contraceptive use

1. Dr. Paul Nyongesa
Senior Lecturer, Dept of Reproductive Health, School of Medicine,
College of Health sciences, Moi University, Eldoret, Kenya.
Jack Odunga.
Research Assistant, Moi University,Eldoret,Kenya.

2. Outline: Contraception use in SSA
 Introduction: Contraceptive use in SSA
 Importance of Contraceptive use (MDG 5)
 Fertility rates in Sub-Saharan Africa
 Contraceptive prevalence in Africa
 Unmet Needs in Africa
 Benefits of Family Planning
 Determinants of Contraceptive use: Contextual and
Proximate
 Female Education and Contraception use
 Cultural Barriers to Contraception
 Family Planning and Religion
 HIV and Contraception
 Approaches to increase contraceptive use: Biopsychosocial
Model
 Recommendations: Beyond 2015

3. Introduction
Family planning is an important strategy in promoting
maternal and child health.
It improves health through :
 spacing of births
 and avoiding pregnancies at high-risk
maternal ages and parities.
This is highlighted in MDG 5: a UN Goal with 2 targets
and 6 indicators since the ICPD in Cairo, Egypt since
1994.

4. MDG 5:Targets and Indicators
 Goal 5: Improve maternal health
 Target 5.A: Reduce by three quarters, between 1990 and 2015, the
maternal mortality ratio
 Target 5.B: Achieve, by 2015, universal access to reproductive
health (Highlighted after the ICPD in Cairo, Egypt in 1994).
 6 Indicators:
 5.1 Maternal mortality ratio
 5.2 Proportion of births attended by skilled health personnel
 5.3 Contraceptive prevalence rate(CPR)
 5.4 Adolescent birth rate(ABR)
 5.5 Antenatal care coverage (at least one visit and at least four
visits)
 5.6 Unmet need for family planning

5. Universal Access to Reproductive Health Care in
sub-Saharan Africa
“Gaps in access to care still exist” and remains a mirage
• Prenatal care is 73.47% on average
• Births attended by skilled health attendant is 46.13%,
• Contraceptive prevalence rate (of women ages 15-49) is
21.83%
World Bank Report For Sub-Saharan Africa
in 2012

6. Benefits of family Planning
(Guttmacher Institute)
 Preventing pregnancy-related health risks in women
 Reducing infant mortality
 Helping to prevent HIV/AIDS
 Empowering people and enhancing education
 Reducing adolescent pregnancies
 Slowing population growth.

7. Family Planning in sub-Saharan
Africa(SSA) Region
Characterized by a paradox of
1. High fertility rates esp. among adolescents
2. Low contraceptive use across all ages
3. High unmet need for family planning
A situation suggestive of both provider-side and
user –side barriers and constraints that are needed to
overcome.

8. Fertility Rates in Africa
 Fertility rates still high in sub- Saharan Africa(UN
Population Division -2012).
 Sub-Saharan Africa has the highest average fertility
rate in the world at 5 compared to 2 for Europe and
2-3 for Asia, Latin America and the Caribbean .
 Fertility rate have converged or are converging
towards 2 by the year 2050 for all regions of the world
except for Africa probably due to sub-Saharan.

9. Global Fertility rates

10. HIV/AIDS Epidemic and Fertility
The HIV/AIDS epidemic has impacted fertility levels in Sub-
Saharan Africa-causing either stagnation or accelerated decline
in fertility.
The region has the highest prevalence of HIV/AIDS and the largest
number of people living with HIV/AIDS in the world.
Stagnation in fertility decline over the past 10 years has been
related to the increase in HIV prevalence. In Zimbabwe, for
example, estimated total fertility was 8.5 percent lower than it
would have been in the absence of HIV, and HIV-associated
changes in fertility behavior accounted for one-quarter of the
drop in fertility since the 1980s (Terceira, Simon, and Gregson
2003)
In South Africa, where the prevalence of HIV is among the highest
in the region, the spread of HIV is expected to accelerate fertility
decline (Moultrie and Timaeus 2003).

