In one long 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 more a three-monthly hormone injection to prevent pregnancy. Some looked to condoms or birth control pills, but most wanted something that would last longer.
“They like implants and injections more than anything,” said Ms Nyamekye, a community health nurse. “It relieves them of worry and it’s private. They don’t even have to discuss it with a spouse or partner.”
The hubbub at the Kwapong clinic reverberates across Ghana and much of sub-Saharan Africa, where women have the lowest rate of access to contraception in the world: Just 26 percent of women of reproductive age in the region use a modern method of contraception — a different by the rate or methods of withdrawal — according to the United Nations Population Fund, known as UNFPA, which works on reproductive and maternal health.
But that’s changing as more women have been able to acquire methods that give them a quick, affordable and discreet boost of 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 non-profit reproductive health organization.
Three factors are driving the change. First, more girls and women are educated: they have more knowledge about contraceptives, often through social media that reaches even the most remote corners of the region. And they have higher aspirations, for careers and experiences, that will be easier to fulfill if they delay having children.
Second, the range of contraceptive options available has improved as generic drug manufacturers have brought more affordable hormonal injections and implants to market.
And third, better roads and planning made contraception possible in rural areas like this one, a nine-hour drive from the capital port, Accra, where products were shipped from manufacturers in China and Brazil.
Improved access results in tangible gains for women. At a busy 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 maintain pregnancy them without openly questioning the husbands who want them. they have many children.
It’s also encouraging for younger, single women, who may be overly optimistic about their current partner’s commitment to supporting a child — and may not realize how much a pregnancy could limit their options.
“Your education, your career, even sexual pleasure: having children disturbs,” Ms. Saahene said before ushering another client through the exam room doors.
Across the region, control of access to contraception has largely been taken out of the hands of doctors, despite resistance from doctors’ associations, which worry about the loss of a reliable revenue stream. In many countries, community health workers go door-to-door with birth control pills and give Depo-Provera shots on site. A self-administered injection is increasingly available in corner shops, where young women can purchase one without the risk of judgmental questions from a nurse or doctor.
In Ghana, nurses like Ms Nyamekye are letting women know they have cheap, discreet options. When she passed a roadside beauty salon not long ago, she spoke to women waiting at a wooden counter to have their hair braided. With just a few questions, she sparked a heated debate: One woman said she thought an implant could cause her to gain weight (probably, Ms. Nyamekye agreed), and another said she might drop into the clinic for an injection, forcing her pigtail tease her about the rapid developments with a new boyfriend.
Sub-Saharan Africa has the youngest and fastest growing population in the world. projected to nearly double, to 2.5 billion people, by 2050.
At the Kwapong clinic, there is a room reserved for teenage girls, where movies are played on a large TV and a specially trained nurse is on hand to answer questions from shy teenagers wearing frilled school uniforms. Emanuelle, 15, who said she had recently been sexually active with her first boyfriend, opted for an injection after talking to the nurse. She only planned to tell her best friend. It was a better option than the pill — the only method she knew of before visiting the clinic — because the uncle she lives with can find them and know what they’re for, she said.
A decade ago in Kwapong, the only options Ms Nyamekye had for women were condoms or pills, she said. Or, once a year, MSI came to town with a clinic built into a bus, staffed by midwives, who inserted IUDs into queues of waiting women.
Despite current progress, the UN reports that 19 percent of women of reproductive age in sub-Saharan Africa had an unmet need for contraception in 2022, the latest year for which data is available, meaning they wanted to delay or limit childbearing but did not was using any modern method.
Supply problems also persist. In a recent quarter, the Kwapong clinic ran out of everything but pills and condoms when supplies did not arrive from Accra.
This is a symptom of how difficult it is to find contraception in places like this, in a system in which global health services, governments, pharmaceutical companies and shipping companies often have more say in the contraceptives women can choose from the women themselves.
Most family planning products in Africa are procured 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, at a time when rich nations were trying to control rapidly growing populations in poor countries.
Major global health agencies have invested in expanding access to family planning as a logical adjunct to reducing child mortality and improving girls’ education. But most governments in Africa have left it out of their own budgets, even though it has brought enormous benefits to women’s health, education, economic participation and well-being.
Countries with tight budgets often choose to pay for health services that are considered more essential, such as vaccines, instead of reproductive health, said Dr. Ayman Abdelmohsen, head of the family planning division of UNFPA’s technical department, because they produce more immediate returns.
However, a recent UNFPA push for low-income countries to shoulder more of the cost has led 44 governments to sign on to a new funding model that commits them to annually increase their contributions to reproductive health.
Even so, there was a significant global shortfall of about $95 million last year for the produce market. Donors currently pay for a large share of the output, but their funding for 2022 was almost 15 percent less than in 2019 as the climate crisis, the war in Ukraine and other new priorities shrunk global budgets for health. Support for the programs from governments in Africa has also stagnated as countries struggle with rising food and energy prices.
The good news is that prices for newer contraceptives have fallen dramatically over the past 15 years, thanks in part to promises of massive bulk orders brokered by the Gates Foundation, which bet on the idea that long-acting methods would appeal to many women in sub-Saharan Africa. Hormonal implants made by Bayer and Merck, for example, fell to $8.62 each in 2022, from $18 each in 2010, and sales rose to 10.8 million units from 1.7 million in the same period .
But this price is still a challenge for low-income countries, where total government spending on health each year averages $10 per person. Pills and condoms are more expensive in the long run, but the upfront cost of long-acting products is a barrier.
It’s not enough to get the contraceptives at a clinic: Health workers have to be trained to insert IUDs or implants, and someone has to pay for it, Dr. Abdelmohsen said.
Hormonal IUDs are still rare in Africa and cost more than $10 each. Dr. Anita Zaidi, who leads gender equality work for the Gates Foundation, said the non-profit organization is investing in research and development for new long-acting products and is also looking for manufacturers in developing countries who can make existing ones even cheaper.
The foundation and others are also investing in new efforts to track data — on which companies are making which products, which countries are ordering them and when they will be delivered — to try to make sure clinics don’t run short. They also want to better track which methods African women want and why women who say they want to use contraception don’t. Costs; 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, has been receiving a regular injection for three months. She had her first child while still in school. “When I got pregnant at 17, it wasn’t planned — family planning wasn’t accessible like it is now,” she said. “You had to travel to town and pay: That’s how much money it involved.”
She had to drop out of school when she became pregnant. If she had the choices she has now, her life might look different. “If it was like it is now, I wouldn’t be pregnant,” she said. “I would have moved on in life, I would have studied, I would have been a judge now or a nurse.”
