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Last month, the World Health Organization published “Family planning in sub-Saharan Africa: progress or stagnation?” which compared current data to data from the early 1990s on the readiness, willingness, and ability of women to use modern contraceptives in sub-Saharan Africa. The data describe very different trends in East and West Africa, notably growing popularity and support for family planning in East Africa and a stagnation in the acceptance and use of family planning in West Africa.
Recognizing that there is variation between countries in eastern Africa, the overall trends show:
In West Africa, it is a different story altogether:
From this data, the authors draw several conclusions:
I agree with many of the WHO Bulletin conclusions, and I also think we need to recognize that health workers, who are crucial in the provision of contraceptives and dissemination of contraceptive information, are also part of and reflect communities’ and cultural attitudes towards family planning. While the Bulletin mainly points us to the need to change individuals’ readiness, willingness, and ability to use modern contraceptives, it doesn’t help us understand the many factors at play in an individual client’s attitudes and decisions.
But I know, because I have seen it, that health workers’ attitudes and perceptions can and do affect decisions about family planning.
In 1997, I started training male health providers in family planning services in West Africa. I heard a lot of resistance from those men, who thought that since the nurses and midwives are more familiar with the female clients, the women wouldn’t want to talk to the male health providers. But I told them, “It depends on how they see you. When you return to your facility you need to change your behavior and tell people what you can do for them, advertise your new skills in family planning services, encourage women to come with their husbands so they trust you as a couple, and build trust within community.” But I could tell that for some male providers, this would be a challenge.
Although many countries have national guidelines on the provision of family planning services, it is still the case that too many health providers make it more difficult than it needs to be for people to get the family planning services they need and want. There is not enough research into how health worker behavior and attitudes do or could affect clients’ attitudes and decisions. Based on some existing research and anecdotally accounts, some of the negative behaviors I have heard about are:
Since it is often difficult for some women to get to a health center or clinic, these provider and manager practices may cause women to delay visits or forgo them altogether. The next visit to a health facility they make may be to the labor ward. It is an all too common problem.
Coming from an organization dedicated to supporting health workers, it is important that we recognize that health workers are often a part of the communities and cultures in which they work. They, too, carry with them cultural understandings about the importance and role of family planning in people’s lives. We need to have a better and more systematic understanding of provider practices around family planning so we can design better training for providers, better supportive supervision, and better management that maximizes and encourage fair client access to family planning services.
Health workers may be a part of the problem, but they are also potential change agents in communities and are crucial to starting and continuing conversations with women, men, and couples about family planning.
This entry was also featured in the Maternal Health Task Force blog.
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