Breaking barriers to access to Family planning in Northern Nigeria

 

Problem: 
In 2007, we started implementation of a package of health interventions in a cluster of villages with a total population of 22,000, in a project called Pampaida Millennium Villages Project. The aim of these interventions is to achieve the MDGs within the cluster by 2015 using proven technologies and low cost investments. We provide these interventions at 3 levels: community level through community health workers (village health workers); clinic level for the provision of basic health services and a linked referral hospital. These interventions were well accepted with good uptake except Family planning service. It was almost a taboo to talk about Family planning in this Muslim dominated community who hold high premium on traditional and religious beliefs. A large family was viewed as a sign of prosperity, and thus it was unusual for a woman to request for family planning in the clinics. The two most important factors found to be responsible for the poor uptake were strong religious influences and resistance from husbands – the decision makers of the family. Other factors were competition among wives to have more children than their rivals, and a general poor knowledge of family planning methods. Even the health staff believed they could not change the people’s perception on family planning. Therefore, to make family planning an attractive service required strategies to overcome these barriers.
 
In 2009, the Total Fertility Rate in the cluster was 7.1, with more than ¼ of adolescent women giving birth every year.  
 
Intervention: 
We developed a multi-prong strategy: local advocacy; behavior change communication; capacity building; and commodity supply.
We employed a vigorous and consistent approach to advocacy on FP at both community and clinic levels. At the clinic level, we integrated FP discussions into other clinic activities. For instance, during group counseling at ANC, women are sensitized about the potential future use of FP.
Community level advocacy was done during health service outreaches, at community meetings, in mosques and churches and at meetings with community and religious leaders (focus group discussions). We invited well known Muslim clerics to facilitate focus group discussions with Imams and heads of households. We also mainstreamed FP discussion into other sectors of the project viz: education, agriculture, water and sanitation.
In one instances, we collaborated with the Agriculture sector to mainstream family planning in a discussion at a community meeting with the theme ‘the relationship between family size and food security’. This is a community of mainly subsistence farmers and pastoralist. Each head of household owns a fixed portion of farmland, often as inheritance from his father, which he will likewise share to his sons. At that meeting, most heads of households in attendance admitted experiencing food shortages for at least one month before the next harvest.
Using this information, we created a hypothetical family of 10, and imagined that they were already experiencing food shortages. We then projected that if in 10 years this family increases its size to 15, what will the consequences be in terms of food supplies? The answer was that there will be longer periods of food shortages in between harvests.

This was the triggering moment and we used it to introduce intensive general discussion on family planning (child spacing). We stimulated discussions on its’ myths, methods and benefits to mother, child, family and society at large. Comments were sought from religious and traditional leaders, including heads of households for their perceptions on child spacing. This was followed up with similar discussions in Mosques, Churches, and cooperative groups over many months. The response was astonishing as women started coming to the clinics to request for family planning methods and in many instances men bringing their wives for the services. Over time, we built a large pool of satisfied clients who took on the roles of child spacing advocates within the community and to neighboring communities.

To increase staff capacity for advocacy and service delivery, we entered into partnership with Marie-Stopes Nigeria (an affiliate of Marie-Stopes International).

Results: 

 

The following table shows the progress in uptake of family planning methods between 2009 and 2011.

 

Method
2009
2010
2011
 
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Pill
2
0
0
13
1
0
41
50
19
13
16
40
Injectable
3
74
45
98
64
64
77
163
37
40
83
89
Insertable
0
0
0
0
0
0
0
66
312
188
83
77
IUCD
0
0
0
0
0
0
0
0
0
0
0
0
Total
5
74
45
111
65
64
118
279
368
241
182
206

 

 
The graph attached shows family planning utilization (all forms) within the cluster from 2009 to 2011.
 

 

Lessons: 
  1. Barriers to family planning can be broken through advocacy.
  2. Changing the views and behavior of a community with strong attachment to cultural and religious beliefs on FP takes time and effort.
  3. The health personnel should believe they can change strongly held views within a community.
  4. Intersectoral collaboration is very useful

A partnership with other organizations to improve staff capacity and commodity supply is very important.

 

 

Report Author(s): 
Dr. Clement Woje
Organization(s): 
Millennium Promise / Pampaida Millennium Villages Project
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