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Organizations That Aree Improving Family Planning in Africa

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Open admission peer-reviewed chapter

Family unit Planning Services in Africa: The Successes and Challenges

Submitted: July 18th, 2017 Reviewed: November 6th, 2017 Published: June 13th, 2018

DOI: 10.5772/intechopen.72224

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Abstract

The globe population is on the increase, and the majority of this increment will be from sub-Saharan Africa (SSA). It is estimated that by 2030 the population of Africa will ascent to 1.3 billion. Published peer-reviewed journals, abstracts, Grayness literature (government documents, technical reports, other reports, etc.), internet articles and Demographic and Wellness Surveys (DHS) reports were used as resource materials. Manual search of reference list of selected articles was checked for further relevant studies. Family planning (FP) programmes that started in 1960s across SSA have fabricated steady progress with contraceptive prevalence rates however very low and unacceptably high unmet need. Despite nearly universal cognition on contraceptives, in that location is an obvious knowledge-practice gap. There are barriers, personal, religious and community levels, to contraceptive utilize. Contraceptives have a lot of benefits to the female parent, child and community. Thus, at that place is a need for publicity campaigns through information, educational activity and communication (IEC) to address social and cultural barriers to FP including misconceptions and misinformation. Contraception should be vigorously promoted in SSA non just for its demographic dividends but also on socio-economic and health grounds and the attainment of sustainable development goals (SDGs).

Keywords

  • contraceptive utilize
  • benefits
  • barriers
  • unmet need
  • SSA

i. Introduction

The globe population reached 7.4 billion in 2016 at an almanac growth charge per unit of 2.55% with Africa accounting for 1203 million. It is estimated that betwixt 2015 and 2030 the population in Africa will reach 1.3 billion [1]. Sub-Saharan Africa (SSA) (excluding North Africa) has seen remarkable population growth in the past iii to four decades. SSA population in 1990 was 510 meg, 688 million in 2002 and by 2016 has reached 974 million [2]. By 2050, three countries (Nigeria, 4th, Democratic republic of the congo, eighth and Egypt, tenth) with a combined population of 779 million will exist the near populous nations in Africa [i]. Sub-Saharan Africa (SSA) has xi% of the world population but accounts for a pitiable 2% of global trade [3]. The population growth is largely driven by loftier fertility rate and rising cohort of women of reproductive age group (WRAG) (15–49 years).

Demographically, in that location is population momentum beyond most of the countries, as more than half of the population are under the age of fifteen years. What this ways is that even if replacement-level fertility is accomplished, the population growth will continue for at least ii decades considering of the momentum congenital up in the historic period construction due to the past high fertility levels that has given ascension to the greater number of couples who are having children. Social forces and pronatalist factors sustaining high fertility and which also impedes family planning (FP) programmes are well known [four, 5]. Added to this is the fact that in SSA husbands tend to desire large families than their wives [6, 7]. Sub-Saharan African countries are even so undergoing both demographic and epidemiologic traditions. Even though nascency rate is declining, it is still in excess of death rates. Thus, the region has the highest rates of fertility globally with full fertility rates (TFR) that ranged from four.8 children per adult female in Kenya, 5.ii in Nigeria, v.7 in Southward Sudan, and 7.6 in the Commonwealth of Niger [1, 4, 8, 9]. It too has a high almanac growth charge per unit of more than ii.v% per twelvemonth.

Again, the same continent is vulnerable to the "destructive forces" caused by nature as recent events have shown. The harsh agin furnishings of global warming in the Sahel region, draught/famine in the horn of Africa, deforestation, overgrazing with declines in soil fertility and incessant floods in W Africa has contributed in sustaining the cruel cycle of poverty and disease. As the number increases, the force per unit area on the environment (both built and natural) including natural resources and available fertile land for agriculture increases. Consequently, the net effect is increased in greenhouse gases (GHGs) with its attendant effects on public health.

Before 1970, majority of Africa countries had not viewed population growth as a major factor in their national development strategies because of their small population (34 of the 48 countries had a full population of less than v million) [8]. By the mid-1970s, the trend started to change with the rise number of national governments that reported having population policies aimed at reducing the rapid growth of their respective populations: 25% in 1976, 39% in 1986, 60% in 1996 and 64% in 2009 [nine]. Previously, pronatalist governments that wanted to maintain or even increase population growth take gradually modified their stance and accustomed provision of FP services as integral role of maternal and child health (MCH) which is a key component of chief health-care (PHC) organization. Also, government policies regarding admission to and availability of modern contraceptives have been an important determinant of reproductive beliefs also every bit maternal and child health. Many governments have given direct support providing FP services through state-owned wellness facilities. The provision of FP services is a key component of Safe Maternity Initiative launched in 1987 in Nairobi, Republic of kenya, to reduce maternal mortality in developing countries, where 99% of all maternal deaths occur [10]. In African region women take i in 42 lifetime run a risk (compared to 1 in 2900 in Europe) of dying prematurely in childbirth [11]. Provision of universal access to high-quality family planning and maternal health services and skilled attendance at delivery are primal activity strategies under the rubber maternity initiative [12]. Contraceptive utilize averts about 230 meg births every year globally, and family planning (FP) is a main strategy for prevention of unwanted pregnancy [13].