11. Fertility Rates in Sub-Saharan Africa

12. Fertility trends in Kenya.
 The KDHS 2008-9 data indicate:
 TFR declined during the 1980s and 1990s, changing
from a high of 8.1 children per woman in the late 1970s
to 6.7 in the late 1980s, and dropping to 4.7 during the
last half of the 1990s.
 However, fertility seemed to rise, marginally, after
1998, reaching a TFR of 4.9 children per woman during
the 2000-02 period.
 The TFR then seems to resume its decline, reaching a
low of 4.6 children per woman during the 2006-08
period

13. Trends in Total Fertility Rate, Kenya 1975-2008

14. The Kenya Family Planning
Program
 The Kenyan family planning program was by a started in the
1950s by a group of volunteers started and launched as the
1st in Africa in 1967 that a national family planning program.
 Under this plan, family planning was integrated into the
maternal and child health division of the Ministry of Health.
 In 1984, the Government ratified a set of population policy
guidelines to assist in the implementation of the program.
 Reflecting the 1994 International Conference on Population
and Development (ICPD), these guidelines were further
revised in the population policy for sustainable
development, issued in 2000 (United-Nations 1994; Jain
1998; CBS et al. 2004).

15. HIV/AIDS IN KENYA(KAIS 2014)
 Among persons aged 15-64 years, 5.6% were living with HIV
infection in 2012, presenting a statistically significant decline from
2007, when HIV prevalence was estimated to be 7.1%.
 There was wide regional variation in HIV prevalence among adults
and adolescents aged 15-64 years, ranging from 15.1% in Nyanza
region to 2.1% in Eastern North region.
 HIV prevalence was significantly higher among widowed men
(19.2%) and women (20.3%) than men (1.4%) and women (3.5%)
who had never married or cohabited.
 HIV prevalence was higher among women (6.9%) than among
men (4.4%). In particular, young women aged 20-24 years were
over three times more likely to be infected (4.6%) than young men
of the same age group (1.3%).
 HIV prevalence among uncircumcised men aged 15-64 years
(16.9%) was at least five times greater than circumcised men
(3.1%).

16. Contraceptive use in SSA
The modern contraceptive prevalence rate vary widely across the
region(World Bank-2011).
Among women of reproductive age, CPRs for modern methods
ranged from 1.2 percent in Somalia to 60.3 percent in South
Africa.
Geographic variations in family planning use were apparent, with
countries in Southern Africa reporting the highest levels of
contraceptive use followed by countries in East Africa.
With a few exceptions, West and Central African countries report
very low rates of family planning use.
Some of the lowest contraceptive prevalence rates in the world
exist in these two sub regions of Africa of West and Central
Africa.

17. Somalia
Chad
Guinea
Angola
Niger
Eritrea
Congo, Dem. Rep. of
Benin
Sierra Leone
Guinea-Bissau
Mali
Côte d’Ivoire
Mauritania
Burundi
Central African Republic
Nigeria
Senegal
Liberia
Togo
Gabon
Mozambique
Cameroon
Congo, Rep.
Gambia, The
Burkina Faso
Ethiopia
Ghana
Madagascar
Djibouti
Uganda
Comoros
Rwanda
Zambia
São Tomé and Princípe
Kenya
Lesotho
Malawi
Mauritius
Botswana
Swaziland
Namibia
Zimbabwe
Modern
Contraceptive
Prevalence Rates in
Sub-Saharan
Africa, by Country
Source: United
Nations Population
Division 2009.
East Africa
Central Africa
West Africa
Southern Africa

18. Changes in contraceptive method
use in SSA
 The use of traditional methods tends to be higher in settings
where acceptance of family planning is low and use of family
planning programs is weak.
 The use of modern methods has increased most markedly in
countries that had the greatest increases in CPR (Madagascar,
Malawi, Namibia, Zambia, and Zimbabwe).
 Use of traditional methods in these countries has either
remained stagnant or has decreased. Ghana, Kenya, Tanzania,
and Uganda showed increases in use of modern methods while
maintaining use of traditional methods. In West African
countries such as Benin, Burkina Faso, Cameroon, Senegal, and
Togo, traditional method use declined and relatively modest
gains in modern method use were observed.

19. Unmet need in SSA(too high)
 Estimated 222 million women in developing countries
would like to delay or stop childbearing but are not using
any method of contraception(WHO, 2014).
 In Africa, 53% of women of reproductive age have an unmet
need for modern contraception compared to 21% and 22%,
in Asia, and Latin America and the Caribbean respectively-
regions with relatively high contraceptive prevalence
 The contraceptive prevalence and fertility in Kenya have
leveled off in the recent past( Ojakaa/AMREF 2006).
 Between 1993 and 1998 total unmet need declined, but then
remained constant between 1998 and 2003, at about 25%.

