By Kate Okorie
“In these hard times, nobody wants to have as many as twelve children anymore,” said Chika Ugochukwu, the founder and director of UC Golden Maternity Home, speaking in her office as her waiting room filled with women, many of them expectant mothers.
Outside, on a wet Thursday morning in Aba, Southern Nigeria, it was raining heavily again, as it had all week. Despite the rain, the crowd of expectant mothers in the reception room of Ugochukwu’s antenatal clinic continued to grow ahead of the morning’s antenatal class. The buzz in the reception room was audible, and the sounds from a TV in one corner added to the liveliness.
From the models on Ugochukwu’s desk, it was very clear that the upcoming class would not only be about the care of infants. It would also be about the health of the mothers after childbirth.
“Women who have chosen to use contraceptives testify that they have more time to care for themselves and their children,” explained Ugochukwu. The maternal health specialist started adding family planning to her courses after it became apparent to her that the post-partum health of a mother and a baby is heavily dependent on the mother’s sexual health.
“Before offering family planning services, I encountered instances where women who had undergone cesarean sections returned pregnant within four months. I was aware of the health risks for both mother and child, but I could not provide substantial help beyond counselling. Presently, for women undergoing surgical delivery, I provide the option of a postpartum contraceptive device as a precaution,” she explained.
Ugochukwu now counsels women to allow at least a two-year gap between consecutive births – a standard set by the WHO to ensure positive maternal and child health outcomes.
In Nigeria, 23.9% of married women aged 15 to 49 have what is referred to in the sector as an “unmet need” for family planning. This number more than doubles to 51% for unmarried women.
An unmet need for family planning refers to women of reproductive age who are sexually active and seeking to delay or stop childbearing but don’t have access to or are not using, any form of contraception.
Modern contraceptives are widely acknowledged as one of the most effective ways to reduce the risk of unintended pregnancies and promote positive health outcomes for mother and child.
However, for many women in Aba, a commercial hub in eastern Nigeria, the primary motivation behind embracing family planning is the economic benefit of having fewer children than they might have had without the help of contraceptives.
“Considering the current state of Nigeria’s economy, it’s wiser to manage childbirth,” said Rose Erondu, one of the women attending the session, alluding to the country’s recent inflation rate, the highest it has been in over a decade.
“My second child was just nine months old when I found out I was pregnant with the third,” Erondu revealed.
This was a watershed moment for Erondu and her husband. Neither of them had been prepared to welcome another child at that time.
Six weeks after giving birth to her third child at Ugochukwu’s clinic, Erondu returned to have a contraceptive implant inserted into her left arm. Ugochukwu had informed her about the procedure at the time she was pregnant.
The contraceptive device helped Erondu achieve a five-year gap before her subsequent pregnancy in 2017. Right now, she has no intention of becoming pregnant again and will continue to renew the implant.
“If I hadn’t opted for family planning, meeting the demands of my job would have been quite challenging,” Erondu remarked.
She has gone from being a secretary to heading a department in the private tertiary institution where she works.
Ugochukwu provides a wide range of health services to women and children within the community, including family planning.
Ugochukwu first introduced family planning to her antenatal clinic activities in 2012 after attending a training event organised by the Society for Family Health. Since then, she has provided family planning services to more than 5,000 women.
The Society for Family Health or SFH, a Nigerian NGO, collaborates with healthcare providers at various levels of society to make family planning services more accessible. They also train and supply these providers with contraceptive commodities to distribute within their communities.
According to UNICEF, one of the threats to the health and development of a child under the age of two is the birth of a sibling. That’s because the mother will have less time – and resources – to provide the necessary care to the newborn. In 2021, Nigeria recorded an infant mortality rate of 70.59 deaths per 1,000 live births, almost three times the global average at the time.
“If a woman gets pregnant without sufficient spacing, it affects the child’s health. We’ve observed this during post-natal visits,” said Chidimma Okoro, a nurse practising for 30 years.
Okoro learned the ropes of administering modern contraceptive devices from Ugochukwu, in 2018, and since then has regularly assisted her in the clinic.
Ugochukwu is often invited to SFH’s family planning seminars in order to get up to date on the latest family planning methods. Through the training sessions, she has become proficient in administering modern contraceptive methods such as injectables, implants, and intrauterine devices (IUDs) – information she then passes on to Okoro and other healthcare providers in Aba.
“Sometimes, when attending to a patient, she invites me to observe. And when I have to perform a procedure for the first time, she stays around to guide me,” Okoro explained.
However, Ugochukwu cannot provide individual lessons to everyone. To educate more providers, she organises training during the monthly meetings of the Association of General Private Nursing Practitioners (AGPNP) in Aba. She had previously served as the association’s chairperson.
The nurses are not the sole beneficiaries of Ugochukwu’s frequent training sessions.
“I also train the IPCAs [Inter-personal Communication Agents] who go to public places to sensitise locals about family planning,” Ugochukwu shared.
IPCAs are usually members of the community they serve.
Ugochukwu estimates that there are about ten IPCAs within Aba. They go to markets, churches, and even television and radio stations to educate the public about family planning.
“We are the foot soldiers,” remarked Oluchi Benson, who has worked as an IPCA for six years.
