On the 24th of June 2022, the United States Supreme Court overturned the Roe v. Wade legal ruling and, in doing so, dismantled federal protection for the right to an abortion in America. As a consequence, questions concerning the extent of women’s reproductive rights are once again dominating the popular discourse. Reproductive rights stem from the assumption that every person has a right to non-interference and, therefore, can do with their body as they wish, including whether they want to have children. The UN defines a reproductive right as the right to decide when and how many children to have and to be given the information and means to enact that decision free from – discrimination, coercion or violence. Yet even outside a rights-based framework, family planning has considerable advantages both on an individual and community level.
This paper considers the importance of family planning for human development, with a focal point on Nigeria, the west African giant set to become the world’s third most populous country by 2050. Through a Nigerian lens and a review of the interventions taking place in the country, systemic barriers to the adoption of family planning will be highlighted. It is argued that solutions rest on the adoption of a firmly choice-oriented approach organised by a range of stakeholders beyond just the government.
Why is there a need for family planning?
Family planning has long been recognised as a highly cost-effective public health intervention. By allowing women to delay their pregnancies and space births, family planning could prevent up to one-third of all maternal deaths. It could also reduce the number of unintended pregnancies that are currently often end up with unsafe abortions. Almost 70 thousand maternal deaths happening each year as a result of unsafe abortions could be prevented with the expansion of family planning.[1]
Additionally, family planning promises to recast women from the status of merely a child bearer to an economically enfranchised agent. This is particularly important in the case of adolescent mothers. As they are unable to complete their education, their lifelong earning potential is reduced and could snare the entire family into intergenerational poverty.[2] There is strong empirical evidence that having the option to plan when to have children is directly correlated with a woman’s participation in the workforce, largely due to increasing the prospect of higher education.[3]
Family planning is also proven to have wider societal benefits, affecting not merely the individual female user. With fewer children, families can invest more in health and education, which ensures a healthier and more educated workforce in the future. As the World Economic Forum notes, ‘no country in the past 50 years has emerged from poverty without expanding access to contraceptives’.[4] The clear economic rewards coupled with social benefits, including women and children’s wellbeing and increased autonomy,[5] offer a well-founded argument for family planning to be integrated into every nation’s development blueprint. This is far from the case at present.
What is the situation in Nigeria?
Sub-Saharan Africa has long been a focal point of global family planning efforts. With the highest fertility rate in the world and the highest unmet need for family planning, the region has become the target of governmental and non-governmental organisations dedicated to reproductive health education and the distribution of contraceptives. Despite this, the modern contraceptive prevalence rate is notably low at around 22%, ranging from 3.5% in the Central African Republic to 49.7% in Namibia.[6] While it may be tempting to reduce this question to a matter of domestic and international funding, the stark differences in family planning outcomes come from the vastly different governance and institutions across sub-Saharan Africa. While Namibia recognised the importance of family planning for its national development since independence in 1990,[7] it was not until 2021 that the Central African Republic finally allocated for family planning in its national budget.[8]
Nigeria, despite being the most populous in the continent, has a contraceptive prevalence rate of only 12%.[9] The unmet need for family planning in Nigeria is estimated to be at 48% among sexually active unmarried women and 19% among currently married women.[10] This reflects a general failure of government and non-profit organisations to meet the demand for family planning options. Indeed, in areas where healthcare facilities are difficult to access, through distance or sparse numbers, obtaining any contraception and family planning advice can be extremely difficult.
Gendered power dynamics within family planning initiatives must also be taken into account. In 2021, John Hopkins’ Breakthrough ACTION published ‘Know, Care, Do: A Theory of Change for Engaging Men and boys in Family Planning’. The research demonstrates that men can act as ‘agents of change’ by showing solidarity with their female counterparts, balancing power dynamics and supporting family planning.[11] While an equitable involvement in family planning is the ideal end goal, entrenched patriarchy could give the dominant gender more decision-making power, resulting in women losing autonomy over their reproductive health choices.[12] In Nigeria, a considerable number of men associate the use of family planning with female promiscuity.[13] The integration of men into family planning should be done carefully and address such negative misconceptions.
