Family planning and reproductive health are a persistent challenge on the African continent, for women and their families, but also for societies and their economic development. High birth rates in Sub-Saharan Africa pose at least as great of a challenge as the shrinking populations do for Europe and other parts of the Global North.
During the years of the pandemic, Covid-19 pushed many things into the background: other diseases were neglected, medications and vaccinations difficult to access. Sexual health, women’s medical care and family planning were amongst those severely affected.
We wanted to know how sexual and reproductive health, family planning, and other factors were currently developing and how they could be positively influenced. On behalf of Global Perspectives Initiative, the African Institute for Development Policy (AFIDEP) analyzed recent developments in three African countries with declining fertility rates.
In all three countries, declining fertility rates were accompanied by improvements in medical care, fewer maternal deaths, and declining infant mortality. Maternal health, sexual and reproductive health, sexual self-determination and gender parity are core objectives of the Sustainable Development Goal 3: Good Health and Well-Being. Despite positive developments, particularly in child mortality, the targets are still far from being achieved. Lower-income countries in particular are dependent on international cooperation to achieve these goals. Better knowledge and understanding of the impact factors, can assist international cooperation to become even more effective.
Africa and Europe share unique ties of collaboration, and in times of Zeitenwende it is more important than ever, to realize we depend on each other. In this spirit, we wish you an enriching read.
CPR – Contraceptive Prevelance Rate
FP – Family Planning
FP2020 – Family Planing 2020 (Global Partnership) GDP Gross Domestic Product
HDI – Human Development Index
MMR – Maternal Mortality Ratio
SRH – Sexual and Reproductive Health
SSA – Sub-Saharan Africa
TFR – Total Fertility Rate
UNFPA – United Nations Populations Fund UNIcEF United Nations International Children’s
High fertility rates can impose costly burdens on developing nations. These include increased health risks for women and children, reduced access to education, employment, natural resources and hindered opportunities for economic development. Whilst global fertility rates reduced from about 5 births per woman in 1960 to 2.3 in 2020, the rate in Sub-Saharan Africa (SSA) still remains the highest of all global regions – total fertility fell from 6.6 births per woman in 1960 to 4.7 in 2020. World population is still growing rapidly and will continue to do so for the next several decades, especially in Sub-Saharan Africa. There is a need to make the right investments to ensure that population growth can be managed for optimum development, especially in resource-poor settings.
Family planning (FP), defined as the ability of individuals and couples to decide freely and responsibly the number, spacing, and timing of their children, and to have the means to do so, can help individuals and countries to reduce fertility rates, which can then lead to improved social and economic outcomes. FP is a basic human right and crucial for achieving gender equality and women’s empowerment. These are entrenched in international and regional commitments including the Sustainable Development Goals and the Maputo Protocol, which is part of the African Union’s Protocol on Women’s Rights. Women who can reliably control their fertility have more control over their lives in general, ultimately resulting in greater well-being. Access to FP services can also help to reduce maternal and child mortality and improve maternal and child health.
Whilst the demand for modern contraceptives has been increasing worldwide, uptake has been slowest in Sub-Saharan Africa. The contraceptive prevalence rate (CPR) among married or in-union women of reproductive age (15-49 years) increased from 54% in 1990 to 63% in 2020 globally; the comparative rates in Sub- Saharan Africa were 13% in 1990 and 33% in 2020ii. However, there are still significant disparities in access to and use of FP services between and within countries even within the region1. At the same time, even within countries that have made significant progress in contraceptive use within the continent, certain population sub- groups are significantly disadvantaged. Key among them are adolescents, and poor urban communities. The disparities need to be bridged, especially for adolescents, as they are the group who have the greatest reproductive potential, and not getting access to FP is likely to result in greater adolescent pregnancy. Adolescent pregnancy perpetuates poverty as it forces many young women to leave school, thereby decreasing their opportunities for economic advancement and reducing their lifetime earnings. This will eventually likely reduce both the trajectory of the gains made in the sub- region and the potential social and economic benefits.
In this paper, we use examples from three countries in Sub-Saharan Africa with unique success stories to discuss the drivers of success in FP uptake and examine the remaining barriers to the uptake of modern contraceptives for meeting health and development goals. Sub-Saharan Africa provides both a case of hope and despair, and the region needs continued efforts to ensure universal access to FP.
