Family Planning Rights: Investigating Obstacles to Accessing Contraceptive Care in Owerri

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 “I told my husband that I wanted to do family planning, he said no, that he is scared. I just took the decision and did it by myself”. 

32-year-old Mrs. Ezinne, who has been exposed to the benefits of family planning, did not let her husband’s disapproval hinder her from accessing the procedure after her fourth child.

There are several other women in Imo State, Southeast Nigeria, whose husband’s refusal has stopped them from accessing Family Planning methods, putting them at the risk of birthing numerous children.

Family planning, which is the ability of individuals and couples to anticipate and attain their desired number of children, the spacing and timing of their births, has contributed to global reductions in undesirable demographic and health outcomes such as unintended pregnancies, unwanted births, unsafe abortion, maternal mortality, and childhood deaths.

The Family Planning Coordinator at Nworiebi Health Centre, Mbaitoli Local Government Area of Imo State, Mrs. Chioma Umezurike, while explaining that family planning is not the absence of conception, but a measure to space and give birth to children by choice and not by chance. Maintained that there must be a mutual agreement between couples before the woman can access FP consumables.

Mrs Umezurike complained that most men do not agree to it out of ignorance and obnoxious superstitious beliefs that their wives may never be able to bear children or might become promiscuous. “Men are obstinate about Family planning. When we invite women to family planning clinics, their husbands are usually not in support of them and they need to seek the consent of their husbands’,  Umezurike  said. She blamed the inaccessibility of the FP consumables on the Igbo tradition that allows a woman to give birth to as many children as she can, especially when a male child has not been birthed, without considering what and how to raise them.

FAMILY PLANNING AND CULTURE 

Some of these beliefs in the Igbo cultural system hinder the effective practice of Family planning in the region. For instance, people from the Mbaise community in Imo state, South -East Nigeria, believe that any woman who has had ten children has attained an enviable status, and deserves to be honored by killing a goat for her, in a ceremony called ‘Ewu-ukwu’ One of such women who had participated in this kind of ceremony is Mrs Rose Ahamba from Uvuru in Mbaise. She said she enjoyed the Ewu-ukwu celebration after the birth of eleven children. The ceremony was done with a goat and a stool which must be bought by the woman’s husband.

‘The ceremony is not performed in the afternoon; it is done at night. Prayers are made, and the woman is kept on the stool, while the goat is taken round her. After that, the goat is killed, and the blood is also used to massage the woman’s waist’, said Mrs Ahamba

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During the ceremony, the woman is cautioned to desist from allowing any woman who had not given birth to eight children, sit on the stool, to avoid the risk of premature abortion. This practice exposed women of the community to birthing many children, so they can be celebrated.  The practice also negates every form of family planning as the children are born without spacing. Although the practice is fading away gradually with the knowledge of family planning, its effects are still visible in the community.

Development expert at Nguru Health Center in Aboh Mbaise local government area, Imo State, Southeast Nigeria, Mr. Samuel Chima, expressed worry that cultural practices, religious and personal beliefs hinder the use of contraceptives in the region. Mr. Chima said some women believe the use of contraceptives makes them gain weight, while others believe it will reduce their sex drive.

For Mrs. Dorothy Ihemtuge, 40, her quest for more male children has left her giving birth to seven children and still counting “I am not on family planning because I want to have another baby. I do not see my period after childbirth till I stop breastfeeding after a year and one month. I have seven children, six girls and one boy, that is why I want to have another baby, it is what my husband and I want’, she said.

Mrs Ihemtuge believes that not seeing her monthly period while breastfeeding is a good enough family planning method.

According to a study  on the extent of utilisation of modern birth control methods among rural dwellers in Imo State, by Ike Nwachukwu and O. O. Obasi, it showed that out of the three hundred and sixty households only 30% of the respondents used modern birth control methods, while 57% of them used the traditional birth control methods especially the withdrawal method.  This happens when the penis is pulled out of the vagina and ejaculates outside the vagina to try to avoid sperm from entering the vagina and prevent pregnancy.

But how effective is the withdrawal method of contraception, or coitus interruptus or pulling out?

Speaking on the traditional method of family planning, Mrs. Umezurike noted that some women do not take up the modern FP procedures, because they still practice the old traditional methods of family planning. She said although the methods worked to an extent for our forefathers, it also failed them, making them give birth to many children.

”In the olden days, they practiced family planning, a woman after birth could take her child to and stay at her parents for a year or more and return when she is ready for another pregnancy. Some drink potash after meeting with their husbands, some put feathers under their pillow while meeting with their husband’, she said.

The Family Planning Coordinator also stated that family planning consumables are free, advising single and married women from age 18, to access the services, which she explained would help reduce the rate of unwanted pregnancies, abortion and its attendant health hazards, space the children and reduce the population of the state.