20. Contextual & Proximate
Determinants
 Kingsley Davis and Judith Blake(Mid 1950’s) worked out
relationships amongst contextual(indirect) and
proximate(direct) determinants of fertility as follows:
Indirect determinants Direct determinants
-Socioeconomic -Intermediate fertility
-cultural, Variables
-environmental variables
Fertility

21. Proximate Determinants of Fertility
 By John Bongaarts(1978) analysed and indicated that
variations in four factors-marriage, contraception,
lactation, and induced abortion-are the primary
proximate causes of fertility differences among
populations.

22. Factors influencing Contraceptive
use:
Reasons for this include supply-side and demand-side
barriers:
 poor quality of available services;
 limited choice of methods;
 limited access to contraception, particularly among young
people, poorer segments of populations, or unmarried
people;
 fear or experience of side-effects;
 cultural or religious opposition;
 gender-based barriers.
Fueled by both a growing population, and a shortage of
family planning services.

23. The Contextual Determinants of
Contraceptive Use:
 Behavioural (demand or user-side)factors:
 Biological(provider or supply-side) factors:
 Socio- cultural factors

25. Women with more than seven years of education have on average
fewer children in Africa than women with no education (Hobcraft
1993)
Female Education Impacts on contraception

26. Cultural barriers to Contraceptive
use
 several socioeconomic factors are shown to be associated
with high fertility
 low levels of female education and income per capita
 rural residence, and high infant and child mortality
 Other barriers to sustained contraceptive use included
medically inaccurate notions about how conception occurs
and fears about the effects of contraception on fertility and
menstruation, which were not taken seriously by care
provider.
 undermined the effective use of contraception by girls.
 Many contraceptives are encumbered with potentially
unnecessary restrictions on their use. Indeed, fear of side
effects, fostered by alarmist labeling, is a leading reason
that women do not use contraceptives

27. Family Planning and Religion
Christian teachings vary depending upon the denomination.
 Roman Catholics are forbidden to use medical or physical
contraception. Abstinence and the rhythm method are the
only officially approved methods of birth spacing. Among
Protestants , no specific forms of contraception are forbidden.
 Islam similarly encourages large families and requires parents
to ensure that the basic rights of children are met. Family
planning is not forbidden but is more commonly used by
traditional adherents for birth spacing.
 Buddhist religious dogma does not stress procreation; thus,
contraception may be used.
 Chinese religious traditions, such as Confucianism and
Taoism, do not prohibit birth control. (Srikanthan & Reid,
2008)

28. Strategies to Contraception in
SSA: The BioPsychosocial Approach
Intervention programs aimed at increasing contraceptive
use may need to involve different approaches:
 Behavioural (demand or user-side)Approaches:
 Biological(provider or supply-side) Approaches:
 Socio- cultural Approaches
Including promoting couples’ discussion of fertility
preferences and family planning, improving women’s
self-efficacy in negotiating sexual activity and increasing
their economic independence.

30. Post-primary Education
 Education will help achieve reproductive
behavioural change in face of challenging socio-
cultural, gender and economic
circumstances(Schultz 1993)

31. Advocate Couple Empowerment
 The World Bank defines empowerment as the “expansion of
freedom of choice and action to shape one’s life. This
definition encompasses two features of women’s
empowerment: process of change (through which a woman
gains power in making decisions) and agency.

32. HIV and Contraception:
Dual Contraceptive Use(WHO
2012)
 A WHO expert group reviewed all the available evidence
and agreed that the data were not sufficiently conclusive to
change current guidance(WHO Feb 2012).
 Condom use should be encouraged in HIV-positive women
 To prevent HIV transmission
 Prevent STI acquisition
 As an adjuvant to contraceptives i.e. dual method
 Condoms alone have a failure rate of 15%-21% at preventing
pregnancy
 In 2012, national HIV prevalence was estimated to be 5.6%
among Kenyans aged 15-64 years, signicantly lower than the
HIV prevalence estimate in 2007, which was reported at
7.2%

33. Beyond 2015-The Way forward
Education
Economic
Prosperity
Universal Access
to SRH care
Health &
survival
for
women
A multi-sectorial approach is imperative to improve women’s
health in Africa:
1. Girl child /Women
Education
2. Access to quality
Reproductive Health Care,
(Maternal, FP, PMTCT
Strategy)
3. Protecting women’s rights
and Empowerment

34. THANK YOU
.