Contraception refers to the prevention of pregnancy as a issue of sexual intercourse using either traditional or modern methods. The 1994 International Conference on Population and Development (ICPD) in Cairo was a paradigm shift and was seen equally a turning point with respect to the role of FP. The earlier population conferences, Bucharest 1974 and Mexico Urban center in 1984 mainly focused on demographic-economic issues. Notwithstanding, the Cairo Conference highlighted the important role FP plays in the context of social and economic development and goals regarding sexual and reproductive wellness and right including FP with a focus on women's empowerment [14, fifteen]. The universal access to FP that links the 1994 Cairo Conference to Millennium Development Goal 5b (MDG 5b) of universal admission to reproductive health is very much connected to the successful achievement of sustainable development goal (SDG) themes of people, planet, prosperity, peace and partnership [16]. Voluntary FP brings transformational benefits to women, families, communities and nations. Without universal access to FP and reproductive health, the impact and effectiveness of offering interventions volition be less, will cost more and will have longer to accomplish [16].

The need for FP will never finish every bit long as life continues to be on earth, and humans want to satisfy their physiological desires and need for procreation (generational species sustainability). At whatever point in time, at that place will always be a accomplice of young adult couples who not only want to fulfill their sexual desires only also want to delay or postpone pregnancy, and and then the demand for contraception will continue.

In SSA, health-care systems are weak and dysfunctional; despite this, there take been some remarkable gains in immunization services with resultant turn down in death rates among under-fives. Withal, fertility has remained high. Added to this dimension is the unprecedented rapid urbanization that is sweeping beyond the continent. In that location is yet a long way to go to achieve pocket-size or desired family size. In the whole region, only 17% of married women are using contraceptives, very much lower than the l% reported from North Africa. Only in five countries (South Africa, Botswana, Zimbabwe, Kenya and Malawi) have FP programmes been a success to increase contraceptive utilise to higher levels [3]. This chapter is based on FP services in Africa. Published peer-reviewed journals, abstracts, Grayness literature (government documents, technical reports, other reports, etc.), Internet articles and Demographic and Health Surveys (DHS) reports were used every bit resources materials. Manual search of reference list of selected manufactures was checked for further relevant studies.

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2. Benefits

The period 1970–1990 marked the golden era of family unit planning during which reproductive revolution occurred worldwide except in SSA. However, past the early on 1990s, changes had begun to occur leading some experts to suggest that population and FP programmes started in the tardily 1960s in developing countries constituted one of the most important public health success stories of the twentieth century [14]. Benefits of FP were known ever since Beard in 1897 observed that ovarian follicles practise non develop during pregnancy and that corpus luteum was responsible [17]. There are a multifariousness of health benefits that are associated with the employ of individual FP commodities; for instance, pills, injectable and implants have been associated with protection against uterine and ovarian cancers, benign cysts of the chest or ovaries and pelvic inflammatory diseases (PIDs). Pills tin too reduce menstrual flow and dysmenorrhea and decreased prevalence of iron deficiency anaemia.

Family planning is a toll-effective public health and evolution intervention. Generally, planned pregnancies which are safer for the mother produce healthier children than unplanned pregnancy. FP allows individuals and couples to at least plan ane aspect of their lives (reproductive life). The price of averting unwanted nascence is quite insignificant compared to the costs to the family and country of unwanted births [9]. Further, fewer public health interventions are as constructive as FP programmes in reducing morbidity and mortality of mothers and infants and result in such a huge positive impacts [9, 18, 19].

The health and socio-economic benefits of healthy motherhood including the utilize of contraception are known. Contraceptive utilise promotes small family size, improves child survival and reduces sibling competition for deficient family and maternal resource [20, 21]. When used correctly and consistently, contraceptive employ in developing countries have been shown to decrease the number of maternal deaths and also prevent more than than one-half of all maternal deaths if total demand of nascency control is met [12, 22]. Spacing children tin reduce mortality among under-fives by 10% and amongst pregnant mothers by 32% [23, 24, 25, 26].

At macro-level, national population growth is slower which reduces strains on the environment, natural resources, pedagogy and health-care systems. FP reduces the risk of maternal mortality per nascence (i.eastward. number of maternal deaths in 100,000 live births per year) [27] equally a result of pregnancies likewise early, too many, likewise close and too late (4Ts of maternal mortality) [28, 29, 30] all of which are prevalent in SSA. The effective use of contraception can help couples achieve the desired number of children they want, foreclose the number of unwanted pregnancies and reduce the risks of sexually transmitted infections (STIs) and thus overall improvement in maternal and child wellness and the nation.

Contraceptive utilize allows couples to realize their total potentials, and the woman tin improve fulfill her roles as a wife, mother, wage earner and customs member. The man can better expand his roles as hubby, father and family caregiver [30]. All these become a long way in curtailing population explosion, reduce dependency ratio (youth), better the health indices for the state and meliorate socio-economic weather. This volition as well assist Africa to make progress in achieving all the sustainable evolution goals (SDGs).

