Contraceptive choices are crucial in empowering women and couples to take control of their reproductive health. In addition to protecting women and girls from unplanned pregnancies and unsafe abortions, contraceptive use promotes the overall well-being of the mother, child, and family. However, despite awareness of family planning, there is still a high unmet need at 48% for sexually active unmarried women and 19% for married women. In addition, the modern contraceptive prevalence rate is still low at 12% among married women (15-49 years) which is at a negative variance with the national target of 27% by the year 2024.
The Power of Options in improving the quality of a woman's life cannot be overemphasised. It resonates with the wide range of contraceptive choices that should be made available to women and girls to help them make an informed choice. The power and autonomy of a woman to have children when she desires, at what interval and the number exemplifies gender equality.
Increasing access to contraception not only provides women and girls with autonomy but is also a major driver of success in reducing maternal mortality. Findings from the exemplar studies presented at the International Maternal Newborn Health Conference 2023 showed success rates in seven countries that improved their maternal and newborn outcomes. The seven countries (Ethiopia, Niger, India, Bangladesh, Nepal, Senegal, and Morocco) showed significant and measurable progress in maternal health. This is compared with other countries that made investments in maternal health. These exemplar countries demonstrated an increase in planned pregnancies helped by an increase in contraceptive use. Therefore, increasing access to a wide range of contraceptive choices for women and girls of reproductive age is imperative.
Increasing access to contraceptives: Home-grown solutions to local problems
With an estimated population of over 200 million people, Nigeria is the most populous country in Africa. However, over 50% of Nigerians live below the poverty line and access healthcare from local Community pharmacies (CPs) and Patent and Proprietary Medicine Vendors (PPMVs), popularly known as "chemist shops". Although informal, PPMVs and CPs have been seen to be the first point of care for various health conditions and are central to providing essential medicines and increasing access to healthcare services, including family planning services. This cadre of healthcare providers are community members and live in the areas where they provide services.
In 2018, the task shifting, task sharing policy was updated after its first approval in 2014, presenting an opportunity to increase access to contraception and service provision through Community Health Extension Workers (CHEWs). However, there were no provisions in the policy for a well-defined role for PPMVs or community pharmacists, despite the significant healthcare gap they evidently bridge within communities.
IntegratE- Providing the Power of Options
From 2017-2021, the IntegrateE project, implemented by a consortium led by the Society for Family Health collaborated with the federal and state governments as well as the Pharmacy Council of Nigeria (PCN) to give the power of options to almost 300,000 women in Lagos and Kaduna states. The IntegratE 1.0 project funded by MSD for Mothers and the Bill & Melinda Gates Foundation aimed to improve access to and uptake of family planning services, as a proof-of-concept that community pharmacists (CPs) and PPMVs can provide a wider range of family planning services, including providing FP counselling, injectable administration, implant insertion/removal, and other basic Primary Health Care (PHC) services rather than only re-supplying oral pills.
The project utilised partnerships with the federal and state governments as well as the PCN to enhance regulation and improve the capacity of CPs and PPMVs to increase access to quality contraception for women and communities, by employing a 3-tiered accreditation system. This made it possible for PPMVs and CPs to offer a wider range of family planning services, depending on their qualification and training received.
Grace, a registered nurse and a Tier 2 accredited PPMV in Alimosho, Lagos State said: "My clients have more (contraceptive) options to choose from and I can confidently provide their preferred services, including the longer acting contraceptives because I have been trained for it."
The project design also considers what the women want and look out for, in accessing services. Speaking at the Celebrating Womanhood Art Gala convened by Nigeria Health Watch in March 2023, Pharm Emeka Okafor, Chief of Party, IntegratE Project shared how the project was expanding access and options available for family planning services to women. "We have a forum that we call the community dialogue, where we sit with women, and find out what they think about the services that they are receiving".
At the end of the life of the project, a total of 293,608 women accessed family planning services from about 550 trained CPs and PPMVs and 17,871 pregnancies were averted. Results from the pilot studies in Lagos and Kaduna states reveal that PPMVs can be trained to safely provide expanded family planning services like injectables and implants when properly supervised and supported.
The lessons learnt and the evidence generated from this pilot phase have led to the scaling-up of the IntegratE 1.0 project to IntegratE 2.0, which is now being implemented in 11 Nigerian states till 2026, thereby increasing access to contraceptives to more underserved communities. According to Pharm. Okafor, the scale-up of the project is being carried out in a step-wise process. After the first pilot phase in 2021, Enugu, Kano, Nasarawa, and Gombe were targeted for the second scale-up phase. However, in Enugu State, the scale-up was only for family planning services and did not include the PHC services.
Empowering more women, one woman at a time
Access to contraception is about empowering woman and girls to make decisions about their bodies, enabling them to lead a healthy and productive life. In response to a question on how she feels about having a wide range of contraception options, Olamide a mother of two children said she felt more empowered. "Taking up a contraceptive of choice makes me unafraid of an unplanned pregnancy, affords me time for myself and my children and saves me the cost of unsafe abortion," Olamide said.
Although some PPMVs cited access to funds as a barrier for some clients to access services, family planning still remains a cost-effective intervention with immediate and long-term benefits for individuals, families, and the nation. The Power of Options ensures that access to a variety of contraceptive methods is easily available, so women and girls can make informed choices.
The IntegratE project has showcased a functional model of increasing access to a wider range of contraceptives through service provision by PPMVs and CPs. Evidence generated calls for incremental policy implementation at the state and federal level. Adoption of this model will provide access to contraceptives for more women and girls, especially in underserved communities and increase the power of their options to have children when they desire, like we say in our local parlance, "having children by choice and not by chance".