Godwin Haruna
5 May 2008
Lagos — In this part of the world when myths are created around a subjectmatter, it becomes very difficult to erase. Experts say this is the kind of misconception woven around contraceptive use in Nigeria thereby fuelling maternal mortality. However, they suggest that the side effect of contraceptive use is no more than taking an over dose of paraceutamol. Godwin Haruna writes
Mr. and Mrs. Sunny Ufom, (not their real names), a middle class family live and work in Lagos. About six years ago they were blessed with a set of twins and Mrs. Ufom said they had to wait for five years before they had their third child last year. In the intervening period, Mrs. Ufom relied on the injectable type of contraception to keep her safe from conception. She told THISDAY last week that when they had made up their minds to have another baby, she stopped going to the Lagos University Teaching Hospital (LUTH), where she assessed the family planning services. Three months after, she took in and she had her baby last year.
The experience of the Ufoms contrast with that of Mr. and Mrs. Ken Enemake, another middle class family in Lagos. About two years ago, they had their first son. Three months later, Mrs. Enemake went from one neighbour to another trying to find out how she and her husband could have intercourse without falling into trouble. She would not want to go to the hospital because of the bad information she hears about the experiences of people either becoming infertile or being infected with fatal diseases as a result of contraceptive use. Wallowing in such ignorance, she became pregnant when her baby was just eight months and less than two years after getting married they have two children today. Although she delivered her first child naturally, the second came through caesarian section essentially because her body had not recovered from the travails of the first child. Experts say she is lucky to be alive to tell her story and also for her babies to be doing well too.
These are two live stories that are at the centre of maternal deaths in the country. A recent United Nations report has confirmed Nigeria as having the second highest number of maternal mortality ratio in the world after India. In Nigeria, this maternal mortality ratio is unfortunately high, ranging from 800 to 1, 500 per 100,000 live births. While 90 per cent of the population knows about family planning, only about 10 per cent access it.
The alarming maternal mortality ratio in Nigeria results from poor primary health care and emergency obstetrics care associated with still birth, ill-equipped and badly-managed hospitals, and carelessness on the part of medical and health personnel. It is said that because of exorbitant bills, many pregnant women are still delivered at home by traditional birth attendants and in the process many of them die.
In most Nigerian villages, women still give birth in the hut with no running water, no sterilization equipment and no skilled birth attendant capable of providing emergency obstetrics care. Socio-cultural and economic factors that relate to the low status of women, poverty, ignorance about family planning services and traditional harmful practices also account for the alarming maternal mortality ratio in Nigeria. With the current trend, experts doubt the possibility of Nigeria meeting one of the Millennium Development Goals (MDGs) of reducing maternal deaths by 75 per cent by the year 2015.
Speaking to THISDAY last week in Ibadan, Dr. Bukola Fawole, obstetrician and gynaecologist with the University College Hospital (UCH) in the city, identified family planning as key to the reduction in maternal deaths in the country. Fawole said way back in 1987, the International women Conference in Nairobi revealed that over 500 maternal deaths occur annually and 99 per cent of these deaths occur in developing countries. He said almost 8 million of survivors suffer serious health problems. These include vesico vaginal fistula (VVF), emclampsia, anaemia, sepsis and a variety of others. He said 61 per cent of maternal deaths occur in ten countries mostly in sub-Saharan Africa including Nigeria.
Speaking on why people do not use contraceptives in Nigeria, Fawole said: "A major impediment to contraceptive use in Nigeria is lack of information. People are unaware of the true benefits of family planning measures. If one went out into the street and asked people generally, most certainly people will confirm that they are aware and they will mention virtually all the methods.
"However, in terms correct knowledge, this is quite poor. People don't have correct information or knowledge that would have to guide their acceptance of using these methods. Unfortunately for us what we have in terms of information in the community is mainly wrong information; therefore, people associate all sorts of myths, misconceptions with family planning methods. Most of this wrong information they gather from friends, relations, who perhaps have used certain methods wrongly".
He said people do not visit family planning clinics to receive the correct information from health professionals, who really know and could guide them on the correct use of these methods. He added that family planning information should not be obtained second-hand, because since a method that worked for couple A might not work for couple B. In addition to this, Fawole said people should be wary of information obtained from providers, who are not trained because the information they offer might not be correct.