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iii. Family unit planning services

The decision to limit one's family size is wholly personal intimate decision between hubby and wife. The practice to limit family unit size by any means has been known since man adult social censor. In SSA, national family unit planning programmes were introduced, respectively, in the belatedly 1960s in Kenya and Nigeria [31], in the early 1970s in Republic of ghana and in the mid-1970s in South Africa [32]. Programmes to promote FP in developing countries began in the 1960s in response to improvements in child survival that led to increase in population growth. The number of developing countries with official policies to back up FP rose from only 2 in 1960 to 74 by 1975 and 115 by 1996 [thirty]. Before the 1960s, African countries had no population policies in whatever form; past the mid-1970s, only 25% had; and this rose to 64% in 2009 [9]. Family planning programmes throughout SSA accept made utilise of three approaches to service commitment:

  1. Health-care facilities

  2. Commercial outlets

  3. Community-based systems

Family planning services and contraceptive article supply were started through assistance by the US Agency for International Development (USAID) and other international donors to national governments across Africa. Afterwards on, not-governmental organizations (NGOs) came in to supply and/or donate FP commodities. Initially, the services were provided at wellness-care facilities in state, district and provincial capitals. During these "infantile" periods, admission to family planning methods was under strict control of medical practitioner fifty-fifty in wellness facilities. During the period clients have to pay a token to access service which too was a huge barrier to many potential users. Firstly, the woman has to meet the eligibility criteria [33], they must exist married and husband must give verbal (seen past the doctor) or written consent and exist seen past the medico as presently as she starts her menses. This was a practiced starting point for FP services commitment, simply the burden and disadvantages of this "solo" practice became patently inconvenient to the clients, long waiting time and other logistics. In that location was an urgent need to overhaul the system in social club to ameliorate access and service utilization. The World Health System (WHO) has published international guidelines on medical eligibility criteria that take proven to be invaluable [34].

Studies have shown that if given an adequate training, paramedical staff (nurses and midwives) could insert intrauterine devices (IUDs) and provide injectable contraceptives to loftier clinical standards and even lay staff, after a short training, could likewise dispense pills, and over-the-counter sale of pills without prescription was justifiable [9, 35, 36, 37]. Facility-based service provision is highly restrictive in terms of geographic access; this means that alternative approaches are in dire need in order to brand the commodities hands accessible. All the same, studies have shown that the use of FP methods falls just modestly with increasing distance or travel time to the nearest source of contraception [38]. But in SSA where poverty index is high, physical accessibility becomes predictable and risky peculiarly during raining flavour, and transport is available only once or twice (during market days) in a week; these are the real challenges to contraceptive employ.

The provision of services through regime facilities follows the PHC approach: all the three tiers (master, secondary and tertiary) of health-care systems. The incorporation of contraceptive services into PHC facilities is an approach to heave contraceptive prevalence rates especially in SSA [39] where this has remained persistently low. In order to meliorate service availability and increase coverage, private health facilities later got involved. This involvement varies widely beyond the continent, existence forty% in Kenya and more than 50% in Uganda but low (<20%) in areas where national regime programmes are stiff such as Namibia and Due south Africa. However, majority of these private facilities are Urban-based and thus serve the needs of urban elites.

Commercial outlets such as pharmacies, drug retail shops and patent medicine or street vendors and bazaars also establish major significant outlets in which contraceptives (e.one thousand. pills, condoms) can be obtained. Social marketing schemes run by NGOs or international organization are popular where advert, logistics and product prices are highly subsidized in club to promote utilization. Information technology is most effective when pills, condoms or both are adequately common methods; need for contraception is well established coupled with a well-adult infrastructure (radio and television) and no brake on promotion of FP methods [9]. In a world that is becoming globalized with rapid urbanization developing across Africa and intense exposure to mass media both formal and informal (WhatsApp, Facebook etc) the role of social marketing of contraceptives will probable rise with time.

3.ane. Customs-based distribution (CBD) of contraceptives

Customs-based distribution (CBD) of contraceptives can exist used to supplement other authorities and private family unit planning services to meet the challenges of making the article widely available and accessible to those in urban slums, rural areas and hard-to-reach communities. CBD can be an important annex or alternative to clinic-based services. Usually, it is inexpensive, easier for many people to reach and available in a broad range of settings. Information technology is a complex concept involving varied operational design to suit local contexts. Information technology is a programme involving non-clinical family planning service approaches that uses community system, construction and institutions to promote the use of safe and simple contraceptive technologies [twoscore]. It expands acceptability and convenience of contraceptives and resolves the cost of service, thereby extending its apply amongst clientele who seek contraceptives but volition non use services that are confined to clinical settings [40, 41].

CBD is thus a good example of the WHO's delivery of PHC by making essential health intendance available to individuals and families in the community in an acceptable and affordable way with their total participation [42]. CBD is also compatible with the tendency in many countries towards the decentralization of health services and the involvement of community in the provision and support of its own wellness services.

The following factors are used to identify populations in need of CBD programme, all of which are applicable to SSA:

  • Low prevalence of contraceptive use

  • Lack of awareness of family planning

  • Low usage of existing family planning services

  • Are far abroad from family planning clinics

  • Cultural barriers that impede omnipresence at clinics [42]

For a successful implementation, the bureau (government, NGOs or international donors) usually worked with its ain staff and the communities to identity local leaders and influential community members (gatekeepers). Regular meetings are held in the community centers, and assistance is sought to identify local volunteers (women and men) who volition act as distributors of contraceptive methods.

