FAMILY PLANNING IN AFRICA SOUTH OF THE SAHARA
The goal of Family Planning is to assist families in achieving the number of children desired, with appropriate spacing and timing to ensure optimal growth and development of each family member (Hatcher 1977, Mange 1991). Failure to plan a pregnancy can adversely affect the health of the individual, the health of the relationship and the health of the family as a whole.
Child spacing is not new in Africa. Traditionally, intensive breast-feeding of long duration (18-24 months) has been the norm, and in many African countries the prevalence of breast-feeding still exceeds 90 percent in the immediate post partum period. Unfortunately this useful and life saving practice for the infant is decreasing especially in urban areas. In some African societies, a long period of abstinence from sexual intercourse after delivery was a major contributing factor to child spacing.
Early marriages have been a regular feature of the African society exposing the adolescents to early sexual activity and pregnancies, both of which can carry major health consequences.
Whereas the first birth control clinic was opened in Britain in 1923 under the auspices of Mary Stopes, the first child spacing clinic was opened in Cameroon only in 1975 at the Central Maternity of the Central Hospital. Also, whereas contraception was accepted by the US Supreme Court in 1965, contraceptives were authorized for sale in Cameroon by law only in 1980. In 1976, family planning objectives were defined for Africa during a regional meeting on Family Welfare and African Development South of the Sahara in Ibadan (Nigeria) under the auspices of IPPF.
In view of the right for couples to have children by choice, governments must not relent their efforts in ameliorating the performance of national family planning programmes. In Cameroon, under provisions of sections 337 and 339 of law No 65/LF/24 of 24 December 1965, and Law No 67/LF/1 of 12 June 1967, abortion is punishable (whether self-inflicted or procured, consented or without consent), except when performed as a medical necessity such as saving the mother from great danger to her health or in the case of pregnancy resulting from rape. Despite these laws, induced abortion continues to be carried out in increasing numbers in all communities. There are no political restrictions on other methods of fertility regulation despite divergences in religious opinion. The 1920 French anti-contraceptive law which prohibited the dissemination of information was repealed in 1967, although its influence and application is still felt in most African countries that experienced French influence.
Men’s attitudes towards family planning
Studies have shown that a good number of men in developing countries approve family planning. The attitude of men does not constitute a major obstacle to family planning but generally, in most developing countries, men have a more reserved attitude toward contraception than women. In a study in Cameroon, we found that 64% of men in the rural areas of Akonolinga and 63% in the rural areas of Obala are favourable to contraceptive practice, while another study among University students in Yaounde showed a favourable attitude in 92% of unmarried couples and 98% of married couples. Family planning has nevertheless more chance of success in developing countries if incorporated into existing health services. In order to ensure sustainability of the programme, contraceptive methods and equipment must be available and in sufficient quantities.
Because 50% of pregnancies occur within 6 months after the start of intercourse, family planning information should preferably reach young people before they begin sexual activity. This is important because many observers have noted very low contraceptive use at first intercourse and within the first months of sexual activity. We have noted the same in our own research. Despite this very low use of contraceptives at the initiation of sexual life, very few (6.4%) women in our study reported that they were hoping to get pregnant. It would appear therefore that, without contraception, most pregnancies occurring in this period would be unwanted.
Evolution of family planning in some African countries
In developing countries, especially Africa, modern family planning is still new and not wholly accepted by the population which does not have family planning " awareness ". Over the last 30 years, several attempts have been made to get family planning to take off in Africa, but often, there has been no political will and commitment.
The drive for child spacing started in Cameroon in 1971 after a seminar on family planning programmes organized by the Institute of Public Affairs in Washington, at which a participant, Professor Nasah, presented the situation of alarming rates of induced and spontaneous abortion in Cameroon and how they could be prevented by family planning. In 1975, Nasah and Drouin opened the first family planning clinic in Cameroon at the Central Maternity, Central Hospital, Yaounde. It was still through this team’s effort that the Cameroon National Welfare Association (CAMNAFAW) which is affiliated to IPPF was founded in Cameroon 1987. Prior to 1980 the Cameroon government had a pronatalist policy and it was not until February 1980 at the Bafoussam Congress that the government was for the first time called upon by the President to undertake actions to sensitize and educate the population on responsible parenthood, and the need to curb the rising population in Cameroon. A law permitting the sale of contraceptives was enacted in July 1980. In July 1986, during the presentation of the 6th plan of action, the President of Cameroon again called on Cameroonians to consider procreation as a fundamental right but stressing that parenthood should be responsible. In 1989, a Department of Maternal Health and Mental Health was created in the Ministry of Public Health and a national family planning policy was adopted in 1991. Since the creation of the family planning clinic in the central maternity, training of personnel in family planning technology has regularly been carried out by the reproductive health training team of the Department of Obstetrics and Gynecology of the Faculty of Medicine, University of Yaounde.
In the last 15 years the attitude of the Government of Cameroon went from open hostility toward family planning to tolerance under responsible parenthood and to commitment to family planning as a national policy. Most African countries, have followed the same pattern of evolution as Cameroon.
Family planning and level of health care in African countries
At every level of health care of the country we need to identify and train personnel that will ensure family planning care.
First level (Community and Village level)
If the village has a health committee and a traditional birth attendant it would be possible through the help of videotapes to train the traditional birth attendant to offer some modern family planning care as well as traditional birth control methods.
Second Level (Health Centre)
Because there is always a nurse or midwife at this level, many family planning methods could be practised if the personnel is trained. Only permanent contraception and implants cannot be offered at this level in the African context.
Third Level (District Hospital)
At this level in Africa, besides nurses and a midwife there is a physician, a general practitioner. At this level most of the contraceptive methods could be offered. Permanent methods by minilaparotomy could be offered by the general practitioner. Here, as at other levels, training is necessary.
Fourth Level (provincial Hospital / CHU / Reference Hospitals)
All family planning methods can and should be offered at this level. Sterilization can be done both by minilaparotomy and laparoscopy by the doctors and gynecologists at this level. A training and research role in family planning at these levels is of capital importance.
Causes of family planning programme failure in developing countries
The socio-cultural environment of developing countries has to be taken into serious consideration in implementing and managing family planning programmes.
Some of the causes of failure of family planning programmes in developing countries would be:
Constraints to family planning in Africa
In order to achieve the complete goal of family planning in Africa the programme must have the following components:
Factors likely to ameliorate health through family planning in Africa
Edited by Aldo Campana,