In western Africa, progress in promoting women's readiness to use contraceptive methods, and in increasing their actual use of these methods, has been "dismally slow," according to the authors of a new analysis of Demographic and Health Survey (DHS) data for 1986–2007.¹ In countries where at least two surveys were conducted during that span, the median proportion of fertile, married or cohabiting women who wanted to postpone or cease childbearing was almost identical in the earliest (46%) and latest surveys (47%). ?Although the median proportion of these women who were using modern contraceptives rose from 7% to 15%, the rate of increase (0.6 percentage points annually) has been slow. Progress has been more substantial in eastern Africa, however: The median proportion wishing to postpone or cease childbearing has risen from 56% to 72%, and the median proportion using a modern method has increased from 16% to 33%, or 1.4 percentage points annually.

To examine trends in family planning uptake in Sub-Saharan Africa, the researchers analyzed data from the 24 countries that had conducted two or more DHS surveys between 1986 and 2007, including 13 in western Africa (Benin, Burkina Faso, Côte d'Ivoire, Cameroon, Ghana, Guinea, Liberia, Mali, Nigeria, Niger, Senegal, Chad and Togo) and 11 in eastern Africa (Ethiopia, Kenya, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe). In western Africa, the median year of the earliest survey for each country was 1991; in eastern Africa, it was 1992. In both areas, the median year of the latest survey was 2004. The researchers examined trends in family-planning–related measures among nonpregnant, fertile women who were married or cohabiting; in assessments of contraceptive use, they excluded women who had had a recent birth but had not yet resumed sexual activity and menstruation.

The analyses focused on four measures. To examine readiness to use contraceptives, the researchers calculated the proportion of women who wished to postpone or cease childbearing. Next, women were classified as willing to use contraceptives if they approved of family planning and they believed their partner approved as well. The third measure, ability to use contraceptives, was examined only among nonusers; it assessed the proportion of women who were familiar with both the pill and the injectable (the two most commonly used methods among married African women) and who knew where to obtain a contraceptive method. The final measure was current use of any modern method. In examining trends for these measures, the investigators adjusted the data for demographic changes during the study period that may have affected contraceptive attitudes and use, such as educational attainment, urban residence and (for the childbearing intentions measure) number of living children and time since most recent birth.

In western Africa, the median proportion of women who wanted to postpone or cease childbearing barely changed between the earliest (46%) and latest (47%) surveys. In contrast, a substantial increase—from 56% to 72%—occurred in eastern Africa; most of this change stemmed from a rise in the proportion of women who wanted to stop (rather than delay) childbearing. Mozambique was an exception to the high proportions seen in eastern Africa: Only 48% of women wished to cease or postpone having children.

Similarly, the change in the median proportion of women who said that both they and their partner approved of family planning was substantially greater in eastern Africa (from 44% to 63%) than in western Africa (from 32% to 39%). Moreover, the range of proportions across countries was much smaller in eastern than western Africa, suggesting greater consistency in attitudes in the former region. In both eastern and western Africa, women were substantially more likely to say that they approved of family planning than to say that their partner approved.

In western Africa, the median proportion of contraceptive nonusers who said they were familiar with both the pill and the injectable and knew where to obtain a method rose from 8% to 29%, although the latter figure is still "shockingly low," according to the investigators. Once again, the proportions were substantially higher in eastern Africa in both the earliest (32%) and latest (64%) surveys.

Finally, among women at risk of pregnancy, the median proportion who were using contraceptives rose from 7% to 15% in western Africa, equivalent to an increase of 0.6 percentage points annually; in eastern Africa, the median proportion increased from 16% to 33%, or 1.4 percentage points per year. Data from the 16 countries in which three or four DHS surveys had been conducted during the study period revealed that in both regions, the rate of increase in contraceptive use was greater during the 1990s (0.7–2.7 points annually) than during the 2000s (0.6–1.5 points annually).

The researchers note that although their measures of contraceptive attitudes were relatively simplistic, the findings suggest that approval and use of contraceptives remains low in western Africa. At the current rate of contraceptive adoption, fertility in the region will decline far less than the United Nations has projected, and population growth will greatly exceed predicted levels (western Africa's population is currently projected to grow from 270 million to 626 million between 2005 and 2050). In eastern Africa, the researchers note, "the prospects for a future decline in fertility are much more positive." They contend that two factors may explain a substantial proportion of the differences in contraceptive attitudes and behavior between the two regions. First, the findings from this study regarding awareness of where to obtain contraceptives suggest that countries in western Africa have not made as strong an effort as their counterparts in eastern Africa to make family planning widely available. Second, educational attainment among young women—a strong predictor of contraceptive use—increased to a much greater extent in eastern than western Africa during the study period. Thus, the investigators suggest that to "reverse stagnation in the use of modern family planning methods in most of western Africa and in some eastern African countries, contraceptive services need to be made more accessible" and "schooling opportunities for girls need to be greatly improved."

—P. Doskoch

REFERENCE

1. Cleland JG, Ndugwa RP and Zulu EM, Family planning in sub-Saharan Africa: progress or stagnation? Bulletin of the World Health Organization, 2011, 89(2): 137–143.