CBD programmes originated in Asia in the 1960s and spread throughout Asia and Latin America in the 1970s and 1980s. It was introduced into sub-Saharan Africa in the late 1980s and 1990s; past 1996 more half of the population of SSA lived in countries with some kind of CBD plan [41, 43]. At inception CBD programmes were integrated into existing health-care services with wellness-intendance providers involved in delivering FP services. But with time, community needs exceeded the abilities of national governments' health programmes [44]. So, lay health workers became a good asset to drive CBD programmes, and selected community members were trained to provide FP services [45, 46]. CBD programmes are implemented through various approaches. These include home visits, group education meetings, fixed and mobile CBD posts, etc., while a variety of services are offered—contraceptive commodity distribution, health teaching and referrals for dispensary-based services.

According to the WHO [42], different kinds of people can be recruited to piece of work as distributors in CBD programmes across the world (Table 1).

  • Market place traders

  • Traditional birth attendants

  • Community health workers

  • Shopkeepers

  • Manufactory workers

  • Hairdressers and barbers

  • Traditional healers

  • Taxi drivers

  • Mothers

  • Farmers

  • Agricultural extension workers

  • Waiters and waitresses

Tabular array 1.

Examples of possible distributors for contraceptive commodities.

Advantages of CBD programmes:

  • Easy access to contraceptives by rural folk

  • Receiving services in 1'south own environment

  • Convenience for clients (in terms of time spent traveling and consultation)

  • Minimal transport costs

In sub-Saharan Africa, Zimbabwe was the first land to initiate CBD programme. On the other hand, Republic of kenya has the greatest diversity in CBD programmes and activities globally. In the 1980s, CBD initiatives proliferated with the encouragement and back up of the National Council for Population and Development and financial assistance from Kenyan USAID. Kenya in a sense thus represents a laboratory of CBD diversity in that about every type of CBD approach that has been tried elsewhere is nowadays in some manner in Kenyan setting [41, 47, 48]. The CBD programme in Tanzania started in 1988, when the International Planned Parenthood Federation (IPPF) launched a programme. Past 1996, CBD programmes were fully functionally in 22 of the 104 districts in Tanzania and Zanzibar [43]. In Ghana, CBD programmes started with two experiments: the Danfa Project and Navrongo Community Health and Family Planning Project. The Navrongo Projection started in the 1990s to address community explanations for failure of family planning outreach schemes [48]. The Navrongo Health Inquiry Heart (NHRC) is part of a commune-wide National Demographic Surveillance System. Mali had its most CBD project in 1986 in the rural district of Katibougou, and by the early 1990s, the 2nd project was funded by USAID to expand FP service commitment in nine rural districts in two regions using village-level family planning promoters [45, 49].

Nigeria has had some form of CBD programmes since the 1990s; just in 2007, the country reviewed the results of pilot program in the utilise of Community Wellness Extension Workers (CHEWS). CHEWS are the everyman cadre of trained medical personnel, who had at least 2–3 years of preparation in basic curative and preventive health services. The land also undertook a study tour to Uganda in 2008 to assess its community-based distribution of injectable contraceptives. By 2012, the National Quango on Health approved the recommendation that allows CHEWS to provide injectable contraceptives beyond the country.

Thus, it can exist said that CBD programmes has expanded in SSA over the past 20 years. A review of 93 developing countries in 1984 revealed that CBD programmes were functioning in 34 countries beyond the earth with 7 programmes operating in SSA [twoscore]. Between the 1980s and 1990s, the plan has expanded considerably. Countries with coverage <21% were designed every bit weak try, while those with ≥21% coverage in all areas are strong [40]. Even though coverage within countries is variable and actual rates of exposure to CBD activities are unknown, more than one-half of populations of SSA lived in countries where CBD activity is operating by 1996 (Effigy one). Then, it can be said that CBD programmes are well grounded in Africa, and considerable experience has accommodated over the years despite initial challenges. Family planning service has also been well integrated into other reproductive health services. It is of import to annotation that contraceptive use relies on the principle of demand and supply. Generating demand is critical in the uptake of contraceptives, but this will non happen if supply system cannot guaranty consistent availability of acceptable and affordable commodities.

Figure ane.

Sub-Saharan countries with CBD programmes, pilot projects or research (1994–1998) [40].

three.2. Family planning methods: Natural and modern

Pregnancies too early, too frequent, besides many and also tardily are ever associated with adverse outcomes [27, 29]. The health of mothers and that of her infant are inextricably spring, and the survival and wellbeing of fifty-fifty the older children are also compromised by their female parent's death. To avert these adverse outcomes, medical guidelines recommend the uptake of family planning method by vi weeks postpartum [fifty]. Contraceptive methods are by definition, preventive methods to assist women avert unwanted pregnancies. The last few decades take witnessed a contraceptive revolution, and advances in medical science have shown us how to interfere with physiology of reproduction-ovulation cycle.

The methods can exist categorized into:

  1. Natural

  2. Modern (temporary and permanent)

The product of an "ideal contraceptive" has continued to be elusive (contraceptive that is rubber, inexpensive, acceptable, effective, reversible and long-lasting enough to obviate frequent administration which requires picayune or no medical attention) [51]. It is too difficult to assume that "one jacket" fits all, every bit a method that may be suitable to an individual may exist unsuitable to another for a number of reasons—medical eligibility [34], religious beliefs and socio-economic situations. The current approach in family planning programmes is to provide a "cafeteria option" where couples or individuals are offered all the available methods for which a selection can be made based on the need. Each method is unique in its mode of activeness, effectiveness, advantages and disadvantages.