Sharing Success: Kenya, Malawi, and Senegal
Kenya, Malawi, and Senegal are three of the countries in Africa that have made significant progress in improving access to family planning services over time. The East African nation Kenya has a population of approximately 55 million people in 2023. The current total fertility rate (TFR)2 is 3.2 children per woman, and 2 out of every 5 persons is under the age of 15. Malawi is in southeastern Africa with an estimated population of 21 million. About 42% of the population is under the age of 15. Malawi’s TFR is 3.8 children per woman. Senegal, in West Africa, has a population of approximately 18 million people currently. About 41% of the population is under the age of 15. Senegal has a TFR of 4.3 children per woman. Overall, all three countries’ fertility rates are higher than the global average of 2.4 children per woman.
In spite of the relatively high fertility rates, all three countries have made significant progress in expanding access to family planning services and reducing fertility rates in recent years. In Kenya, the contraceptive prevalence rate (CPR) for married women increased from 39% in 2003 to 61% in 2022. This increase in contraceptive use has contributed to a decline in the TFR. Between 1989 and 2022, the TFR declined by 3.3 children (from 6.7 to 3.4)vii. In Malawi, the CPR increased from 28% in 2000 to 69% in 2022. The corresponding decline in the TFR has been by almost 2 births (6.3 in 1990 to 4.4 in 2020). In Senegal, the CPR increased from 9% in 1990 to 28% in 2022 and has been accompanied by a decline in the TFR of almost 2 births as well (6.6 in the 1980s to 4.7 in 2020). In the three countries, there are still disparities in CPR amongst different groups of women, resulting in lower prevalence rates when all women are combined (Kenya 45%, Malawi – 51%, Senegal 21%, in 2022). Additionally, despite the FP progress, they all have relatively young populations and thus, the potential to increase in size substantially.
In all three countries, the efforts to expand access to family planning services have also been associated with improvements in maternal and child health outcomes. The maternal mortality ratio (MMR) in Kenya almost halved, from 651 deaths per 100,000 live births in 1990 to 342 deaths per 100,000 live births in 2017. In Malawi and Senegal MMR declined even more drastically, from 1,120 deaths per 100,000 live births to 439 deaths per 100,000 live births in Malawi, and for Senegal, from 870 deaths per 100,000 live births to 325 deaths per 100,000 live births. These improvements in health out- comes are likely to contribute to progress in other development indicators, such as the human development index (HDI) and gross domestic product (GDP), over time.
The Drivers of Success
The success of family planning programs in the three countries can be attributed to a combination of political leadership, international support, the involvement of traditional and religious leaders, legal provisions, investments in funding, and a multi-sectoral approach to service delivery involving both health and non-health sectors, among other factors.
In Kenya, the government has prioritized family planning and included it in national development plans. In 2012, the government launched a national campaign to increase contraceptive use, which included efforts to address myths and misconceptions about family planning. Kenya has also worked to expand access to family planning services through both the public and private sectors. It has leveraged partnerships to obtain increased funding from both domestic and international sources. Legal provisions have also been implemented, including the Kenya Reproductive Healthcare Bill (2019) which guarantees reproductive healthcare services to all persons. The government has worked to mitigate staffing challenges by train- ing mid-level health workers and expanding the use of community health workers to provide family planning services. Outreach efforts have focused on engaging traditional and religious leaders and young people to promote family planning. There has also been a focus on increasing access to long-acting and permanent methods.
Despite these successes, challenges, discussed later, remain in achieving equitable access, particularly for marginalized groups such as adolescents and rural populations.
Similarly, political leadership has played a critical role in expanding access to family planning services in Malawi. In 2012, the government launched the National Reproductive Health Strategy, which prioritized family planning and included targets for increasing contraceptive prevalence. Additionally, Malawi has made legal provisions to support family planning, including signing onto the Maputo Protocol and changing the legal age at marriage to 18. The government has also increased funding for family planning programs and worked to expand access to long-acting and permanent methods. Additionally, Malawi has leveraged partnerships with international organizations such as UNFPA and FP2020 to support its family planning programs. The government has also worked to mitigate staffing challenges by training mid-level health workers to provide family planning services. Traditional leaders and religious leaders have been involved in the push to promote family planning, and there has been a concerted effort to increase access to long-acting and permanent methods. Again, however, challenges remain in achieving equitable access, particularly for young people.
