Birth control in Africa

Africa has the highest maternal death rate, which measures the death rate of women due to pregnancy and childbirth.[37] The maternal mortality ratio in Sub Saharan Africa is 1,006 maternal deaths per 100,000 live births.[38] An article by Baggaley et al. suggests that increasing access to safe abortion would reduce maternal mortality due to unsafe abortions in Ethiopia and Tanzania.[39] Alvergne et al. argue in "Fertility, parental investment, and the early adoption of modern contraception in rural Ethiopia" that an increase in usage of family planning increases birth spacing which consequently decreases infant mortality, although it had no observed effect on overall child mortality, possibly due to a recent overall decrease childhood death rates among both contraception users and nonusers.[10]

Additionally, increasing condom use in Africa would decrease rates of HIV transmission.[40]

According to Gyimah, women who have their first child at a younger age are less likely to finish school and will be more limited to low-paying career options.[9] Research suggests that desire to continue with their education is one of the largest reasons that women use birth control and terminate pregnancies.[41][42] Since birth control is not widely available, beginning a family at a young age is additionally correlated with a higher overall fertility rate.[9] Alvergne suggests that another benefit of longer birth intervals due to contraception use is an increase in parental investment and proportion of resources dedicated to each child.[10] Two of the most prevalent reasons for married women to use birth control are to plan birth spacing and postpone pregnancies to achieve their desired family size.[43]

According to Gyimah, fertility rates are declining in some African countries, particularly Kenya, Botswana, Zimbabwe, and Ghana.[9] The decrease in fertility rates in Ghana is largely attributed to investment in education that has caused an increase in age at first birth and improved job opportunities for women.[9]

Increased use of family planning leads to economic development because women are more likely to work and their children are more likely to be healthy and educated.[44] There is an estimated 140%-600% return on investment in family planning methods due to health care savings and economic development.[11][12] "The Economic Case for Birth Control in Underdeveloped Nations", published in 1967, argues that decreasing the birth rate in countries with high fertility levels is crucial to economic growth and that "one dollar used to slow population growth can be 100 times more effective in raising income per head than one dollar to expand output."[45]

Since the majority of African countries have high fertility rates relative to the rest of the world, it is clear that most African countries have not undergone a demographic transition. In other parts of the world, there is evidence that economic growth increases after a country undergoes demographic transition.[46] This is due to more women working, greater parental investment in children in terms of education and attention, and longer, more productive working life due to health improvements. Although other improvements in public health are necessary to fully undergo a demographic transition, it can not occur without family planning. It is unclear, however, how exactly the demographic transition will affect society in sub-Saharan Africa.[47]

An economic downside to using birth control to limit fertility is the possibility that parents will not having enough successful, living offspring to support them financially in old age. This is a significant concern among parents.[48]

The United Nations created the "Every Woman Every Child" initiative to assess the progress toward meeting women's contraceptive needs and modern family planning services.[13] These initiatives have set their goals in expected increases in the number of users of modern methods because this is a direct indicator that typically increases in response to interventions.[13] The London Summit on Family Planning is attempting to make modern contraceptive services accessible to an additional 120 million women in the world's poorest 69 countries by the year 2020.[13] The summit wants to eradicate discrimination or coercion against girls who seek contraceptives.[13]

One of the Millennium Development Goals is improving maternal health.[14] The maternal mortality ratio in developing regions is 15 times higher than in the developed regions.[14] The maternal health initiative calls for countries to reduce their maternal mortality rate by three quarters by 2015.[14] Eritrea is one of the four African countries on track to achieve Millennium Development Goals,[14] which would be a rate of less than 350 deaths per 100,000 births.

In the traditional northern Ghana society, payment of bridewealth in cows and sheep signifies the wife's obligation to bear children. This deeply ingrained expectation about a woman's duty to reproduce creates apprehension in men that their wife or wives may be unfaithful if they use contraception.[49] Arranged marriages, which generally occur at a young age, limit female autonomy and therefore often result in a culture in which females do not feel in control of their reproductive health.[50] According to a 1987 study by Caldwell, large families are seen as socially favorable and infertility is viewed negatively, causing women to use birth control mainly to increase birth intervals instead of limiting family size.[48] The possibility that women may act independently is also regarded as a threat to the strong patriarchal tradition. Physical abuse and reprisals from the extended family pose substantial threats to women. Violence against women was considered justified by 51% of female and 43% of male respondents if the wife used a contraceptive method without the husband's knowledge.[15] Women feared that their husband's disapproval of family planning could lead to withholding of affection or sex or even divorce.

In areas with communal grazing areas or "tribal tenure," large families are desirable because more children means more productive capability and therefore higher status and more wealth for the father, according to Boserup. Additionally, having more children decreases the mother's workload. However, most people in Africa today live in urban areas or agricultural communities with private land ownership. In these communities, having a family that is larger than one can support is viewed negatively. Private landowners do not need to rely on financial support from children in old age or in crises because they can sell their land. Despite these changes Boserup suggests that large families are still seen as symbols of wealth and higher social status by men.[51]

In the cities of Nairobi and Bungoma in Kenya, major barriers to contraceptive use included lack of agreement on contraceptive use and on reproductive intentions. There were also gaps in knowledge on contraceptive methods, fears from rumors, misconceptions about specific methods, perceived undesirable effects and availability and poor quality of services in the areas studied. About 33% of wives in Nairobi and 50% in Bungoma desired no more children; husbands desired about four or more children than wives wanted.[52] Lack of couple agreement and communication were primary reasons for nonuse. Compared to Ghana, the man is considered the decision maker. The husband has a greater desire for more children, preferably sons, because they are able to provide financial security for their parents.

In other Sub-Saharan African cultures, spousal discussion of sexual matters is discouraged. Friends of family and in-laws are used between partners for them to exchange ideas and issues pertaining to this matter.[53] Couples in these cultures may use other forms of communication — such as specific music, wearing specific waist beads, acting a certain way, and preparing favorite meals — to convey unambiguous sex-related messages to each other.[53] In the case of contraception, a man's use of a contraceptive may itself be a nonverbal indicator of approval.[53] Therefore, discussion may improve knowledge of family planning attitudes only when it is more efficient than, or augments the effectiveness of, other forms of communication.[53]