3.2.1. Traditional (natural) family planning methods

In every human social club, there are traditions that are passed down from generation to generation through the teaching of certain beliefs, cultural norms, attitudes, community and habits. These traditional behavior and practices cover all aspects of life including reproduction. Throughout human being history, traditional family planning practices to space children have been rich and varied [52]. Traditional methods of contraception are those methods which do not involve the utilise of orthodox medicine. Some of these methods have existed dating back to prehistoric times. Today, traditional family planning is proficient worldwide for a number of reasons: beingness natural does not involve a tertiary party (health-intendance provider) and does not autumn under any religious ban [53].

Natural family planning (fertility awareness) is a method of family planning and preventing or spacing pregnancy by observing naturally (physiological) occurring signs and symptoms of the menstrual cycle. The couples avoid intercourse in the days (fertile menstruation) during the menstrual bicycle when the adult female is almost likely to go meaning. Fertility awareness is based on a scientific knowledge of the female and male reproductive systems and on the understanding of the signs and symptoms that occur physiologically in women'due south menstrual cycle to indicate when she is fertile or infertile. This is frequently referred to every bit rubber menses.

Natural family planning provides women with alternatives for those who practise not wish to employ mod (artificial) methods. In low-income countries, women tend to adopt postpartum family planning methods just after resumption of sexual intercourse or menstruation [54, 55, 56]. In sub-Saharan Africa, both events tin be delayed as typically women do prolonged breastfeeding (upward to 2 years) which lengthens their menses of amenorrhea, and in Center and West Africa, women abstain from sexual intercourse for extended periods of time afterward a birth [57]. Indeed, many African cultures discourage sex during breast-feeding because of misconception that semen pollutes the breast milk. Withal, contempo written report has shown that the mean duration of postpartum insusceptibility to pregnancy (combined menstruum of amenorrhea and abstinence) is between 15 and 20 months in most SSA countries [58, 59]. The safety of these methods despite their use cannot exist guaranteed. For instance, withdrawal method (coitus interruptus), ane of the oldest methods of fertility control, the slightest error in timing of withdrawal may outcome in deposition of some corporeality of semen. Thus, the failure rate may be as high as 25% [51]. Many women erroneously believed that they were protected completely when amenorrhoeic. At the population level, amenorrhoea is related to low run a risk of pregnancy; the absence of menstruum does non guarantee protection from pregnancy for individual women (except during the fourth dimension frame of lactational amenorrhoea). Despite these problems, till date they continue to exist used alongside mod contraceptives as evidenced by Demographic and Health Surveys (DHS) conducted across Africa.

Table 2 shows the percentage of women who use mod and traditional methods of contraception in 1992 and most recent DHS reports of some selected countries in SSA.

Country 1 2
Whatever method Traditional method Modernistic method Any method Traditional method Modern method
Burkina Faso 10 vi four fifteen 1.0 15
Ghana 20 10 10 23 5.0 22
Republic of kenya 33 6 27 58 4.8 53.2
Malawi xiii 6 7 59 1 58
Niger four 2 2 14 2 12
Nigeria vi iii 4 15.1 5.four nine.8
Senegal 7 3 five 25.1 two.1 23.1
Tanzania eighteen 5 13 38 6 32
Republic of uganda 15 4 9 39 4 35
Zambia 26 12 14 49 four.3 44.8
Zimbabwe 48 6 42 67 1 66

Table 2.

Family planning methods currently used (percentages) past married women (15–49 years) [threescore, 61].

(i) Robey et al.; (2) data from recent DHS of various countries.

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4. Hormonal contraceptives

Since the 1960s when oral contraceptives (OCs) were first marketed, they have symbolized modernistic contraception and have remained the almost widely used hormonal method globally. OCs provide millions of women with constructive, convenient and prophylactic protection from pregnancy. Currently, more than 100 1000000 women apply OCs. Data on both ever use and current use of contraceptive revealed the standing popularity of OCs [63]. Hormonal contraceptives tin can be classified into:

  1. Oral pills

    1. Combined oral contraceptives (COCs)

    2. Progestogen-simply pill (POP)

    3. Emergency contraception

  2. Slow-release (depot) formulations

    1. Injectable

    2. Subcutaneous implants

    3. Vaginal rings

Worldwide, an estimated 8% of all married women currently utilise the pill and rank tertiary among all family planning methods currently used by married women. The use of pills accounts for most i-quarter of all contraceptive employ amid both married and single women in sub-Saharan Africa [62]. Overall, most fifteen% of married women use family planning, and less than four% use the pill.

In some countries in Africa, OC usage is among the highest in the world: 33% of married women in Republic of zimbabwe, 21% in Mauritius, 1.8% in Nigeria, 18% each in Botswana and Greatcoat Verde respectively [62]. The use of COCs has been associated with wellness benefits. It reduces menstrual blood flow and dysmenorrhoea and lowers the prevalence of iron deficiency anaemia [63, 64, 65]. By and large, when taken correctly, OCs offering highly effective contraceptive. Among perfect users (women who exercise not miss pills and follow the instructions correctly), merely one in every 1000 women becomes pregnant in the first year [62]. Among typical users, about 60–80 women in every 1000 will become pregnant during the commencement year [66]. Appropriate wellness education and counseling of clients are the key ingredients to the successful utilize of OCs.