"As a matter of fact we do know that it is not all family planning methods that are appropriate for an individual. Therefore our people should always seek the right information and also very importantly, be examined and then be helped to select the proper methods that are appropriate for them by healthcare professionals. When people do that, they will appreciate that family planning methods have a great number of benefits and they will be helped to use the method they have selected for as long as they wish to help the space their children", the consultant said further.
He discountenanced the misconception that family planning pills could make the user infertile, and added that any one obtained at a certified clinic has no such effects. He said such ones obtained from qualified providers have the potential of promoting the health of the couple.
He said the only fact which he knows is that because of the way the family planning method works, if she discontinues use, she may not conceive immediately as it would take a short time for the effect of that family planning method to wear off. As soon as this happens, he said, the woman should experience conception if there are no other complications, which might not certainly come from the pills.
Fawole said he was aware that some religious denominations emphasise the natural methods of family planning to control births. As a professional, he said that too, is highly recommended for couples. "The duty of the family planning provider is to give correct information. All methods of family planning guide the woman to select the method they prefer. Of course, we counsel adequately regarding the natural planning method, which is most suitable for women, who know their circle", he added.
Fawole said the natural methods also have different types, which includes exclusive breast feeding. He said a woman does not ovulate provided she breast feeds her baby exclusively and it is effective mainly for six months after child birth. He also spoke of a method whereby a woman with help from a qualified provider, understands her menstrual circles and therefore, she is able to determine the fertile period and times when she is not. So, she now knows the time to avoid intercourse having been properly counseled.
Another natural method he mentioned involves a woman employing signs to determine the time she is save and to know the time she is likely to be fertile. He said the man necessarily would be involved in this to determine when to have intercourse or avoid it.
He said essentially, where the citizenry have all got it wrong is with getting the correct information and this, he added, has resulted into the myths created around family planning. "Unfortunately for us, we have allowed the myths and misconceptions to become widespread. That wrong information have been disseminated widely and so the urgent task we have now, is to work against this myths by disseminating the right information through all available means. We must provide information for the populace to reassure them that all of these methods are safe when there used appropriately by the correct individuals. That you have obtained a method does not mean you should not visit the clinic regularly. More women will be enrolled with the correct provision of the right information", he stated.
He said government was not giving enough attention to the issue in the country. The reason for this, he said, is that in most clinics, not all methods of the family planning are available to the patients, who desire them. He said because of this anomaly, government needs to fund family planning services more adequately such that when a woman visits a clinic, she has all the choices and it is left for her to select, which is convenient.
In addition, he emphasized the dissemination of correct information and the ability to use faith-based organizations to reach the people. He said the youths should not be left out as they too, needed to be involved. He said although, it might be a daunting task involving the youths but it is practicable. He advocated the establishment of youth friendly clinics where they should be encouraged to visit regularly. The programme could also be taken to them directly, where the youth congregate such as youth centres, sports centres and institutions and ensure that the services are available.
Also speaking, Mrs. Adebukola Salako, national coordinator of the family planning unit of the Federal Ministry of Health said although three-quarters of women know of at least, one method of modern family planning less than 10 per cent of married women are using it. Salako was of the strong conviction that family planning could make a difference on maternal, newborn and infant mortality. She said family planning could reduce maternal mortality by 20 per cent or more.
She added that spacing births by at least two years could reduce neonatal deaths by up to 50 per cent. She said family planning is not about population control, but a strategy to promote the health of the childbearing woman. She added that the myths woven around contraception have no basis in facts as evidence has shown that application of any of the methods essentially promotes a woman's health.
"Our people believe in what people tell them than what the providers can give them because they don't believe in going to the clinics. So they would rather hear from the woman beside them or their next door neighbour, who do not necessarily have the correct information. It is better obtained from a provider, who will be able to tell you the benefits of the method you want to choose, the disadvantages, and whether your body will accept it. People have the wrong notion that it is what happened to Mrs. A using a particular method that will happen to Mrs. B, this is not so. Meantime, Mrs. A would not tell them, I was asked to do certain things, which I failed to do them. She will only say the disadvantage of what happened to her", Salako stated.
She said people should not rely on other people's experiences and put themselves in more difficult situations by not accessing services that would be beneficial to them on the long run. She added that the ministry was designing strategies to involve the male segment of the population in the family planning process.
