On a busy day at the Kwapong Health Center in rural Ghana, Beatrice Nyamekye inserted contraceptive implants into the arms of half a dozen women and gave eight or nine others a three-month hormone injection to prevent pregnancy. Some were looking for condoms or birth control pills, but most wanted something longer lasting.
“They especially like the implants and injections,” said Ms Nyamekye, a community health nurse. “It frees them from worry and is private. They don't even have to discuss it with a husband or partner.
The uproar at the Kwapong clinic is echoed throughout Ghana and much of sub-Saharan Africa, where women have the lowest rate of access to contraception in the world: only 26% of women of reproductive age in the region use a modern contraceptive method. – something other than the pace or methods of abstinence – according to the United Nations Population Fund, known as UNFPA, which works on reproductive and maternal health.
But things are changing as more and more women have been able to obtain methods that give them a quick, convenient and discreet increase in reproductive autonomy. Over the past decade, the number of women in the region using modern contraception has nearly doubled to 66 million.
“We have made progress, and it is growing: you will see huge numbers of women gaining access in the near future,” said Esi Asare Prah, who manages advocacy for the Ghana office of MSI, a reproductive health nonprofit.
Three factors are driving the change. First, more and more girls and women are being educated: they have greater knowledge about contraceptives, often through social media reaching even the most remote corners of the region. And they have bigger ambitions, in terms of career and experience, that 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 introduce contraception in rural areas, like this one, a nine-hour drive from the port in the capital, Accra, where products were shipped from manufacturers in China and Brazil.
Improving access translates into tangible benefits for women. At a bustling 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 out their pregnancies without openly challenging the husbands who want them to do so. have many children.
It also encourages them for younger, unmarried women, who may be overly optimistic about their current partner's commitment to supporting a child — and may not realize how much a pregnancy might limit their options.
“Your education, your career, even sexual pleasure: having children is disturbing,” Ms. Saahene said before ushering another client through the doors of 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 revenue stream. 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 shot is increasingly available at corner stores, where young women can purchase one without the risk of judgmental questions from a nurse or doctor.
In Ghana, nurses like Ms. Nyamekye inform women that they have affordable and discreet options. When she passed a roadside beauty salon not long ago, she chatted with women waiting on a wooden bench to have their hair braided. With just a few questions, she kicked off a lively conversation: One woman said she thought an implant might make her gain weight (possible, Ms. Nyamekye agreed), and another said she could go to clinic for an injection, prompting her braider to tease her about rapid developments with a new boyfriend.
Sub-Saharan Africa has the youngest and fastest growing population in the world; it is expected to nearly double, reaching 2.5 billion people, by 2050.
At the Kwapong clinic there is a room reserved for teenage girls, where films are shown on a large TV and a specially trained nurse is on hand to answer questions from shy teenagers who come in wearing pleated school uniforms. Emanuelle, 15, who said she was sexually active with her first boyfriend, opted for an injection after chatting with the nurse. She only intended to tell her best friend. It was a better choice for her than the pill—the only method she knew about before her clinic visit—because the uncle she lives with might find them and know what they are 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, the MSI came to town with a clinic built on a bus, staffed by midwives, who inserted IUDs into the lines of waiting women.
Despite all the current progress, the UN reports that 19% of women of reproductive age in sub-Saharan Africa had unmet contraceptive need in 2022, the latest year for which data is available, meaning they wanted to delay or limit pregnancy but they were not. using any modern method.
Supply problems also persist. In a recent three-month period, the Kwapong clinic ran out of everything except pills and condoms because supplies failed to arrive from Accra.
This is a symptom of how difficult it is to obtain contraceptives in places like this, in a system where global health agencies, governments, pharmaceutical companies and shipping companies often have more say in which contraceptives women can get. choose over women themselves.
Most family planning products in Africa are provided 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 the rapidly growing populations of poor countries.
Large global health agencies have invested in expanding access to family planning as a logical complement to reducing infant mortality and improving girls' education. But most African governments have excluded it from their budgets, even though it has produced enormous benefits for women's health, education levels, economic participation and well-being.
Countries with limited budgets usually choose to pay for health services considered more essential, such as vaccines, rather than reproductive health, said Dr. Ayman Abdelmohsen, head of the family planning branch of UNFPA's technical division, because they produce results more immediate. come back.
But a recent push by UNFPA for low-income countries to shoulder more of the costs has led 44 governments to sign up to a new financing model that commits them to increasing their contributions to reproductive health every year.
Even so, there was a significant global shortfall of approximately $95 million in product purchases last year. Donors currently pay for most products, but their funding for 2022 was nearly 15% less than in 2019, as the climate crisis, war in Ukraine and other new priorities squeezed global health budgets. Program support from African governments has also remained stagnant as countries have struggled with 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 large bulk orders brokered by the Gates Foundation, which is betting big on the idea that long-acting methods can attract many. women in sub-Saharan Africa. Hormone implants made by Bayer and Merck, for example, fell to $8.62 in 2022, from $18 each in 2010, and sales rose to 10.8 million units from 1.7 million in the same period.
But that price still poses a challenge for low-income countries, where total public health spending each year averages $10 per person. Pills and condoms are more expensive in the long term, but the initial cost of long-acting products is a barrier.
It's not enough to bring contraceptives to a clinic: Health workers have to be trained to insert intrauterine devices or implants, and someone has to pay for it, Dr. Abdelmohsen said.
Hormonal IUDs are still scarce in Africa and cost more than $10 each; Dr Anita Zaidi, who leads work on gender equality for the Gates Foundation, said the non-profit organization is investing in research and development of new long-acting products, and also looking for manufacturers in developing countries that can produce existing ones even more cheaply.
The foundation and others are also investing in new efforts to track data — about which companies are making, which products, which countries are ordering them, and when they will be delivered — to try to ensure clinics don't run out. They also want to better track what methods African women want and why women who say they want to use contraception don't. Is it a cost? Access? Cultural norms, such as providers' reluctance to deliver to unmarried 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 still at school. “When I got pregnant at 17, it wasn't planned: family planning wasn't as accessible as it is now,” she said. “You had to go into town and pay – there was a lot of money at stake.”
She had to leave school when she became pregnant; If she had had the options she has now, her life might have looked different. “If it had been like now I wouldn't have gotten pregnant,” she said. “I would have taken a step forward in life, I would have studied, now I would be a judge or a nurse.”