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5. Injectable contraceptives

When oral contraceptives were introduced in family unit planning programmes, they were hailed as a major quantum. However, overtime, it became obvious that not many women are good in remembering to take their pills on a daily basis and follow the schedule of administration. The use of injectable contraceptives provides many advantages: no user error, privacy and less dependence on the women's compliance. The virtually commonly used is depot medroxyprogesterone acetate (DMPA). Irregular spotting, bleeding and amenorrhoea are well-known problems associated with the use of DMPA.

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6. Intrauterine devices (IUDs)

The story of a small pebble placed in the uterus of a camel to forestall pregnancy during long caravan journeys past Arabs in Middle East is regarded as the beginning of intrauterine contraceptive devices [67]. The IUDs is one of the most effective reversible contraceptive methods with an average pregnancy rate later on 1 year of use of iii–5 per 100 typical users. Considering IUDs accept longer continuation rates than the OCs or injectable contraceptives, the overall effectiveness of IUDs and oral contraceptives are about the aforementioned in family planning programmes [68]. A major business of IUDs is expulsion and pregnancy rates as shown in Table 3.

Device Pregnancy rate Expulsion rate
Lippes Loop
C three.0 xix.1
D 2.7 12.vii
Progestasert 1.eight three.1
Copper-7 1.9 5.half-dozen
Cu-T-200 three.0 seven.8
Cu-T-200c 0.9 8.0
Nova T 0.7 five.eight
Multiload 250 0.5 2.ii
Multiload 375 0.1 2.1

Table 3.

Rates of pregnancy and expulsion per 100 women later 12 months of use [69].

As the use of contraceptives increment in Africa, IUDs are becoming more acceptable. Nonetheless, its popularity varies widely throughout the continent and even within the countries as evidenced by recent DHS reports. For instance, its employ in Nigeria between 1990 and 2013 was 0.8–1.1%, [lxx], while in Mali and Uganda, very few women employ IUD [71].

The training of doctors and paramedical staff to deliver family planning services is the cornerstone to the success of family unit planning programmes. In Africa, the master goal is to train doctors, nurses, midwives and other field workers to manage family planning clinics equally a squad. The family planning nurse is essential to the success of the family unit planning programme.

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7. Condoms

Condoms are the most widely known and used every bit barrier device by male partners effectually the earth. Condoms are easy, effective and condom method of preventing pregnancy and sexually transmitted infections (STIs) including HIV. Although rates of condom use accept been low in many areas of sub-Saharan Africa, many people now utilize condoms because of HIV education and prevention programmes [72, 73].

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8. Permanent methods: Female person sterilization

Globally, millions of couples of childbearing historic period in developing countries used voluntary surgical contraceptive (VSC), making it a popular method of family planning in the globe [74]. But information for sub-Saharan African countries are scarce; notwithstanding, based on world fertility survey results for Kenya, Kingdom of lesotho and Sudan, female and male person sterilization appears to exist rare [75]. In another study, the use of vasectomy was nether ane% [52]. This method of family unit planning is not too popular in SSA for a number of reasons. The method requires skilled personnel that are not available at the primary healthcare (PHC) level used past bulk, and services are only available in urban areas. On the conservative side, in situations where the matrimony has failed or death of partner occurred, the woman by cultural and religious norm is encouraged to remarry, and in social club to "secure" her marriage, position and respect in the family and the lodge, she will be desirous to have at least a child to the new married man.

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9. Knowledge, attitude and practice of family planning

The dividends accrued from improvements in reproductive health are cumulative and fundamental to achieving sustainable evolution goals (SDGs) by improving maternal health, reducing kid mortality and eradicating extreme poverty. Family planning brings transformational benefits to the women, families, communities and nations [16]. In the twenty-first century, the maternal mortality in the continent is still unacceptably loftier. The lifetime risk of maternal mortality of women in SSA is 1 in 39 alive births, the highest when compared to other regions.

Despite recent increases in contraceptive utilise, sub-Saharan Africa is even so characterized past high levels of fertility with TFR of v (number of births per adult female) and a considerable unmet need for contraception [76]. Sub-Saharan Africa is still undergoing demographic transition (i.e. a shift to low death rate and birth rates). This is largely due to high birth rates with low contraceptive employ. It is estimated that 90% of ballgame-related and twenty% of pregnancy-related morbidity and bloodshed together with 32% maternal deaths could be prevented past the use of effective contraceptive [9, 77]. In SSA, about 14 million unintended pregnancies occur each year, with about half occurring amid women anile 15–24 years [78, 79]. The low level of utilization of contraceptives is due to several factors, the health systems and the framework within which family planning (FP) services are delivered, and suboptimal service factors [79]. Others are barriers at the individual level: risk perception, lack of or insufficient cognition needed to make desired conclusion or choices, male partner disapproval and economic and geographic access to service facility. Cognition of FP is crucial to make informed choice. Too noted are barriers to utilization of FP: commodity stock-out, limited provider skills and limited number of methods [eighty]. Even though contraceptive methods and services are frequently geared towards women, men are the main determination-makers on family unit size and their partners' use of family unit planning methods [viii, 81, 82].