"We realize in the ministry of health that men think they are being exempted from the family planning process, but contrary to this notion, we have always emphasized the male involvement in reproductive health. We know that without male involvement, we cannot move family planning forward. This is because it is the man that says to the wife, 'don't go, I still want to have more children', but if we make them realize the benefits of family planning not only as population control, but for healthy living, healthy family and for healthy children, they will know that the benefits outweigh whatever it is that is preventing the woman. We want the men to accept reproductive health as an issue", Salako said further.
She tasked family planning providers across the country to take ownership of the programme in order for them to discharge their duties effectively. "We don't want any top down approach, we want bottom up so that ownership is given to them in the states and once that exists, they will give the best shot to the programme. We want to enhance their information dissemination capabilities by building their capacities", she said.
She said the local governments too have a vital role to play and urged political leaders in that tier of government to build into the programme. In answer to a question, Salako said the natural planning method has always been part of the national plan. She said the circle bead is part of the promotional programme currently running in the country. She added that the ministry is involved in developing a policy for the Catholic Church, which counsels her adherents to adopt the natural planning method. The bead, she added, is like a rosary, which a woman uses to regulate her menstrual circle and determine her safe period when she can have sex. She said it is a simple method, which any body could learn.
Providing her own perspective on the issue, Mrs. Emiola Adeyinka of the Association for Reproductive and Family Health, Ibadan said the laxity of government health workers remains the greatest impediment to accessing family planning services. Adeyinka said the attitude of the providers and their non-challance often drives a number of care seekers from their facility.
She said if a provider is not courteous to somebody seeking information about an issue, there is the likelihood that the fellow would not come back there. According to her a change in orientation of some of the providers would go a long way in encouraging more people to look up to them.
Also speaking Ms. Salamatu Suleiman of the Ministry of Health, Sokoto State said the ministry recognises the important role family planning could play in the health of the citizens and therefore, has embraced it whole-heartedly. Suleiman said because the ministry encourages it, more women are seeking help from the providers across the state without hindrance.
She said one area they are now working on is female condoms, which is somehow new to them. She added that husbands also encourage their wives to seek help from the providers even though they do not necessarily accompany them. Although she said there was a tiny minority that accesses the services without their husbands knowing.
In her contribution, Hajia Hauwa Mohammed, family planning coordinator for Borno State said women in the state accept the modern methods of family planning. However, she said the acceptance was declining of in late in the state. She attributed this to the general apathy, lack of political will and non-committal of the service providers.
Mohammed also stated that the Islamic religion does not preclude people from accessing the services of family planning. She said although a number of people will readily accept the services because of their health, there is inconsistency on the part of service providers. She promised to advocate to government agencies so that services could be readily available to people seeking it. Her concern, she said, was essentially to reduce the rising maternal deaths in the country. "If the women of childbearing age access better and quality healthcare, their bodies would be prepared adequately before they conceive, that way, mother and child will live happy and healthy lives", Mohammed noted.
A study of awareness and use of family planning methods among 1188 married women aged 15-40 years by some consultants in Ibadan revealed that, attending antenatal clinic in four different locations revealed that most respondents (94.3%) were aware of the use of family planning but only 12.0% had ever visited a family planning clinic. Awareness of specific methods was 82.6% for condoms, 75.7% for oral contraceptives, 75.5% for injectable contraceptives and 65.3% for intrauterine device. Current use of family planning methods was low with 10.0% using withdrawal, 8.1% oral contraceptives, 5.2% using intrauterine devices and 4.7% using condoms. Perceived constraints to the use of family planning methods included husband's opposition, fear of complications and perceived insufficient knowledge about family planning methods. It is concluded that there is a knowledge-practice gap in the use of family planning methods among married women in Nigeria. Improved education strategies and better access to services are needed to solve these problems.
From the submissions of the various stakeholders, the solution to the high maternal deaths in country lies in overhauling the National Health System to appreciate family planning as an integral part. World Health Organisation (WHO) sources say that Sri Lanka reduced its MMR from 550 per 100,000 live births in the 1950s to 80 per 100, 000 live births in the 1970s. This was achieved when it overhauled its healthcare system to ensure skilled attendance at child birth even in remote rural areas. In Nigeria, the basic primary, secondary and tertiary healthcare facilities are practically comatose.
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