In Senegal, political leadership and legal provisions have been key drivers of success in family planning programs. In 2011, the government passed a law that provided for free family planning services and made contraception available to adolescents. The government has also worked to expand access to family planning services through the public and private sectors and has very successfully leveraged partnerships with international organizations such as UNFPA and WHO. Senegal has also focused on reaching out to religious and traditional leaders to promote family planning and reduce social stigma. Senegal has been particularly successful in achieving equitable access to family planning services, with efforts to reach marginalized populations such as young people and rural communities.
Expanding access to family planning services has required a multi- sectoral approach involving both the health and non-health sectors in all three countries. The involvement of non-health sectors such as education, agriculture, and finance has helped address underlying socio-economic factors that influence fertility. In addition, efforts to achieve equitable access to family planning have been critical in reducing disparities among different population groups. For example, efforts have been made to increase access to family planning services among young people who may face additional barriers due to social and cultural norms.
Prevailing Barriers to FP Access and Utilization
In spite of the great strides in FP in the countries, there are several barriers to access and utilization of family planning services in these countries as well as much of Africa. These particularly limit subgroups who are marginalized. One major barrier has been politics and leadership, as sometimes there has not been consistent political will or leadership commitment to prioritize family planning programs, through ensuring the right investments are made, especially to reach the groups who need services most. This can result in insufficient funding, inadequate staffing, and a lack of access to necessary resources and infrastructure. In spite of legal provisions in all three countries, financing the FP budget relies mainly on external donors, and the budgetary allocations for SRH, especially for young people, are woefully inadequate.
Inequity is another major barrier to access and utilization of family planning services, with adolescents and young people often being the most disadvantaged. Young people may face barriers such as lack of access to accurate information about family planning and limited access to youth-friendly services. Cultural norms and beliefs around sexuality and gender often result in stigma and discrimination and discourage them from seeking out services. In some countries, child marriage is still prevalent, in spite of laws to mitigate it. For example, in Kenya, Malawi and Senegal respectively, the most recent statistics from UNICEF show that 22%, 38%, and 31% of women aged 20-24 were married before age 18, the legal age at marriage.
Girls who marry young usually face peculiar hurdles in obtaining and using modern contraception. These include greater societal pressure to prove their fertility and reduced autonomy to negotiate family planning use with their partners. Pregnant girls are more likely to experience health complications before and during child-birth, and their children are at a much higher risk of infant mortality. Young mothers are more likely to suffer from social bias, limited education, and reduced economic prospects in the long term.
Currently, pregnancy and childbirth complications are the leading cause of death of adolescent girls aged 15-19 worldwide. Pregnant adolescents are more likely than other women to experience complications and maternal mortality during childbirth due to physiological reasons, poor nutrition, and lack of access to health- care. There are numerous possible complications for pregnant girls, particularly in developing countries where access to quality prenatal care is challenging. In addition, abortions, which are only legal under certain circumstances in Kenya and Malawi and illegal in Senegal, are often performed in unsafe conditions. Babies born to adolescents are also at higher risk of low birth weight and severe neonatal conditions.
There is a variety of challenges for family planning, especially for marginalized groups, including lack of leadership commitment, funding, and overarching inequality.
Thus, despite the barriers to accessing FP/SRH services for young people, it is important to make them available because there are long-term positive implications for the health and well-being of young people, their families, and their countries.
How can we deal with barriers to FP/SRH for youth?
There are a few examples of countries that have made an effort to expand FP access, particularly for young people. Ethiopia and Chile are two developing country examples that have made significant progress in increasing access to family planning for young people. The governments legitimized the provision of contraception to adolescents through national policies and strategies and invested in strengthening and expanding youth-friendly health services. They tracked progress to identify and solve problems that arose. Consequently, the countries have seen an increase in contraceptive prevalence rates among young people, contributing to improvements in maternal and child health outcomes and economic growth.
Lessons from such countries which have made great strides in dealing with barriers to FP/SRH for youth show that several vital considerations need to be taken into account for success. The impetus for change must come from within countries, and the provision of FP commodities and services must be coupled with other structural changes. Strong political systems with good governance and political stability as pillars, and political commitment to reduce structural imbalances are key to successful interventions. Commitments to improving gender parity in all spheres are also essential.
