A small, happy family. Urban and wealthier women have more access to family planning services than rural women

By Irene Nabusoba

THERE is increasing demand for family planning services worldwide, especially in developing countries because of growing populations and wider acceptance of contraceptive use.

Recent findings contained in the US-based Population Reference Bureau’s Family Planning Worldwide 2008 data sheet show that between 2005 and 2015, the number of women of reproductive age (15-49 years) in developing countries will grow by 125 million. Consequently, the demand for contraceptives is projected to grow.

In Tanzania for instance, the number of women using contraceptives is likely to grow by 90%, from two million to 3.7 million between 2005 and 2015. Currently, only 20% of women are using a modern family planning method, up from 7% in the early 1990s. Yet Tanzania has the best indicators in East Africa, with an unmet need of 22% compared to Kenya’s 24% and Uganda’s 41%.

“This means that we are not able to meet the rising demand for family planning services. For the last five years alone, our unmet need for modern contraceptives has gone up by 2%. What will happen by 2015, with our population projected to increase by two million?” Dr. Anthony Mbonye, the assistant commissioner for reproductive health at the Ministry of Health, says.

“We need facilities and trained personnel to provide the services,” he says, noting that the problem of drug stock-outs has worsened the situation.

Last week, the Government launched the 2008 National Population policy aimed at emphasising child spacing and prevention of risky pregnancy.

“Our population is growing at a very fast rate. We are not estimated to be 30 million, but by 2025, our population is projected to reach 55 million,” says Charles Zirarema, acting director Population Secretariat.

Only 24% of married women use contraceptives, yet there is low child spacing (less than 24 months).

“There are hardly any stocks of family planning drugs in rural health facilities. Even at the district health stores, officials do not know how much to order or do not order them in time. Districts do not have funds to transfer the requirements to rural health centres, leave alone the difficult means of transport and communication. They do not have the capacity, but the services are available,” Mbonye says.

Mbonye’s remarks point to why wealthier women are more likely to use modern contraceptives than poorer women.

The report says the disparities are more pronounced in countries with overall low contraceptive use such as Uganda, where contraceptive use may rise, but the poor will always lag behind until it becomes more acceptable and available.

“It’s the poor who are illiterate, holding onto myths and prejudices and cannot afford the service while the rich are exposed, easily embracing contraceptives and affording the service, leave alone the fact that it is readily available in urban areas,” he says.

In countries like Bangladesh, strong programmes have reduced the gap by making the services more accessible.

However, despite increased accessibility, there are key concerns about the rate at which couples stop using family planning methods and the reasons for stopping.

“The most common reasons for discontinuing the use of the pill are the side-effects and health concerns,” the findings reveal. Family planning programmes should focus more on counselling and follow-up of users to help women deal with the various obstacles to continued use.

Elly Mugumya, the executive director of Reproductive Health Uganda (formerly Family Planning Association of Uganda) concurs with the findings, adding that the difference between method preference and convenience should be focused on during counselling.

“Many women come asking for a particular method of family planning because a friend is using it, yet it may not be a convenient for them.

“There are also minor side-effects like nausea, and health concerns like periodical headaches, weight gain or loss, or prolonged bleeding. Women need to understand what they are consuming. Keeping in constant touch with the health provider is critical for continued use,” Mugumya emphasises. He advises health providers to examine convenience from a client’s location as well.

“It’s like advising a rural woman to go on the pill when the supply and stocks are not guaranteed. From this perspective, periodical injectaplan could be more reliable,” Mugumya says.

This is where female sterilisation, the modern permanent method of contraception, would be ideal for those who want to permanently stop having babies. With hardly any side-effects, apart from the minimal discomfort of the procedure, it is guaranteed continuity.

However, while female sterilisation is the most common method, used by one-fifth of married women worldwide, in Uganda it accounts for only 2.4%, compared to injectaplan at 10.2%. It is even worse with male sterilisation which accounts for only 0.1%, though it is low world over.

“It is ideally the most expensive method of contraception, but we offer it free of charge in government facilities,” Mugumya says.

But for Maria, 29, sterilisation would not be her idea of contraception, given the high infant and child mortality rates. “Besides, in Africa where children are a passport to marriage, what would I do in case I remarried?” she asks.

This underplays the advantage of reduced costs that could be addressed with the one-time-sterilisation in limiting births.

As a result, the total cost of contraceptive supplies to meet couples’ needs is projected to rise by nearly 50% in countries like Tanzania and Nepal, where short-acting methods like pills and injectapan are preferred.

“The costs are certain to grow throughout the developing world, placing pressure on governments to increase their family planning budgets, raise additional donor funds, obtain better prices for commodities, and/or shift a greater share of costs to users,” the report says.

Martin Oteba, the health minstry’s acting assistant commissioner for health services in charge of pharmaceuticals, says family planning drugs are part of essential drugs, but only sh1.2bn is allocated to contraceptives.

“We need ten times this amount,” Oteba says, noting that many times family planning services are invisible on the ground because of mis-prioritisation at the district level.

“We normally send the money to districts with tentative budgets, but the districts re-prioritise and family planning may not get the vote it deserves,” he says.

Critics argue that family planning should get an independent vote, just the way certain programmes like HIV/AIDS and malaria do.

“We need to ensure stocks, train more providers, especially midwives and counsellors who form the majority in rural facilities,” says Nabutono.