By Chioma Obinna
Voluntary family planning has been widely accepted throughout the world. Today, over half of all couples in the developing world including Nigeria use a modern method of contraception for healthy timing, spacing, and limiting of births to achieve their desired family size. However, although, family planning has saved the lives of millions of mothers and their children and has improved the well-being of families and communities, the success of family planning has not been consistent across countries or even within countries.
In Nigeria for instance, the level of contraceptive use has risen slowly over the years. It is no longer news that there are women without access to family planning services. Reports show that an estimated 222 million women in developing countries, that would like to space or limit their pregnancies, are not using a contraceptive method.
And whereas family planning enhances efforts to improve health and accelerate development, factors such as traditional beliefs favouring high fertility, religious barriers and lack of male involvement have weakened interventions. Reports further show that the combination of these factors has led to low contraceptive use, high fertility rates, and high unmet needs for family planning. Sunday Vanguard spoke to the Country Director of Pathfinder International Nigeria, Dr. Farouk Jega, on some controversial issues regarding family planning and the need for male involvement. According to Jega a knowledgeable service provider will make a difference in the uptake of family planning among adolescents in the country.
There is this claim that a woman’s womb cannot be left fallow for a long time; with family planning, how safe is the womb? Is there a link between fibroid, infertility and family planning?
I have had several people say that the womb was made by God to carry babies. I don’t think God consulted anyone before he made the womb. And even if it is so, family planning is not suggesting in any way that a woman should absolutely not have children.
There are several hard facts about family planning. Family planning helps couples prevent unintended pregnancy. It enables them to time pregnancies in a way most beneficial to the health of the mother and children.
What family planning is saying is that a woman should have the number of children she can cater for. We are talking about spacing the number of children and not actually stopping the number of children. Several studies have shown that birth spacing for a number of years, like a minimum of two years between one pregnancy and the next, can have a lot of health benefits and none of these studies has shown any relationship with any disease or disorder including fibroid.
What we know is that there is a definite correlation between fibroid developing in the womb and some forms of infertility but that is not to say that it is because the woman refused to have children that the fibroid arose, it may be the same genetic factors that are responsible for the woman not having children that are also responsible for the fibroid to grow. We know of millions of women that have taken up family planning that we are following up and none of them developed fibroid. These women have had children before and are using family planning either to space or limit the number of children they were having. But we know of some women who did not use family planning and have been trying to become pregnant but did not and later on they had fibroid. These women also tried to become pregnant but they couldn’t. So fibroid has a strong relationship with infertility but there isn’t any correlation between limiting or spacing of children and fibroid.
In a country like Nigeria where men dominate decision making, how can male involvement help in deepening family planning?
Men should be involved in family planning because a woman cannot be pregnant all by herself. It takes a man and a woman to adequately plan for the family and not only their next birth but their resources like education of the children, foods and general upkeep of the family. A lot of times, men often shy away from these key responsibilities and they go away but, unfortunately, the reproductive biology of the female is much more amenable to interruption and manipulation than the male reproductive biology. A woman at least has one fertile cycle every 28 days and at most every 30 days. It takes an average of 90 days for male spermatozoa from the beginning of the life cycle until they become fully mature and they are able to impregnate a woman. That is three times the number of a female reproductive cycle. And the various hormones that are at play in reproduction are very easy to understand and manipulate whereas the process of spermatogenesis is not easy to manipulate. Why am I saying this? Almost all the family planning methods are for women.
The various hormones that are at play in reproduction are easily manipulated but the spermatogenesis cycle of the male is much more complex and cannot be manipulated. Almost all the family planning methods are for women and not men because of trials. Scientists have tried very hard but they did not have any break way in developing a male-specific method.
Perhaps, if some of these hormones with terrible side effects are directed at men, perhaps we would have seen much male involvement. It is not right that simply because most of the methods are targeted at women, men will just sit back and not be involved. I think men can play a key role. A typical Nigeria society is always male-dominated. The man always makes all decisions including whether his wife or his woman should have family planning or not, that alone suggests that men should be fully involved. As I know, I play that role very well. A man can be very useful in terms of making sure that the woman not only takes a useful method but also maintains that method. These methods are not 100 per cent full proof. Almost all of them have one or two issues that are not life-threatening but are usually self-limiting with time and almost 100 per cent reversible once the woman stops using a method but they can constitute a huge nuisance. So many times, I am the one encouraging my wife because I am a doctor and I understand family planning effects very well. The spotting, headache, feeling of blotting, all of these are normal. People should think of the benefits. I usually encourage my wife to think of the benefits that we are having about spacing or limiting the number of children. The little nuisance women are feeling is a small sacrifice to me. I believe men can play more of these larger roles than the smaller ones I just mentioned.
In many parts of the country, men are the total decision makers, they decide everything including family income and contraceptives and I think they should be fully involved in making these critical decisions.
Is it ideal to preach family planning to a married woman that is approaching menopause but wants to have children?
