients. Every girl post-menarche is a potential nation builder and must be accorded this regard. In Akoko-Edo Local Government Area where I have been working for a month, Maternity Centers are those entrusted with family planning services and the problems are immediately evident vis-à-vis the primary intention these centers serve. There is next to none utilization of these services by adolescents. More must be done to create youth friendly centers especially in the rural areas in which this family planning methods are offered.
There is limited availability of diverse family planning services especially in the rural areas where I have been working. Studies done have shown that among the health facilities; availability of contraceptives is higher in private hospitals than government clinics or maternity centres8. The Maternity Centers here in the rural setting have very limited modern contraceptive options with copper intrauterine device the only long acting method available. Women are therefore left with little or no option but to discontinue if there are side effects. Auxiliary methods offered include natural family planning methods which are less efficacious.
Religion and culture also play a major role in acceptance of these methods. A study revealed that Catholics and Muslims access their contraception from patent medicine shops while other Christians utilize private and general hospitals9. This might not be unrelated to religious objections to modern contraceptive methods. In situations like this, involvement of religious groups and provision of relevant information to them so as to be able to carry them along will go a long way in promoting maternal health of the nation. In Nigerian societies where men are the main determinants of family size, more must be done to involve men in family planning methods.
The case for a political prioritization of family planning in Nigeria is self-evident.
Countries like Indonesia that have been able to half their fertility rates and increase contraceptive prevalence from below 5% in 1967 to about 60% in 2006 by focusing on community and rural based strategies have seen an increase in their maternal health indicators10. We must also align this services to cater for adolescents who up till now have been neglected. The next time we see a case of preventable maternal death in a hospital and we shed a tear, we must ask what are we doing to prevent this. Prevention, they say, is better than cure.
- Contraceptive Review in Nigeria: Recommendation for Future Policy Decisions by Emmanuel Monjok, Andrea Smesny, John E Ekabua, E James Essien (2010)
- CIA World FactBook (2016)
- THISDAY newspaper September 3rd 2016.
- Sexual activity and contraceptive use among female students of tertiary institution in Ilorin, Nigeria by Abiodun OM, Balogun OR (2009)
- Emergency Contraception Knowledge and perception among female students in the Niger Delta of Nigeria by Akani CI, Enyindah CE, Babatunde S (2008)
- Centre for Development and Population Activities: Community Strategies to increase family planning in Nigeria (2009)
- National Population Commission: Nigeria Demographic and Health Survey (2003)
- Contraceptive prevalence among young women in Nigeria by Oye-Adeniran BA, Adewole IF, Odeyemi KA, Ekanem EE, Umoh AV (2005)
- Sources of Contraceptive commodities for users in Nigeria by Oye-Adeniran BA, Adewole IF, Umoh AV (2005)