Nigeria is subject to a high fertility rate of 5.2 births per woman as of 2020.[14] In addition, according to UNICEF, the West African country suffers from disproportionally high levels of birth-related health issues. Nigeria accounts for 2.4% of the global population yet constitutes a staggering 10% of global deaths for pregnant women.[15] Factors contributing to maternal deaths include the inability to receive quality health services in certain resource-poor regions, though it should be noted that even increased access does not always guarantee improved outcomes. Research in Ogun State in Southwestern Nigeria has indicated that many women maintain that delivery in a traditional setting is preferred over a modern health facility because of birth attendants in the former display more compassion than those in the latter.[16] However, increased access to delivery in a traditional setting does not lead to the improvement of maternal mortality outcomes.
Regretfully, infant mortality rates are equally high at 6.9%, rising to 12.8% for under-fives.[17] 64% of these deaths are caused by malaria, pneumonia, and diarrhoea. It is evident that high rates of infant mortality could also be easily reduced through proper medical practice and continuation of care post-birth. Moreover, providing contraception and family planning services to postpartum mothers extends the time between pregnancies, protecting the health of both mother and new-born[18] as the former is able to fully recover.
Access barriers
Despite knowledge of family planning being fairly widespread in urban areas of Nigeria, the uptake of services remains low because of persistent systemic barriers. Notably, poor infrastructure, both health and transport related, presents a significant obstacle to the delivery of contraceptives. Resource allocation is another point of friction. The Nigerian State Primary Health Care Board currently oversees last-mile distribution, yet it transports supplies to Service Delivery Points (SDPs) only after receiving federal or donor funding.[19] Facilities, therefore, experience frequent stock out and, without clear distribution policies, there are concerns that urgent demand will continue to be unmet and patients will be unable to acquire contraceptives.
A further systemic barrier in Nigeria is the acute shortage of health workers. According to the 2018 WHO[20] report, there are approximately a mere 4 physicians per 10,000 people.[21] In more rural regions, this figure is even lower, with healthcare facilities sparsely dispersed and often inaccessible. In 2014, the Ministry of Health implemented a new task-shifting, task-sharing policy in order to better scale-up essential healthcare services through the use of community extension health workers. The policy, however, still requires further progress in delineating the role of private sector providers, including Community Pharmacists (CPs) and Patent and Proprietary Medicine Vendors (PPMVs), which are responsible for around 60% of family planning services in Nigeria.[22] So, in 2019, the policy was revised to allow PPMVs to administer the contraceptive DMPA-SC[23] and train women to self-administer. Despite the wide reach of the private sector, they tend to be geographically focused on urban areas.[24] In rural areas of northern Nigeria (a region accounting for the majority of the population), misaligned profit-driven incentives at PPMVs account for suboptimal patient FP outcomes, such as a reluctance to teach patients self-injection for DMPA-SC.[25] With an 87% poverty rate in states such as Jigawa, rural Nigerian women also see the difficulty in paying for family planning options. PPMVs certainly should play a key role in contraceptive access, but more evaluations on different care models are needed.[26]
Furthermore, in spite of advocacy efforts on the part of both the government and non-profit development organisations, misconceptions about the side effects of various contraceptives are prolific. Amongst the most cited concerns is the enduring myth that modern contraceptives can cause long-term infertility and harm a woman’s uterus.[27] Global health programs in northern Nigeria highlight that key means of tackling these misbeliefs are through social programmes which actively engage with the community, achievable through mass media, outreach and health worker counselling.[28]
Another barrier is the sociocultural landscape that has long harboured antagonistic attitudes towards family planning. There is an established tradition of larger families indicating wealth and prosperity as well as providing social insurance for parents in later years. In the northern states, Islam is the majority religion. Studies have indicated that beliefs such as high fertility and honouring Allah are influential in determining perspectives on family planning.[29] They have also emphasised how religious factors, such as the allowance of polygamy, can influence a woman’s desire to have children. She may believe she can hold her husband’s attention if she is pregnant with his child.[30] Those beliefs result in lower usage and demand for family planning products in the northern states as compared to their southern Christian counterparts.[31]
Interventions
A significant amount of investment, particularly from US-funded organisations, has been injected into the family planning landscape. The key large-scale players include FP2030[32] (formerly FP2020), a global partnership centred on advancing rights-based, voluntary family planning. Through partnering with multiple governments and aiding them on their path to their development goals, FP2030 is encouraging countries to commit to better contraceptive access and reproductive autonomy practices. Similarly, the Bill and Melinda Gates Foundation has made noteworthy contributions devoting US$280 million annually from 2021 to 2030 to contraceptive technology development and strengthening local family planning programmes. Marie Stopes International is another key global agent in the reproductive health arena, promoting a choice-based approach. Their very ambitious 2030 target of completely dispelling unsafe abortions and providing accessible contraceptives to every individual across the globe is reflective of their dedication to women’s health.
