A year ago, I met a 26-year-old breastfeeding mother who was a graduate student. She was married with three children; the youngest was just eight months old. She started using oral contraceptives after the return of her menses following the birth, but she hid the pills from her husband. When he discovered them, he forced her to throw them away.
Not long after that, she conceived again. Three months later, she had a miscarriage caused by stress. She was admitted into hospital with infection and blood loss. Thankfully, she survived, and her husband has since changed his attitude towards contraceptive use.
In my work in rural areas of Nigeria, attending mostly to uneducated women, their inability to make their own decisions on contraceptive use, combined with lack of awareness of what contraceptive methods are available, are prominent factors that affect contraceptive uptake. About 80 percent of the women we see do not use modern contraceptives because of lack of knowledge, or because their spouses are against it.
However, it is cheering to note that when I talk with couples about the importance of contraception to a woman’s health and her family’s welfare, I see a marked change in attitude. From my conversations with others working in reproductive health services, it seems that they have also had success when they talk to couples.
It is already a government policy to increase the use of modern contraceptives in Nigeria. The official goal, first set in 2012 and revised in 2017, was to reach a modern contraceptive prevalence rate of 27 percent by the year 2020. Unfortunately, the level of contraceptive use reached in 2020 was only 12 percent, one of the lowest rates in the world.
A key reason for the low level of contraceptive use is lack of government leadership. Despite making promises to fund modern contraception, the government actually cut funds for family planning by 80 percent in its 2019 budget, with further cuts in 2020. In effect, the government is leaving international non-governmental organisations (NGOs) to pay for most of the contraception and family planning services in Nigeria. While NGOs do an admirable job, none has the capacity to run a sustained national awareness campaign, or to change deeply ingrained social attitudes affecting contraceptive uptake. This is the work of government, which needs to invest in family planning education, including in schools, and ensure modern contraceptives are widely available at little or no cost.
The government also needs to tackle stigma. Here in Nigeria, we need to stop being embarrassed about contraception or treating it as a secret. We can learn from the success of immunisation campaigns against childhood diseases, for example, which have used massive awareness campaigns and health workers going house to house to carryout vaccinations.
Today, it is quite normal to vaccinate children when it was previously viewed with suspicion. The government should apply the same strategy to family planning, using health workers to educate couples and deliver contraceptive services at home. They would have an opportunity to speak to couples together, and importantly include men in the conversation.
By speaking with couples normally about contraception, we in the health sector can show that there is nothing to be embarrassed or ashamed about, reassure both women and men that the products are safe, and address any misconceptions and answer questions. The problem now is that the system encourages secrecy and misinformation, making it even harder for women to control their fertility, and often putting their health and welfare at risk.
The cost of this problem to the country is significant. The health and social impacts that I see frequently include unplanned pregnancies, unsafe abortion, maternal deaths, perpetuation of poverty, malnutrition, frequent hospital visits and children dropping out of school.
If all the unmet needs of modern contraception were satisfied, it is estimated that unintended pregnancies in Nigeria would drop by 77 percent – from 2.5 million to555,000 per year – and the number of abortions would drop from 1.3 million to287,000. Full provision of modern contraception, combined with other medical care, would reduce maternal deaths by 68 percent (61,000 to 19,000 per year) and newborn deaths would drop by 85 percent (from 255,000 to 38,000 per year).
We know that our rapidly growing population is one of the country’s biggest economic and political challenges. Latest official data puts Nigeria’s Gross Domestic Product (GDP) and population growth at 2.2 percent and 2.6 percent, respectively. We are poised to be the third most populous country in the world by 2050, ahead of the United States. Finding jobs for all these people is already extremely difficult. Protecting our environment in the face of massive population growth is another challenge. Contraceptives have always been a vital tool for countries to build viable societies, and when given the option, most families make responsible decisions, ensuring that they can provide for the children they have.
I want to emphasise that this is not just a problem facing poor people in rural areas. The woman I described at the beginning of this article is well-educated, living a comfortable middle-class life. Yet the taboos around family planning affected her just as much as the rural women I also treat on a regular basis.
This is a problem impacting every part of the Nigerian society. Therefore, I call on government at all levels to prioritise family planning. It will be necessary to increase spending, employ more health workers, carry out awareness raising campaigns, and take contraceptive services to homes, as they do for immunisation. Perhaps they can combine these roles – training vaccination teams to also deliver contraception.
As a man, a father, and a husband, as well as a doctor, I also call on all men to educate themselves about these issues and consider their wives and children’s well-being above all. The benefits of change will flow not only to women, but to the whole country, by enabling families to prosper, reducing poverty, protecting our environment, and building a more sustainable future.
Dr Tijani Salami is a physician, sexual and reproductive health expert and founder of Sisters Caregivers Project Initiative