There are two ways to answer this question. The first is, family planning is for every woman not just for this scenario. Family planning is even for a woman whose womb God opened at 18 years and she has had seven children before the age of 30. It is voluntary. What every woman deserves is information that, first, there is something called family planning. A lot of women keep on having children and they don’t even know that there is something they can do. Secondly, access to service. Even those who have the information, they know that something can be done but they don’t know how to go about it. Some their husbands or mothers-in-law will not allow them to go while some, their community frowns at it. What we are saying is that every woman, no matter her circumstances, has the right to have quality information and good service. That decision is her own, either to go on having the children or access family planning services.
There is no discrimination or coercion whether she started early or late. She has the right to know and decide. We believe that women should know to be able to make a quality decision about their lives including that woman that started late and is now having children.
Implications of having children late
As a medical doctor, there is a definite correlation between late reproduction and the development of serious congenital anomalies in children. The closer a woman is to menopause, the more likelihood of having a child with abnormalities. Every female child is born with about 2 million eggs that are not fully mature. They mature to a certain extent and then they become dormant even while the female babies are inside the womb. Once the female child is born, those 2 million eggs stay in that state of dormancy until when she reaches sexual maturity age of about 12 – 13. When she reaches the age of maturity, those eggs that she was born with begin to mature at every cycle (every 28 days), one of them will reach full maturity and it will be released at a certain time of the cycle. If that one meets the spermatozoa, it results in pregnancy.
The woman does not add to the eggs that she is born with. Again, the eggs that she sheds at the early phase of her maturity are the ones that are likely to be good quality eggs. The ones that stay 40 years and above are the ones that are likely going to spoil. So the closer the woman is to menopause, the more likely she will have bad eggs. And those are the eggs that will result in babies with conditions such as down-syndrome and all forms of congenital problems. Even for that alone, we should counsel women against having children close to menopause. It is not judgmental even as a gynaecologist, if I see a woman that is 45 years and already had children and she wants to try one more time, it is my duty to caution her that there is a high chance that ‘if you have another baby, it may have this or that’. It does not matter if she has had a baby or not. She needs that information to make a decision because the decision is still hers. In developed places where they have genetic testing materials, they can actually do the testing way before the baby matures. And in those societies, abortion is legal; so if they found something or defects when the baby is two or three months in the womb, they can do elective abortion. They don’t go ahead to carry a monster or a malformed baby. Unfortunately, we cannot do any of those things here. I understand that in Lagos where there is one of two places where you can do some of the tests but even if we can do them, abortion is still illegal. You cannot perform an abortion.
Many adolescents have been discouraged from taking up family planning due to the attitude of service providers. What is your take?
The issue of provider barriers is not only for adolescent but for all groups. Unfortunately, it has no place for modern contraceptives. The only thing we can do is to raise awareness, continue teaching and building capacity. We expect the media to write stories about these issues because they are really a hindrance in the uptake of family planning. All of us are clients and, as clients, we have a role to demand good and quality services and not in a judgemental way. It is also not bad for an adolescent to take up family planning. Providers of family planning have no reason to be judgemental. Being judgemental is a breach of service and code of ethics is thwarted in providing services in a very judgemental way. Service providers have no reason to think that they will make a decision on behalf of the adolescent. You have no reason to think that and I see no reason anybody should do that. We are too often at being judgemental especially in our traditional setting. Unfortunately, it continues and the only way we will deal with it is by training and Pathfinder ensures that we train our health workers. In our training, we include issues of values to address provider bias. You have to respect the wishes of the client and part of it is for you to provide services without being judgemental.
The rate of unplanned pregnancy has continued to rise among adolescents. How can the country increase youth- youth friendly centres for family planning services?
From the little I know, the concept of having adolescent-friendly centres have really not been impactful. Research in retrospect did not meet the expectations of a lot of adolescents. But having the providers themselves to be very well trained, you may call it adolescent-friendly providers; I think it will make a difference. It is not the health facilities or hospitals or family planning centres but for the providers to be adolescent-friendly that makes all the difference. No matter what centres they are working in, if they understand their duties and they understand that it is their duty to provide information and services irrespective of the age of the adolescent that makes the difference. I think what I feel we should do, in any way possible, is to make sure we create the critical mass of those providers that are adolescent-friendly that know exactly what to do; that is the only way out. Pathfinder and other civil society organizations have finite resources from donors, so we can only reach finite numbers of providers and hospitals and other facilities. I agree that government should lead because they have the capacity. If government brings out a circular, every doctor or nurse will comply. Our own is to cajole, plead with them. Human beings are rational and they want a rational argument and reasons they should do something. Most times these providers have failed to provide service to these young people and they actually feel they are doing the right thing. When they do this, they feel it is a normal thing for adolescent not to have sex. They feel that if adolescents have access to contraceptives, they are encouraging them to have premarital sex. For me, the key thing is that they are just being judgemental. The best thing is not to judge anybody. All of us were once adolescents before we became adults. Our experience is enough for us to make a rational decision on what to do.