Within Nigeria, a range of organisations are focused on impact. Lafiya Nigeria[33] is one of these NGOs, actively pioneering community-centred and local efforts toward areas in which the status quo has struggled to reach its family planning targets, particularly the northern state of Jigawa. Lafiya’s intervention focuses on the delivery of Sayana Press, self-injectable contraception effective for three months, and provides family planning counselling so that women can make informed decisions about their own reproductive health. Successfully leveraging the tangible benefits of contraceptive technologies alongside trust-based, community-first models is certainly an effective, viable solution to the family planning availability issue. With further investment to test best practices and an effective scaling-up operation, it is feasible that such models could be a potent tool for other nations in Sub-Saharan Africa and beyond.
Conclusion
Universal access to family planning is an ambitious but achievable objective. The continuation of financial support from organisations such as the Gates Foundation and Children’s Investment Fund Foundation fosters opportunities for localised NGOs and governments to create targeted approaches to increasing access to contraceptives and counselling. The effect of community-level interventions that address misconceptions surrounding family planning should not be underestimated.
However, the persisting systemic barriers, such as infrastructural and supply chain inefficiencies, must be addressed in order to successfully incorporate family planning practices into primary healthcare services. In Nigeria, this means improving transport systems and supply chain bottlenecks through clear policies and better allocation of limited resources. The Nigerian Federal Government set a target of a modern contraceptive prevalence rate of 27% by 2024 in its revised National Family Planning Blueprint.[34] This can only be achieved by creating well-functioning public-private sector collaborations. The Nigerian Federal Government set a target of a modern contraceptive prevalence rate of 27% by 2024 in its revised National Family Planning Blueprint.[35] This can only be achieved by creating well-functioning public-private sector collaborations. Though given the scale of the problem and the continuing rapid increase in population, the Federal Government will struggle to achieve the 2024 target without significant domestic and international funding.
Family planning is not only a Nigerian issue, it is a global one. In 1984, Reagan introduced the ‘global gag rule’, preventing foreign global health organisations to receive US funding and support for widening access to legal abortion. The infamous 2017 expansion of this rule emphasised that the future of global sexual and reproductive health programs has not been assured. The recent Roe v. Wade decision only further demonstrates the precariousness of this fundamental human right. Immediate and decisive legislative actions need to be prioritised to create a positive environment for sexual and reproductive global health programs to flourish and effectively address the existing gaps. Ultimately, having children should be a preference rather than a sheer possibility and a choice every individual is able to make.
Notes
[1] Population Reference Bureau (2009) ‘Family Planning Saves Lives’,
<https://www.prb.org/wp-content/uploads/2009/03/family-planning-saves-lives-2009-En.pdf>.
[2] Elias, C. (2016) ‘Why family planning is an issue we should all care about’, World Economic Forum, <https://www.weforum.org/agenda/2016/02/why-family-planning-is-an-issue-we-should-all-care-about/>.