The Sustainable Development Goals (SDGs) in its article three aims “to ensure universal access to sexual and reproductive health services by 2030, which includes family planning, sex education, prevention and management of sexually transmitted infections, pre-conception counselling and infertility management”

Although the federal and state governments have introduced different programs, as the demand and the supply-side interventions of Nigeria Urban Reproductive Health Initiatives to improve contraceptive use and provide access to free family planning commodities, millions of women continue to have unintended pregnancies and unwanted births. This can be attributed to some barriers that have threatened the progress of Family planning.  In Imo state, South- East Nigeria, some of these barriers have been identified as limited access to services, poor quality of services, fear of adverse effects, partner’s disapproval, cultural and religious beliefs, illiteracy, and contraceptive discontinuation due to health complications and several other myths and misconceptions.

According to  Mr. Chima, most of the misconceptions are not based on truth, some of these women have side effects due to difference in body structure or wrong choice of FP service.  “There are three side effects, bleeding, spotting during the monthly period and some women do not see their period, it is normal, that thing in the body is foreign and will change the system’’. Mr. Chima said that despite the barriers hindering the intake of FP services, the state records between 8,000 to 11,000 women in the 210 health facilities in the 27 Local Government Areas of the state taking up FP services. He encouraged women to embrace FP services to develop themselves and be able to plan their lives and that of their children.

Another mother of four, 32-year–old Mrs. Chetachi Alfred, said she had to discontinue her family planning intake, due to health complications and maintained she would not accept any type of family planning procedure again.  “After the three months elapsed, I could not get pregnant for three years. The fourth year, I took in, and it was ectopic,’ she narrated.

Mrs. Alfred said although the side effect might have been from the wrong choice of FP method, the trauma from what she went through would not let her take up another. Like Mrs. Alfred, many women have discontinued the use of FP consumables because of reasons which include method failure, desire to become pregnant, other fertility-related reasons, with concerns of side effects and discomfort

For 28-year-old mother of three, Mrs. Ehirim, her mother advised her not to take up FP services for reasons she did not explain to her. This buttresses the fact that the misconception of fear of the unknown is another major reason women do not access FP procedures.  Mrs. Ehirim said she had no plans of taking any of the consumables since she was done with childbearing. “My mum asked me not to do it, that it is not necessary. I still don’t have plans of doing family planning because I do not see anything positive in it,’ the 28-year-old mother remarked.

 Overview Of Family Planning Prevalence Rate. 

Despite governments’ alleged commitment to providing free access to family planning commodities, the contraceptive prevalence and other relevant FP indicators remain poor in the state. According to the Nigerian Demographic and Health Survey DHS of 2018, the country’s modern contraceptive prevalence rate rests at 12% among currently married women which is one of the lowest globally. The 2018 DHS also revealed that Unmet need for FP is high at 48% among sexually active unmarried women, and 19% among currently married women, and the contraceptive discontinuation rate among women in Nigeria was 41%,

A family health physician, and a Director at the Imo state ministry of Health, Dr. Austin Ikeji, decried the low uptake of family planning consumables in the state despite the high rate of contraceptive knowledge. According to the Director, a survey by the Demographic Health Survey reveals that the Contraceptive Prevalence Rate at the national level is 27%, while that of Imo State is 10.9%. Dr. Ikeji, who described family planning as a positive intervention approach to economic, social, maternal and child health improvement, urged women to take advantage of the free services at the health centers in the 27 local government areas of the state.

“The cultural institution where the man is the ultimate approver of everything in the family including for the wife, as much as the body of the woman, is an issue. Women should get empowered in taking charge when it concerns their bodies or health,” the Director argued.

Dr. Ikeji, encouraged women of childbearing age to go for Family Planning services, as it would help to reduce the number of unsafe abortions, prevent sexually transmitted infections (STIs) and empower them by making them control the number and timing of their children to improve their own future and that of their families.

According to a survey    titled;” Prevalence, Pattern and Determinants of Contraceptive Use among Women of Reproductive Age (15-49 Years) In Rural Communities in Imo State, Nigeria”, which aimed to show the prevalence, pattern and determinants of contraceptive use among women of reproductive age (15-49 years) in rural communities of Imo State, with a view of generating data that will help policy makers to develop policies that could help improve the use of contraceptive methods in the state, recorded that  the prevalence rate of women who have ever used of any form of contraceptive was 42.5%, while that of current use was 19,4%.

The study further revealed that there is regrettably, a high awareness level among the respondents (96.1%) but a low contraceptive use, (19.4%), this goes to show that women have knowledge of FP consumables, but do not access it, due to different limiting factors.

Influence Of Religion

The Roman Catholic church  does not support the use of any form of artificial methods to prevent pregnancy. The Church considers the practice of any means of artificial intervention to be a grave sin. They emphasise natural family planning methods for fertility reduction. Use of family planning methods such as the pill, intrauterine devices (IUDs), diaphragms, and condoms are perceived as an abortifacient which forces the uterus to expel eggs-an embryo, which they believe has a soul, and is a human. The accepted family planning method of the Catholic church is the Billings method which is also called the cervical mucus method and the ovulation method. It is the observation and tracking of the changes in the cervical mucus to detect when a woman is ovulating. [Ovulation is the time in your menstrual cycle when you’re most likely to get pregnant. The cervical mucus, or vaginal discharge, changes over the course of the menstrual cycle

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 Confirming the stand of the Catholic Church on family planning, a Clergy of the Catholic Dioceses of Mbaise, Reverend Father Pius Nwauzor, maintained that the Billing method remains the accepted because other artificial methods alter the cause of nature as designed by God.  ”Artificial contraception is considered evil but methods of natural methods of family planning like the billings ovulation method may be used, as they do not usurp the natural way of conception or contravene the natural law, neither do they go contrary to the commandments of God’, the Priest said.