Benson conducts community outreach thrice a week, engaging with at least 15 women each day.
Benson’s motivation stems from the rising maternal mortality rate in the country. A recent report from the Integrated African Health Observatory revealed that between 2017 and 2020, the maternal mortality rate in Nigeria increased by 14% to reach 1,047 deaths per 100,000 births.
The role of IPCAs in promoting family planning in a bustling city like Aba is not without challenges. In 2018, Favour Achu, another IPCA, was confronted by a group of six women who believed that childbirth should not be restricted.
“In those days, women used to have as many children as they wanted, and they were still healthy,” the women argued, according to Achu.
It was a heated confrontation, but Achu succeeded in changing the minds of four of the women and directed them to clinics that offered family planning services.
“We use the OARS strategy to guide our conversations with the locals,” Benson disclosed.
The OARS model, representing open-ended questions, affirmations, reflections, and summaries, is a communication approach used in counselling to build rapport.
Lillian Nwankwo, a 35-year-old mother of four, adopted a contraceptive method after encountering Benson in 2020. Due to misconceptions about family planning rife within the community, Nwankwo was initially hesitant.
The locals in the community have different accounts of these myths and misconceptions. However, most misconceptions associate family planning with female infertility, heavy bleeding and pregnancy loss.
“People who believe in reincarnation claim that women using contraceptives won’t bear children in their next life,” Ugochukwu said.
However, Nwankwo was well aware that her family’s modest income from her food vending business and her husband’s earnings as a driver would be strained if they were to have more children.
“People around me held biased opinions about family planning, but I believed it would be different for me,” Nwankwo remarked.
She is now seated at the clinic’s reception, patiently waiting for her turn to consult with Ugochukwu regarding new implants. The first one she received three years ago has now expired.
Initially, the clinic offered these implants free of charge, but patients are now required to pay between 3,000 naira ($3.94) and 7,000 naira ($9.18) for them, based on the brand.
Ugochukwu shared that she charges nominal fees for providing family planning services.
“Sometimes 500 naira [$0.66] or 1000 naira [$1.33], depending on the type of contraceptive device,” she revealed.
Additionally, contraceptives at the clinic are heavily subsidised and occasionally provided for free, thanks to support from organisations like SFH.
“Here, it is the poor people who end up having more children than they can afford. To reach them, we have to make these services affordable,” Ugochukwu added.
However, affordability is not the sole criterion for placing a patient on contraceptives.
“After counselling patients on different family planning methods, we conduct eligibility tests. If a patient isn’t eligible for a specific method, we can’t offer it,” Ugochukwu explained.
An unsupportive husband can also hinder a woman’s adoption of a modern contraceptive.
“If the husband is not on board, it can affect a woman’s family planning goals,” Ugochukwu said.
Okoro has leveraged her relationships with men in the community to change their views on family planning.
“If I find that the husband is the obstacle, I approach him to explain how family planning can benefit him as well,” she said.
Among the many advantages she emphasises is that fewer children can reduce the financial pressure on them in their role as their families’ breadwinners.
Sometimes, even the woman is not open to adopting modern contraceptive methods.
“I’ve heard about family planning, but people say it can cause bleeding and infertility. Since I don’t understand how it works, I haven’t used it,” admitted Chinenye John-Bosco. Formerly a mother of five, John-Bosco now has four children. One died at a young age.
She said she was now reconsidering her stance after an unintended pregnancy.
“I have no plans for another child at this time, especially since the immediate older sibling is barely two years old,” she revealed.
John-Bosco had to frequently take short breaks to check on her newborn, whom she said she hoped would be her last child.
Their limited knowledge of, and access to, modern contraceptive methods has led women like John-Bosco to rely on traditional family planning methods. In developing countries, women who use traditional methods, such as the rhythm or withdrawal method, face nearly three times the risk of unplanned pregnancies compared to those using modern contraceptives.
John-Bosco has learned from her own experience and said she hoped others would not have to face a similar situation. Spacing out births, she said, would give women more time to establish businesses and support their families financially.
Oluomachi Friday, a 29-year-old seamstress and first-time mother, said she was eager to start using a modern contraceptive method.
“As a sole proprietor, frequent pregnancies will cause me stress and negatively impact my work,” she said.
She further explained that failing to meet her customers’ demands would reflect poorly on her business and could result in the loss of their patronage.
Friday said she planned to consult with Ugochukwu to identify the most suitable contraceptive method for her.
Despite not yet achieving its goal of a 27% modern contraceptive prevalence rate among all women by 2020, Nigeria has witnessed an 8.5% improvement in the adoption of modern contraceptive methods from 1990 to 2018.
“The progress we’ve seen is because of the increase in public awareness, donor funding and political will to support family planning projects,” said Dr Eze Nwokoma, Programme Coordinator of the Reproductive Health/Family Planning Unit at SFH.
He also acknowledged that the economic benefits linked to contraception may have contributed to its adoption in commercial centres like Aba.
To address unmet family planning needs and enhance the uptake of modern contraceptive methods, Nwokoma stressed the importance of creating demand, mobilising communities, and building the capacity of healthcare providers. That way, providers like Ugochukwu would be better supported in their efforts to offer various family planning methods to meet growing demand.
bird story agency