West Africa finally starting to embrace family planning

A health worker counsels a client in rural Senegal on family planning options. Photo courtesy of IntraHealth International, © 2014 by Jonathan Torgovnik/Reportage by Getty Images

This blog originally appeared on Global Health TV on March 24, 2015.

BAMAKO, Mali — When my wife and I lived here in the late 1980s and early 1990s, our housekeeper, Korotumu, hid her birth control pills on the top shelf in our kitchen, so her husband would not find out she was using contraception. He was unemployed and they had two children. Koro figured that two was enough, at least as long as her husband was not working.

I didn’t realize it then, but Koro was in a progressive minority of Malian women at that time. The 1987 Demographic and Health Survey of Mali revealed only 1.3% of married women were using modern contraception and the fertility rate (the average number of children a woman has in her lifetime) was 7.1. Koro was part of that 1.3%.

Flash forward a quarter of a century and what has happened in Mali? Use of modern contraception has increased to 9.9% and the fertility rate has dropped from 7.1 to 6.1.

This paltry progress is far less than we have seen in other parts of the world, even in Eastern and Southern Africa, in countries like Ethiopia, Kenya and Malawi. More importantly, it is far from what Malian women themselves want: The unmet need for family planning for women “in union” is 26%, and for women not in union who are sexually active, it is a whopping 55%, according to the 2012-2013 DHS.

Taken together, the nine French-speaking countries of West Africa have the lowest modern contraceptive use and the highest fertility rate in the world. The modern contraceptive prevalence rate (CPR) for all of sub-Saharan Africa is 23%; in West Africa, it’s 11%. The highest modern CPRs in West Africa (not including the island nation of Cape Verde) are Senegal with 20%, Liberia with 19% and Ghana with 18%. More typical are Mali and Nigeria, the seventh most populous country in the world, both with only 10%.

But West Africa is on the verge of change. One manifestation of that change is the Ouagadougou Partnership, an initiative of nine French-speaking, West African countries to promote family planning that started in 2011. At its annual meeting in December, the Partnership announced that new data from 2013 shows the nine countries are on track to reach their goal of creating one million new users with modern contraception by 2015.

“You might say that 1 million is not a lot for nine countries together but to reach that 1 million each country has to double its CPR in three or four years, which is tremendous,” says Fatimata Sy, director of the Coordination Unit of the Ouagadougou Partnership. “It’s really a challenge and very ambitious.”

“Family planning is going to happen in West Africa,” says Roy Jacobstein senior medical advisor of IntraHealth International. “In organized programs, we’re trying to make it happen faster. But you can already see it happening naturally in the cities and the higher wealth quintiles. It’s only a question of how soon it happens.”

Senegal is already an emerging family planning success. It experienced a significant increase in modern contraceptive prevalence from only 12% in 2011, to 16% in 2013, and 20% in 2014. Sy said that the previous average CPR growth rate was 0.5% to 1% per year, and points out three other countries that that she considers emerging family planning successes — Burkina Faso, Niger and Togo.

Even in Mali, you can see the signs of change in the cities and the higher wealth quintiles. Modern CPR is 22.5% in Bamako and 23.3% in the highest wealth quintile. Jacobstein says those contraceptive users are the leading indicators of a wave that is coming.

There are many reasons why West Africa has been behind the rest of Africa. One of the big reasons is the weakness of the health systems. Even in countries with large unmet need (like Mali), many women cannot access contraception or, if they can, many cannot afford it.

Sy says the social norm is early marriage and having lots of children. “The more children you have, the better you feel,” she says.

There’s been little money for family planning, especially in Francophone countries.

Religion plays a strong role in West Africa and many people feel, rightly or wrongly, that their religion is against family planning.

But all of these things are now changing. Jacobstein says urbanization has forced people to evaluate their lifestyles. “What is it about urbanization?” he says. “Living quarters are smaller, it’s harder to feed people and pay school fees. The calculus among families is that it is smarter to invest more per child in fewer children. We’ve also had success in child survival so people no longer feel they need to have eight children so that five will survive.”

Even some religious leaders are starting to champion family planning.

“The most fundamental change in family planning in the last 50 years is going from ‘You have the number of children that God wants’ to ‘You have the number of children that you and your spouse want,’” says Jacobstein. “People can see the link between smaller, healthier families and a better economic situation. That’s what happened in Southeast Asia. That’s what happened in Latin America. And now it’s starting to happen in West Africa.”

When Koro was using oral contraceptives and hiding them from her husband in the 1980s and 1990s, she was clearly an outlier. Increasingly, she would be considered the mainstream.