Reverend Father Nwauzor who noted that the Catholic position on family planning was postulated by Pope Paul the 6th, decried that most of the artificial family planning methods have adverse effects on the woman and can alter their hormonal system, unlike the artificial methods.  Natural family planning methods do not exhibit the same consistency characteristic of artificial methods. Unfortunately, many couples, particularly in rural communities, are illiterate and lack the necessary knowledge to adapt to contemporary family planning methods, coupled with the prevailing poverty rate. Without a comprehensive understanding of the nature of family planning techniques and the factors that affect their access and use, there is the likelihood that fertility levels will remain high. However, the education and knowledge required to effectively achieve it have been noticeably lacking.

HOW THE GOVERNMENT HAS FARED 

Although the Federal government recognizes that increasing access to family planning services as crucial to improving maternal and child health, reducing poverty, and promoting economic growth, and claims it has implemented several innovative approaches to expand family planning services, yet, it has not done enough.

Photo Credit: Planned Parenthood Federation of Nigeria PPFN website.  

The executive Director Planned Parenthood Federation of Nigeria, PPFN, Dr. Kai Harima said that although the federal government tries to meet up with its share of the counterpart funding for the healthcare sector, having the healthcare sector on the concurrent list is a major issue and challenge on the healthcare of the citizens. “Our major problem is funding for the different types of FP and commodities. The federal Government is not doing enough, with health being on the concurrent list” he said. Dr. Kai maintained that the PPFN would continue to do their contribution by creating awareness to let people know about FP services, screen, threat and refer people to higher or secondary health facilities where need be and follow up to ensure the patient got the required service.  “We start from village, door to door, town crier, we also use Community Health Essential Workers that are familiar with the people, and gathering of people, like market, churches or mosques to create awareness,’ the PPFN director said.

The Acting Director of Programs PPFN, Dr. Paul Odigbo who placed the population of Nigeria at 220 million, with 49.4% female and 50.6% male, disclosed that; “There are 19% unmet need for FP services in the country, with 19% teenage pregnancies and 552 mortality rates for every 100,000 life births”.

Dr. Odigbo said that the statistics according to the National Demographic Health Survey of 2018 are what informed the reason why the organisation advocates and sensitises people to take up FP services.

Speaking on the government’s efforts towards FP rights, sensitisation and distribution of services, A development expert and Marie Stopes representative at Nguru Health Center in Aboh Mbaise LGA, Imo State, Mr. Samuel Chima recalled that FP services were low during the Covid 19 pandemic. He said that the donors could not send funds or consumables, due to the lockdown across the world.

 “The Covid 19 period should give us an idea, the foreign countries cannot keep helping us forever, the government needs to think out of the box on how to raise money to fund the reproductive healthcare sector, should the developed countries stop financing this venture”. 

The Federal Ministry of Health says it set a goal to improve the modern contraceptive prevalence rate (mCPR) to 27% by 2020; in 2018, the mCPR was 17% among currently married women aged 15–49 years, and unmet need for FP among currently married women was 19%. Considering that the set target was not met by 2020, a review of progress and restructure of a timeline for targets was conducted as part of the Nigeria FP2030 commitment, with a renewed commitment to achieve 27% mCPR by 2030.

Going by the country’s sustainable development goals, it is expected that by the end of 2030, everyone can make informed choices, have equitable and affordable access to quality family planning, and participate as equals in society’s development.

BREAKING BARRIERS HINDERING FAMILY PLANNING CARE  

Experts believe that concerted efforts are needed to break the barriers hindering accessibility to family planning care in the Country. They are of the opinion that these factors must be considered to break these barriers:

• Prioritising and strengthening healthcare in Nigeria by removing it on the concurrent list during budgeting in Nigeria
•    Implementing comprehensive reproductive health education programs, targeting both men and women.
• Engaging with community leaders, religious leaders, and influencers to promote family planning acceptance.
• Promoting gender equality, education, and economic empowerment to enhance women’s autonomy and decision-making.
•  Offering accessible, confidential, and non-judgmental family planning services for young people. , Addressing indoctrinations, stigma and misconceptions by Implementing awareness campaigns to dispelling myths and misconceptions about family planning methods.

Editor’s Note: The names of the survivors have been altered in this report for their security.  

This story is part of the African Women in Media (AWiM) ‘Reporting Violence Against Women and Girls’ project,’ supported by the Wole Soyinka Centre for Investigative Journalism