A year ago, I met a 26-year-old breastfeeding mother who was a graduate student. She was married and had three children; the youngest was only eight months old. She started using birth control pills after her period returned after giving birth, but hid the pills from her husband. When he discovered them, he forced her to throw them away.
Soon after, she conceived again. Three months later, she suffered a stress-induced miscarriage. She was admitted to hospital with an infection and blood loss. Fortunately, she survived and her husband has since changed his attitude towards the use of contraceptives.
In my work in rural Nigeria, which primarily targets uneducated women, their inability to make their own decisions about contraceptive use, combined with a lack of knowledge of available contraceptive methods, are important factors that affect contraceptive uptake. About 80% of the women we see do not use modern contraceptives because of lack of knowledge or because their spouses are against it.
However, it is gratifying that when I speak with couples about the importance of contraception for a woman’s health and the well-being of her family, I see a marked change in attitude. From my conversations with others working in reproductive health services, it seems that they have also had success when talking to couples.
It is already government policy to increase the use of modern contraceptives in Nigeria. The official target, first set in 2012 and revised in 2017, was to achieve a modern contraceptive prevalence rate of 27% by 2020. Unfortunately, the level of contraceptive use reached in 2020 was only 12%, one of the lowest rates in the world.
One of the main reasons for the low level of contraceptive use is the lack of government leadership. Despite promising to fund modern contraception, the government actually cut funds for family planning by 80% in its 2019 budget, with further cuts in 2020. In effect, the government is letting nongovernmental organizations ( International NGOs) pay for most contraceptive and family planning services in Nigeria. While NGOs are doing admirable work, none have the capacity to conduct a sustained national awareness campaign or to change deep-rooted social attitudes affecting contraceptive use. This is the job of the government, which must invest in family planning education, including in schools, and ensure that modern contraceptives are widely available at little or no cost.
The government must also tackle stigma. Here in Nigeria, we need to stop being embarrassed about contraception or treating it as a secret. We can learn from the success of vaccination campaigns against childhood diseases, for example, which used massive awareness campaigns and health workers going from house to house to carry out vaccinations.
Today, it is quite normal to vaccinate children, whereas previously this was viewed with suspicion. The government should apply the same strategy to family planning, using health workers to educate couples and provide home-based contraceptive services. They would have the opportunity to talk to the couples together and, most importantly, include the men in the conversation.
By talking normally about contraception with couples, we in the health sector can show that there is nothing to be embarrassed or ashamed of, reassure women and men about the safety of products, dispel any wrong and answer the questions. The problem now is that the system encourages secrecy and misinformation, making it even harder for women to control their fertility and often putting their health and well-being at risk.
The cost of this problem for the country is significant. The health and social impacts that I see frequently include unplanned pregnancies, unsafe abortions, maternal deaths, perpetuation of poverty, malnutrition, frequent hospital visits, and children dropping out of school.
If all unmet need for modern contraception were met, it is estimated that unintended pregnancies in Nigeria would fall by 77% – from 2.5 million to 555,000 a year – and the number of abortions would drop from 1.3 million to 287,000. Full provision of modern contraception, combined with other medical care, would reduce maternal deaths by 68% (from 61,000 to 19,000 per year) and newborn deaths would decrease by 85% ( from 255,000 to 38,000 per year).
We know that our rapidly growing population is one of the country’s greatest economic and political challenges. The latest official data put Nigeria’s gross domestic product (GDP) and population growth at 2.2% and 2.6%, respectively. We are on track to be the third most populous country in the world by 2050, ahead of the United States. Finding jobs for all these people is already extremely difficult. Protecting our environment in the face of massive population growth is another challenge. Contraceptives have always been an essential tool for countries to build viable societies, and when given the opportunity, most families make responsible decisions, ensuring that they can support the children they they have.
I want to emphasize that this is not just a problem faced by the rural poor. The woman I described at the beginning of this article is well-educated and leads a comfortable middle-class life. Yet the taboos around family planning affected her just as much as the rural women I treat so regularly.
It is a problem that affects all components of Nigerian society. Therefore, I call on government at all levels to prioritize family planning. It will be necessary to increase spending, employ more health personnel, conduct awareness campaigns and bring contraceptive services to the home, as they do for vaccination. Perhaps they can combine these roles – train vaccination teams to also provide contraceptives.
As a man, father and husband, as well as a doctor, I also call on all men to educate themselves on these issues and to consider the welfare of their wives and children above all else. The benefits of change will benefit not just women, but the whole country, enabling families to thrive, reducing poverty, protecting our environment and building a more sustainable future.
Dr. Tijani Salami is a physician, sexual and reproductive health expert and founder of Sisters Caregivers Project Initiative