Getting family planning right

At the 2012 London Family Planning Summit, government committed to raising its contraceptive prevalence rate for all women of reproductive age to 60 percent by 2020. What should be done to achieve that? Writes EPHRAIM NYONDO:

There is still high percentage of married women who want to space their next birth or stop childbearing entirely, but are not using contraception.

The 2010 Malawi Demographic Health Survey (MDHS) found that 26 percent of married women have an unmet need for family planning with 14 percent of them having a need for spacing births and 12 percent for limiting births.

The figures are worse among adolescents.

The 2010 MDHS found that contraceptive prevalence rate for girls and young women aged between 15 and 19 years is at 29 percent, yet nearly 90 percent of adolescents approve of family planning.

To mean, unmet need for planning for women and girls of reproductive age in Malawi is still high.

Low use of contraceptives has been blamed as causing unintended pregnancies and births, a recipe for high fertility rates which is the major reason behind rapid population growth in the country.

Acknowledging the problem, government, in 2012, was part of the London Family Planning Summit where nations made a commitment to increase their contraceptive prevalence rate to 60 percent by 2020.

But is that possible?

Adrian Chikumbe, spokesperson for the Ministry of Health, is counting on the achievements of the road travelled.

He says in April 2008, government approved a change in policy which allowed health surveillance assistants (HSAs) who are government employees that provide basic health care services in the community to provide injectable contraceptive method at the community level in order to expand method mix. This was after a 2004 Malawi Demographic and Health Survey (DHS) reported that 60 percent of women in Malawi preferred injectable contraception but only 18 percent had access to this contraceptive method—something affecting their choice.

The change in policy action, adds Chikumbe, has seen a tremendous increase in modern contraceptive prevalence rate (CPR) of family planning from 28 percent in 2004 to 42 percent in 2010 according to the 2010 DHS.

Actually, notes Chikumbe, the End line survey of 2014 estimated CPR to be at 58.6 percent.

“Additionally, the ministry through the Directorate of Reproductive Health has made family planning a number one strategy in the roadmap for reducing maternal and neonatal morbidity and mortality,” he says.

Beyond that, Chikumbe notes that government has fulfilled some of the commitments it made, namely: finalising and approving the National Population Policy by December 2013 and establishing a budget line item for Family Planning in the 2013/2014 financial year.

Yet, despite that, achieving the London Summit will be a challenge given the fact married women, as told by the story of Patuma Yusuf from Katuli, Mangochi, still have their reproductive controlled by their husbands and also their community beliefs.

Not only that.

Adolescents, too, are still failing to increase their access to contraceptives due to many factors. In a 2012 study titled Attitudes towards contraceptive use among schooling adolescents in Malawi, Kamuzu College of Nursing (KCN) researchers Esnath Kapito, Abigail Kazembe, Alfred Maluwa, Address Malata and Jon Oyvind Odland found that two themes that emerged from the adolescents’ narrations were positive and negative attitudes towards contraceptive use.

The study shows that positive attitudes were developed from acknowledging benefits of contraceptives; and having beliefs and values that recognised responsibility; readiness; and motivation for contraceptive.

“The motivation factors included the desire for good life, health, stable future family, higher education and independence,” reads the study.

The study also notes that negative attitudes, on the other hand, arose from challenges, disadvantages, misconceptions as well as beliefs and values that disapprove the use of contraceptives among adolescents.

Arguably, to achieve the London Summit goal, then, there is an urgent need to address these two issues—unmet family planning needs for married women and adolescents.

Population expert Jesman Chintsanya says the greatest challenge with achieving the London Summit goal is that despite the commitment made there are few policies or strategies specifically aimed at reducing fertility rates.

“Child and maternal mortality programmes have received much attention and comparatively, were well funded over the previous years. These can be attested to the fact that child mortality rates have declined substantially and Malawi is on record of achieving the Millennium Development Goals of reducing child deaths.

“In sharp contrast with family planning issues, the focus was on the survival of the child and the health of the mother,” he says.

Chintsanya also points out that generally, the focus in Malawi has been on the family planning supply side and not on reducing the demand for children.

“This position may be the case given that the government of Malawi emphasised preventing pregnancies for the health of the mother and the child,” he says.

He also notes that another factor may be that it was easier for government agencies to manage and implement such programmes with support from the donors.

“In contrast, it is difficult to motivate people to have fewer children given the high mortality levels.

“Thus the focus concentrated on supplying contraceptives, with a view to reducing the demand for children, but without necessarily changing the cultural factors that make people want high numbers of children,” he explains.

That is why Maria Jemusi, a nurse midwife technician at Katuli Health Centre in Mangochi, thinks the future of family planning lies in investing in community health centres and local health service providers.

“In the few years I have been at Katuli Health Centre, I have seen a surge of married women, not demanding as such, but raising many questions regarding contraceptives,” she adds.

On the youths, Jemusi notes that, there have been more of them, both girls and boys, getting condoms in their outlets.

“We see this as progress—one resulting from increased door-to-door family planning interventions in the communities by HSAs and also various non-governmental organisations (NGOs),” she observed.

Yet more need to be done, Jemusi advances.

“What is key now is to ensure that the working relationship between government and NGOs at a community level is strengthened,” she says.

On the youths, a study by Kapito and others recommends that to increase contraceptive use among sexually active adolescents, there is a need for adequate information about contraceptives in terms of advantages, disadvantages and side effects.

“This would help mitigate negative attitudes on contraceptives from misinformation and misconceptions,” reads the report.

However, for women such as Yusuf their insistence is on having men, their husbands, taking a leading role in encouraging their wives to choose family planning.

“If you look at the contraceptives that we are taught every day, they all target us, women. It is only a male condom and vasectomy which targets. I think this makes our husbands feel family planning is for women only,” she says.

Perhaps that would help women like Yusuf to decide for their womb.