More women in Africa are using long-acting contraception, changing their lives

On a busy day at the Kwapong health center in rural Ghana, Beatrice Nyamekye put contraceptive implants in the arms of half a dozen women and gave eight or nine others a hormonal injection of three months to avoid pregnancy. A few were looking for condoms or birth control pills, but most wanted something longer lasting.

They are the ones who prefer implants and injections, said Ms Nyamekye, a community health nurse. It frees them from worry and it's private. They don't even need to discuss it with a husband or partner.

The unrest at the Kwapong clinic is echoed across Ghana and much of sub-Saharan Africa, where women have the lowest rate of access to contraception in the world: just 26 percent of women in reproductive age in the region use a modern contraceptive method. anything other than the pace or methods of withdrawal according to the United Nations Population Fund, known as UNFPA, which works on reproductive and maternal health.

But that is changing as more women have been able to access methods that give them a quick, affordable and discreet boost to their reproductive autonomy. Over the past decade, the number of women in the region using modern contraception has almost doubled to 66 million.

We have made progress, and it is increasing: you are going to see a large number of women gaining access in the near future, said Esi Asare Prah, who manages advocacy for the Ghana office of MSI, a nonprofit organization specializing in reproductive health.

Three factors are behind the change. First, more girls and women are educated: they have more knowledge about contraceptives, often thanks to social media that extends even to the most remote corners of the region. And they have bigger ambitions, in terms of careers and experiences, which will be easier to achieve if they delay having children.

Second, the range of available contraceptive options has improved, as generic drug manufacturers have brought more affordable hormonal injections and implants to market.

And third, better roads and planning made it possible to get contraception to rural areas, like this one, a nine-hour drive from the port of the capital, Accra, where the products were shipped from manufacturers in China and Brazil.

Improving access translates into tangible gains for women. At a busy MSI clinic in the city of Kumasi, Faustina Saahene, who runs the operation, said women from the country's large Muslim minority value implants and IUDs for their discretion, which allows them to space their pregnancies without openly challenging husbands who wish to do so. I have many children.

She also encourages them for younger, single women, who may be overly optimistic about their current partner's commitment to supporting a child and not realize how pregnancy might limit their options.

Your education, your career, even your sexual pleasure: having children is disruptive, Ms. Saahene said before ushering another client into the exam room.

Across the region, control over access to contraception has largely been taken out of the hands of doctors, despite resistance from doctors' associations concerned about the loss of a reliable source of income. In many countries, community health workers go door to door with birth control pills and administer Depo-Provera injections on the spot. A self-administered injection is increasingly available at convenience stores, where young women can buy one without the risk of being asked judgmental questions by a nurse or doctor.

In Ghana, nurses like Ms. Nyamekye are informing women that they have cheap and discreet options. When she passed a roadside beauty salon recently, she chatted with women waiting on a wooden bench to have their hair braided. With just a few questions, she sparked a lively conversation: one woman said she thought an implant might make her gain weight (possible, Ms. Nyamekye agreed), and another said she might to the clinic for an injection, prompting her braider to tease her about rapid developments with a new boyfriend.

Sub-Saharan Africa has the youngest and most vibrant population in the world; it is expected to almost double, to 2.5 billion people, by 2050.

At the Kwapong clinic, there is a room just for teenage girls, where films are shown on a large television and a specially trained nurse is on hand to answer questions from the shy teenage girls who slip in in pleated school uniforms. Emanuelle, 15, who said she had recently been sexually active with her first boyfriend, opted for an injection after speaking with the nurse. She had only planned to tell her best friend about it. It was a better choice than the pill, the only method she knew about before her visit to the clinic, because the uncle she lives with could find them and know what they were for, she said.

Ten years ago in Kwapong, the only options Ms Nyamekye had for women were condoms or pills, she said. Or once a year, MSI would come to town with a clinic built into a bus, staffed by midwives who inserted IUDs into lines of waiting women.

Despite all current progress, the UN reports that 19 percent of women of reproductive age in sub-Saharan Africa had unmet contraceptive needs in 2022, the latest year for which there is data, meaning they wanted to delay or limit childbearing but were not using any modern methods.

Supply problems also persist. For the past three months, the Kwapong clinic has run out of everything except pills and condoms due to lack of supplies from Accra.

It's a symptom of the difficulty of introducing contraception in places like this, in a system in which global health agencies, governments, pharmaceutical companies and shipping companies often have more say over contraceptives that women can choose for themselves.

The majority of family planning commodities in Africa are purchased by the United States Agency for International Development or UNFPA, with support from the Bill & Melinda Gates Foundation. This model dates back more than half a century, to a time when rich nations sought to control rapid population growth in poor countries.

Major global health agencies have invested in expanding access to family planning as a logical complement to reducing child mortality and improving girls' education. But most African governments have left it out of their own budgets, even though it has brought huge gains in health, education levels, economic participation and women's well-being.

Countries with limited budgets generally choose to fund health services considered more essential, such as vaccines, rather than reproductive health, explained Dr. Ayman Abdelmohsen, head of the family planning branch of the technical division of the UNFPA, because they produce more immediate results. Back.

But a recent UNFPA push for low-income countries to shoulder more of the cost has led 44 governments to sign up to a new funding model that commits them to increasing their contributions to reproductive health each year.

Despite this, there was a significant global shortfall of around $95 million last year for product purchases. Donors are currently funding much of the output, but their funding for 2022 was nearly 15% lower than in 2019, as the climate crisis, the war in Ukraine and other new priorities reduced global health budgets. Support for programs from African governments has also stagnated as countries face soaring food and energy prices.

The good news is that prices of new contraceptives have fallen dramatically over the past 15 years, thanks in part to promises of massive orders negotiated by the Gates Foundation, which bet big on the idea that long-acting methods would appeal to many people. women in sub-Saharan Africa. Hormonal implants made by Bayer and Merck, for example, fell to $8.62 in 2022 from $18 each in 2010, and sales increased to 10.8 million units from 1.7 million during the same period.

But this price tag remains a challenge for low-income countries, where total public health spending averages $10 per person each year. Pills and condoms cost more in the long run, but the upfront cost of long-acting products is a barrier.

It's not enough to bring contraceptives to a clinic: health workers need to be trained to insert IUDs or implants, and someone needs to pay for it, Dr. Abdelmohsen said.

Hormonal IUDs are still rare in Africa and cost more than $10 each; Dr. Anita Zaidi, who leads gender equality work for the Gates Foundation, said the nonprofit is investing in research and development of new long-acting products, and is also looking for manufacturers in developing countries that can produce existing products even cheaper.

The foundation and others are also investing in new efforts to track data on which companies make which products, which countries order them and when they will be delivered to try to ensure that clinics do not run out. They also want to know better which methods African women want to use and why those who say they want to use contraception do not do so. Does it cost? To access? Cultural norms, such as providers' reluctance to deliver to single women?

Gifty Awuah, 33, who works at a small roadside hair salon in Kwapong, receives a regular injection for three months. She had her first child while she was still in school. When I got pregnant at 17, it wasn't anticipated that family planning wouldn't be accessible like it is today, she said. You had to go to town and pay: it was a lot of money.

She had to leave school when she became pregnant; If she had the options she has now, her life could have been different. If it was like now, I wouldn't have been pregnant, she said. I would have moved on in life, I would have studied, I would be a judge now or a nurse.