[3] Sonfield, A., Hasstedt, K., Kavanaugh, M., and Anderson, R. (2013) ‘The Social and Economic Benefits of Women’s Ability To Determine Whether and When to Have Children’, Guttmacher Institute, <https://www.guttmacher.org/sites/default/files/report_pdf/social-economic-benefits.pdf> .
[4] Yasukawa, Y. (2017) ‘Just $8.39 per person could give women control over their fertility’, World Economic Forum, <https://www.weforum.org/agenda/2017/07/women-family-planning-developing-world/> .
[5] Gahunghu, J., Vahdaninia, M., and Regmi, P. (2021) ‘The unmet needs for modern family planning methods among postpartum women in Sub-Saharan Africa: A systematic review of the literature’, Reproductive Health, 18, Article number 35,
<https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-021-01089-9>.
[6] Boadu, I. (2022) ‘Coverage and determinants of modern contraceptive use in sub-Saharan Africa: further analysis of demographic and health surveys’, Reproductive Health, 19, Article number 18, <https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-022-01332-x>.
[7] United Nations Population Fund (2022) ‘Namibia Launches National Family Planning Guidelines’, United Nations.
[8] Track20 (2021) ‘Central African Republic’, Country Reporting, < http://track20.org/Central_African_Rep>.
[9] Fadeyibi, O., Alade, M., Adebayo, S., Erinfolami, T., Mustapha, F. and Yaradua, S. (2022) ‘Household Structure and Contraceptive Use in Nigeria’, Frontiers in Global Women’s Health, 10, <https://www.frontiersin.org/articles/10.3389/fgwh.2022.821178/full>.
[10] National Population Commission (2019) ‘ICF Nigeria demographic and health survey 2018’, Abuja, Nigeria, and Rockville, Maryland, USA.
[11]Breakthrough ACTION (2021) ‘Know, Care, Do A Theory of Change for Engaging Men and Boys in Family Planning’, John Hopkins Centre for Communication Programs, <https://breakthroughactionandresearch.org/wp-content/uploads/2021/11/Know-Care-Do-Engaging-Men-Boys.pdf> .
[12] Garg, S., and Singh, R. (2014) ‘ Need for integration of gender equity in family planning services’, Indian Journal of Medical Research, 140 (Suppl 1): S147-51,
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345746/>.
[13] Adankin, A. I., McGrath, N., and Padmas, S. S. (2017) ‘Impact of men’s perception on family planning demand and uptake in Nigeria’, Sexual and Reproductive Health, 14: 55-635,
<https://pubmed.ncbi.nlm.nih.gov/29195635/>.
[14] World Bank Data (2020) ‘Fertility Rate Total (Births per woman) – Nigeria’, <https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?end=2020&locations=NG&start=1960&view=chart>.
[15] UNICEF Nigeria, n.d, ‘Situation of women and children in Nigeria: Challenges faces by women and children in Nigeria’, UNICEF, <https://www.unicef.org/nigeria/situation-women-and-children-nigeria#:~:text=Latest%20figures%20show%20a%20maternal,world’s%20second%20highest%20national%20total>.
[16] Wuraola Ope, B. (2020) ‘Reducing maternal mortality in Nigeria: addressing maternal health services’ perception and experience’, Journal of Global Health Reports, <https://www.joghr.org/article/12733-reducing-maternal-mortality-in-nigeria-addressing-maternal-health-services-perception-and-experience>.
[17] UNICEF Nigeria, n.d, ‘Situation of women and children in Nigeria: Challenges faces by women and children in Nigeria’, UNICEF, <https://www.unicef.org/nigeria/situation-women-and-children-nigeria#:~:text=Latest%20figures%20show%20a%20maternal,world’s%20second%20highest%20national%20total>.