Ensuring adequate SRH laws and policies that protect all individuals’ rights and provide access to FP/SRH services are the basis to supporting young people’s FP access. This can involve working with governments to create or strengthen legislation and with civil society organizations to advocate for change. In Malawi, for example, due to concerted efforts by government bodies, advocates, activists, public officials, traditional authorities, politicians, religious leaders, teachers and young people themselves, in 2017, the legal age of marriage was changed from 15 to 18.
Education and training are particularly important, as they can help young people to develop the knowledge and skills needed to make informed decisions about their sexual and reproductive health. This can involve providing comprehensive sexuality education in schools and other settings and offering vocational and skills training to help young people gain employment and achieve economic independence.
Investing in Women’s Economic Empowerment (WEE), which involves promoting equal rights and access to economic opportunities for women is a key facet to improve gender parity. Investments can include initiatives to support women’s entrepreneurship, provide access to finance and other resources, and promote flexible working arrangements that allow women to balance reproductive and productive roles.
Overall, by addressing these structural barriers and promoting access to FP/SRH services for youth, countries in Africa can help to ensure sustainable development and create a brighter future for all their citizens.
The way forward
Ultimately, the structural changes discussed above must be coupled with the provision of FP commodities. Funding for FP/SRH programs remains a major source of contention for developing nations. This funding comes from various sources, including domestic government budgets, donor assistance, private sector contributions, and individuals’ out-of-pocket payments. However, in many developing countries, donors remain the primary funding source for FP/SRH programs. According to FP 2030, in 2020, donor governments, specifically, contributed 40% of the total funding for family planning. For example, Mozambique gets up to 72% in donor aid for its family planning programs. However, funding commitments from both domestic and donor sources have been affected in recent years, especially by the COVID-19 pandemic and other global political events such as the Ukraine crisis. These have led to cuts in foreign aid and diverted resources toward competing needs.
In Senegal, for example, recent funding cuts have led to a shortfall of funding for the health sector, which relies almost entirely on donor funds for support, and the most recent statistics indicate a decline in the CPR.
In addition to funding, there are other crucial elements needed to provide FP/SRH access for young people. Governments, NGOs, and other stakeholders need to raise awareness about the importance of FP/SRH and the benefits that come with it. This can be done through various channels, including media campaigns, community engagement, and advocacy efforts. Governments, international agencies, and donors need to make long-term commitments to FP/SRH funding. This will enable sustained investment in FP/SRH programs and ensure that young people have continued access to these services. Even when funding comes from external sources, the acceptance and uptake of family planning products and services rely on domestic government backing. African governments can provide the gateway for funding family planning products and services by ensuring they are adequately included in budgets. Governments can also provide direction on the use of family planning funding, for example, supporting culturally appropriate youth- friendly services, assisting the process of importation and distribution of family planning commodities, and investing in personnel and infrastructure development for FP.
Strengthening local capacity to collect, analyze, and use FP/SRH data, to understand the needs of young people and continually feed into and improve data collection and analysis is essential to designing effective FP/SRH programs. Governments and other stakeholders should invest in strengthening local capacity to collect, analyze, and use FP/SRH data. Effective supply chain management is also critical to ensuring that young people have access to a steady supply of high-quality FP/SRH commodities. Governments and other stakeholders should invest in strengthening supply management systems, including local production of commodities, to ensure that young people have access to the FP/SRH products they need.
Contributions from economic powerhouses in Europe
Whilst pushing for increased domestic funding and support for FP/SRH, it is important to keep up donor funding. Donor funding for FP/SRH has far-reaching benefits not only for the recipient countries but also for the donor governments. The benefits to donor governments include boosting the economic strength of potential trading partners, improving stability and cooperation, and achieving humanitarian goals.
For the German as well as other European governments, supporting these critical factors is essential in sustaining the progress towards achieving FP/SRH access and equity, especially in developing countries where domestic resources are limited. It is also important to raise awareness about the benefits of FP/SRH and the importance of funding it, both domestically and through donor support. The commitment of donors, governments, and other stakeholders toward achieving FP/SRH access for all is crucial for sustainable development and progress in Africa and beyond.
- Dr. Eliya Zulu, Founder and CEO African Institute for Development Policy
- Naa Dodoo, Senior Researcher, AFIDEP
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