Men's fertility preferences and attitudes towards family planning seem to influence their wives' attitudes towards the utilize of modern contraceptives [83]. This translates to the fact that the importance of male interest in whatever family planning programme cannot be overemphasized. Information and knowledge on contraceptive methods are necessary tools to informed choices and utilization. Meliorate informed and knowledgeable women are able to seek for desired data and as well know where to access appropriate services. On the other hand, lack of noesis together with cultural, social and religious factors is a major impediment to service utilization [81, 84, 85].

At the community level, since individuals get out in communities, it definitely tin influence personal health-seeking behavior, as there are intersections between personal beliefs and attitudes and community norms. Previous studies revealed that women may choose to accept family planning or indeed choose a particular method because of the methods adopted by those in the customs [86]. Again, recently, several studies have explored the role of contextual factors in contraceptive use in African countries [87, 88, 89, 90]. Beyond individual and family unit factors, the context in which women live does influence their contraceptive decisions. The growing body of literature has identified a number of contextual factors that influence the apply of contraceptive: presence and quality of reproductive health services, macroeconomic factors, customs fertility norms, female autonomy and availability of concrete infrastructure [91]. Previous studies [26, 76, 92] and reports of Demographic and Health Surveys [61] in SSA reported a near universal cognition on family planning among women of reproductive age group. Unfortunately, this has not translated into increased utilization of contraceptive methods as evidenced by depression contraceptive prevalence rates (CPRs). This can well be demonstrated by contraceptive prevalence in the earth and by region of Africa (Effigy 2) [93] with W Africa having the everyman prevalence rate amid married or in-spousal relationship women (fifteen–49 years old) in 2015.

Effigy 2.

Contraceptive prevalence and unmet need for FP (per centum) in the world and African region.

The low usage and CPRs could exist attributed to negative attitude directed at the methods and other factors discussed earlier. Thus, the promotion of modern contraceptive apply will crave multifaceted interventions across all the levels of society. Specifically, addressing some or all of these barriers to the use of modern FP volition chiefly contribute to family unit, community and national socio-economic development. Particularly, contraceptive use needs to exist promoted in W Africa on both health and economic grounds.

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10. Unmet needs for family planning

The turn down in fertility in SSA has been boring than expected and has stalled in some countries [94, 95]. The full fertility rate varies from four.8 children per woman in Republic of kenya to vii.6 in the Republic of Niger [8, ix] and the everyman contraceptive prevalence of 22% among married women [96] and globally the highest level of unmet demand for FP of about 25% [96]. Worldwide, over 222 million women have unmet demand for contraceptive [97], and most 34 million women in Africa had unmet demand for FP in 2009 [98]. The demand for contraceptives, with improved access and uptake, is the central public health intervention to improve maternal health outcomes, thereby reducing maternal mortality. Increasing contraceptive utilize has many demographic dividends, and unmet need denies women these benefits and violates their reproductive health rights. Studies accept shown that several obstacles have hindered women access to FP services: unavailability of services, cultural and religious barriers, lack of knowledge and rural residence [99, 100]. Additionally, weaknesses in the existing FP programmes coupled with the fact that in SSA FP programmes tended to offer select methods (as a affair of convenience) or equally a means of promoting the well-nigh effective and long-lasting methods [78]. Reasons for not using contraceptive are quite unfounded as contraception is a prophylactic medical intervention. Information technology is estimated that mortality take chances of unplanned and unwanted pregnancy is 20 times the risk of any modern contraceptive method and x times the risk of a "properly" performed abortion [101].

The concept of unmet needs for contraceptive dates back to the 1960s, the "KAP-Gap" era, and was used as a rationale for investment in family planning programmes [102]. Information technology is the proportion of currently married, fecund women who do not want any more children but are not using any course of family unit planning (unmet demand for limiting) or currently married women who want to postpone their next birth for two years but are not using whatever class of family planning (unmet need for spacing) [103]. Unmet demand is substantially a disharmonize between what a adult female wants and what she does about it. She might desire fewer fertility but fails to have action needed to forbid pregnancy. The full demand for family planning is the proportion of married women with unmet need and married women with met need for family planning. In other words, information technology is the sum of contraceptive prevalence plus unmet demand for family planning. Currently, the full demand for FP (sum of unmet need and electric current contraceptive use) is around 44% in SSA [104]. Also, unique to the continent is the fact that predominantly the unmet need is for spacing rather than for limiting births. Thus, information technology shows the importance attached to child spacing in Africa and a reluctance to commit to a final abeyance of childbearing [9]. It too shows that demand for contraception (to space) exists within this population that can be explored. In countries where growing numbers of women desire to avoid a pregnancy but contraceptive use is low, unmet need is higher. Rwanda, Senegal, Togo and Uganda all have unmet need of about 30% or higher [104]. The main objective for the study of unmet need is to guess the potential demand for FP [102].

Basically, its purpose is to identify women who are currently exposed to the risk of unintended pregnancy but who are not using any method of contraceptive. In theory, these women either practice not desire any more births (limiting) or desire to postpone the next nativity for at least 2 more than years (spacing). The computation of unmet need is complex and can vary depending on which categories of women are included in the definition [104]. When this is summed up with current contraceptive apply, information technology provides a picture of total potential demand for FP in a country (Figure 3).

