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:

• The demand for contraception has risen sharply.
• Women have more positive attitudes towards contraceptives and report having better access to them.
• Every year since the 1970s, a greater percentage of the population uses contraceptives.

In West Africa, it is a different story altogether:

• Demand for contraceptives is low and remains virtually unchanged in the last ten years: fewer than half of married or cohabiting women express that they need or want family planning services.
• The approval of family planning also remains low.
• Many women are still unfamiliar with family planning methods, cannot name two contraceptive methods, and do not know where to get contraceptives.

From this data, the authors draw several conclusions:

• Contraceptive services need to be more widely available to encourage continuing growth in their use.
• Countries need to invest more in family planning, including in public campaigns that educate people about family planning and make its use more accepted and popular.
• Family planning should be a political priority, and strong local leadership can effectively promote small family size and family planning as acceptable.
• Offering girls more opportunities in school is crucial to changing societal attitudes and enabling girls and women to make informed decisions about childbearing.

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:

• Unfounded restrictions. For example, too often health providers tell married women they cannot have access to family planning methods or that they must have spousal approval first. Some providers will make judgments about young clients seeking family planning and mislead young women, particularly those who are unmarried, by telling them there are age restrictions on obtaining contraceptives.
• Judgments on parity. Some providers promote the false idea that there are a minimum number of children a woman must have before she can have access to injectable contraceptives. Some of these health providers also wrongly believe that injectables delay fertility, cause infertility, and are unsafe for women living with HIV/AIDS.
• Unnecessary examinations, requiring lab work without cause or symptoms, and/or requiring too many follow-up visits. For example, instead of giving women several packs of oral contraceptives at once, providers may ask patients to come back once a month to receive subsequent doses or require women with IUDs to come for follow-up visits every three months instead of the necessary once-a-year visit.
• Viewing family planning as only a primary health service and failing to make it available in the delivery room and in obstetric emergency treatment rooms in hospitals. Even when family planning services are made available in hospitals, too often the services and commodities are not closely linked or in the same room or clinic as other care, which leads to unnecessary referrals and unwanted pregnancies.
• Provider convenience. Some providers recommend family planning methods that are easier and faster for them to provide, rather than finding out what method the client is considering or what method the client is likely to continue using.

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.