[18] Akamike, I. C., Okedo-Alex, I. N., Eze, I. I., et al (2020) ‘Why does uptake of family planning services remain suboptimal among Nigerian women? A systematic review of challenges and implications for policy.’ Contraceptive and Reproductive Medicine, 5, Article number 30, https://doi.org/10.1186/s40834-020-00133-6
[19] Bayer, n.d, ‘Taking Stock: Nigeria’s Supply Chain Race to Fulfill Family Planning Demands’, Bayer Global,
<https://www.bayer.com/en/pharma/nigerias-supply-chain-race-to-fulfill-family-planning-demands>.
[20] Ahmat, A., Okoroafor, S., Kazanga, I., et al (2019) ‘The health workforce status in the WHO African Region: findings of a cross-sectional study’, BMJ Global Health, <https://gh.bmj.com/content/7/Suppl_1/e008317>.
[21]World Bank Data (2018) ‘Physicians per 1000 people – Nigeria’, <https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=NG&most_recent_value_desc=false>.
[22] Nigeria FP2030 Commitment Form, available at: <https://fp2030.org/sites/default/files/Nigeria_FP2030_Commitment_20220314.pdf>.
[23]DMPA-SC is a lower-dose, easy-to-use self-injectable hormonal contraception developed by PATH and manufactured by Pfizer. It is approved by regulatory agencies in more than 40 countries worldwide, including the European Union, <https://www.path.org/articles/dmpa-sc/>.
[24] Beyeler N., Lium, J. and Sieverding, M. (2015) ‘A Systematic Review of the Role of Proprietary and Patent Medicine Vendors in Healthcare Provision in Nigeria’, PLOS Global Public Health, 10(1), https://doi.org/10.1371/journal.pone.0117165/
[25] Ademayo A. (2018). ‘Examining and strengthening the role of patent and proprietary medicine vendors in the provision of injectable contraception in Nigeria’, Population Council, The Evidence Project,
[26] Liu, J., Shen, J., Schatzkin, E., et al (2019) ‘Accessing DMPA-SC through the public and private sectors in Nigeria users characteristics and their experiences’, Gates Open Research, <https://gatesopenresearch.org/articles/2-73>.
[27] Gueye, A., Speizer, I., Corroon, M. and Okigbo, C. (2015) ‘Belief in Family Planning Myths at the Individual And Community Levels and Modern Contraceptive Use in Urban Africa’, International Perspectives on Sexual and Reproductive Health , 41(4): 192, <https://www.jstor.org/stable/pdf/10.1363/intsexrephea.41.4.0191.pdf?refreqid=excelsior%3A610a0698924cbd6154b4a60ec4c08834&ab_segments=&origin=&acceptTC=1>
[28] Ibid: 197.
[29] Chimaraoke O. and Izugbara, A. (2010) ‘Women and High Fertility in Islamic Northern Nigeria’, Studies in Family Planning,41(3), <https://onlinelibrary.wiley.com/doi/10.1111/j.1728-4465.2010.00243.x> .
[30] Obasohan P. E. (2015) ‘Religion, Ethnicity and Contraceptive Use among Reproductive age Women in Nigeria’, International Journal of Maternal and Child Health and AIDS, 3(1): 63-73,
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948172/> .
[31] DMPA-SC Access Collaborative Nigeria Dashboard, accessed August 2022, https://fpoptions.org/resources/tag/nigeria/
[32] https://fp2030.org/
[33] https://www.lafiyanigeria.org/
[34]Federal Ministry of Health, Nigeria (2020) ‘Nigeria Family Planning Blueprint 2020-2024’, Federal
Government of Nigeria, Abuja, <https://ngfrepository.org.ng:8443/jspui/bitstream/123456789/3303/1/NIGERIA%20FAMILY%20PLANNING%20BLUEPRINT%202020%20-%202024.pdf> p. 11.
[35]Federal Ministry of Health, Nigeria (2020) ‘Nigeria Family Planning Blueprint 2020-2024’, Federal
Government of Nigeria, Abuja, <https://ngfrepository.org.ng:8443/jspui/bitstream/123456789/3303/1/NIGERIA%20FAMILY%20PLANNING%20BLUEPRINT%202020%20-%202024.pdf> p. 11.