Figure three.

Potential need for family planning.

Experts have also raised the following concerns on its measurement:

  • The term does not necessarily reflect actual or potential interest in method use.

  • Women's personal opposition to family planning.

  • Information technology does non reverberate how women perceive themselves to exist at risk of pregnancy.

  • Failure to differentiate between married women who are sexually agile and those who are not and thus not at risk of pregnancy [105].

  • Underreporting of natural methods [106] in large-scale surveys which is a long continuing methodological effect.

Today, the major source of data for measuring unmet demand globally is the Demographic and Health Surveys (DHS) and for which data is bachelor in about countries in SSA. Many countries have had two or iv rounds of such surveys between 1990 and 2014. The DHS questions administered to women asked whether they are doing anything to avoid a pregnancy. If the woman reports the use of a natural method and does not simultaneously use a more than constructive method, she is counted as a user of natural methods. Currently, in the DHS questionnaire, there is no follow-up questions specific to natural methods resulting in possibility of under reporting in some developing countries [106]. Despite these drawbacks, measurement of unmet need has endured as a skilful analytical tool till engagement. Its importance cannot be overemphasized: the gauge is useful as information technology helps to reveal the size and characteristics of the potential market for contraceptives, allows for projection of how much fertility could turn down if additional needs for FP were met. Reducing unmet need for FP is key to helping couples achieve their reproductive rights and achieving demographic goals.

The lessons here are to understand the variations in unmet need beyond the continent. Respective national governments volition need to understand uniqueness of unmet needs in lodge to strengthen family unit planning programmes to reduce unmet need. Studies have revealed that strong programmatic interventions non only reduce unmet need and increase contraceptive use merely also increase the proportion of women using mod contraceptives [107].

11. Challenges

The challenges to family planning programmes are many, varied and require attention at the highest policy level in social club to realize the huge demographic, socio-economic and development dividends of depression fertility levels. This will besides make SDGs achievable. Continued political will and back up are prerequisite for sustainability and acceptability of FP program:

  • Data collection and assay are still problems coupled with weakened and dysfunctional health-care systems in near all countries beyond Africa. This makes monitoring and evaluation of programmes a challenging task.

  • Persuading national governments to adjust their budgetary priorities to run across wellness requirements is one of the biggest challenges. Indeed, in 2001, African leaders made Abuja (Nigeria) declaration with a commitment to allocate 15% of public expenditure to health past 2015 [108]. Till date, in that location is notwithstanding huge funding gaps equally the health sector is heavily underfunded.

  • There is a need for broader attending to ever-increasing reproductive health needs including FP of women especially the cohort of women coming into maternity or childbearing age.

  • Studies in SSA and around the world reveal a near universal knowledge on contraceptive methods, nonetheless the exercise has shown the contrary. So, addressing all or some of these barriers responsible will significantly influence service uptake.

  • Expanding FP services in a variety of "correct mix" of contraceptive commodity availability to the rural folk and hard-to-reach areas has notwithstanding persisted and needs to exist addressed.

  • At that place is a need to link population pressure on both the built and natural environments to reproductive health interventions as a national policy to FP service utilization.

  • More enquiry is needed on family planning: virtually studies are based on cross-sectional designs that cannot establish temporal sequence of crusade and effect. Researches based on longitudinal information assay methods or experiment or randomized control trial designs are needed to generate quality evidence that underscore of import causal linkages betwixt factors of interest and adolescent, maternal, child, family and population outcomes [109].

12. Conclusion

Over the past five decades, the use of FP methods has steadily increased in SSA with pct of married women using modern contraceptives ranging between <20% and 69%. Unmet demand for FP is unacceptably high. Despite near universal knowledge on contraceptives, practise remains low. Thus, in that location is a demand for publicity campaigns through data, education and communication (IEC) to address social and cultural barriers to FP including misconceptions, misinformation and myths about modern FP methods.

Since controlling power notwithstanding resides with men, creating an environs in which both sexes can seek services and encouraging men to discuss FP with their wives will go a long way in promoting service utilization. Contraceptives for spacing are the predominant forms of FP preferred in SSA and show that even within this population need for contraceptives exists. Then, campaigns and provision of services that frame contraception equally a method to space births and improve maternal and child health may exist more culturally acceptable to promote use. Contraception should exist vigorously promoted in SSA not only for its demographic dividends but as well on socio-economic and wellness grounds and the attainment of SDGs.

13. Recommendations

Of import shift in political delivery and priorities together with expert governance, acceptable funding is needed to sustain FP programmes. Efforts need to be intensified to encourage partner advice and appointment in order to better FP practice. Farther, research is needed to accost unmet needs for FP.

Conflict of interest

I declare that 50 have no conflict of involvement in writing this chapter.

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Submitted: July 18th, 2017 Reviewed: November sixth, 2017 Published: June 13th, 2018

© 2018 The Author(south). Licensee IntechOpen. This affiliate is distributed under the terms of the Artistic Commons Attribution iii.0 License, which permits unrestricted use, distribution, and reproduction in whatever medium, provided the original piece of work is properly cited.

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