Misinformation as a barrier to family-planning use
Monday, July 19th, 2010In this article, Sirina Keesara discusses the issue of misinformation as a barrier to use of family planning and slowing of population growth in Ghana.
From the invention of the birth control pill in 1960, and the subsequent proliferation of family planning programmes, access to contraception has expanded incredibly (1). Knowledge of at least one method of contraception is now nearly universal in almost all areas of the world, with pills, injectables, and male condoms as the most cited examples (2). Unfortunately, this improvement in knowledge has not been accompanied by an increase in contraceptive use. Use is especially low in Sub-Saharan Africa (2). The juxtaposition of these two findings seems to indicate that people who know about contraception don’t want to use it, probably because they want more children. However, this conclusion is inconsistent with the finding that more than 137 million women throughout the developing world do not want another child but are not using anything to prevent pregnancy (3). So why aren’t they using contraception if they know about contraception, but do not want to continue growing their families?
Researchers who have worked on this question for the past half century, have created a theory of fertility behaviour that attributes this gap in knowledge and practice to factors such as cultural traditions, low education rate, high mortality rate, and lack of women’s autonomy (4). The video at girleffect.org is one of the best popular culture products of this accepted theory. Using only animated words the video conveys a simple and powerful message: empower girls, change the world. At the start of the video, we see the word “girl” associated with the burdens of “child”, “husband,” “HIV”, and “hunger.” Then, with the introduction of “education”, all the burdens fall off, the music changes from gloomy to hopeful and the video rushes full force into the solution of education, micro-loans, and opportunity for girls to fix the world. The viewer is so elated by an elegant solution to complex problems, that many don’t notice one key omission: the family planning factor.
Rewind and click pause to the point when all the burdens fall off. How exactly are these burdens supposed to magically fall away? Giving a girl education prevents babies? No, not directly- only a condom or a set of pills (or any other form of contraception) can do that. Well, a girl will be able to obtain contraception if she has the opportunity for an education and a career… correct? Not necesarily!
The key, but faulty, assumption here is that women and couples will rationally weigh the costs (money or education lost, time that could be spent working, effort) and benefits of having a child and then will take necessary precautions to prevent any unwanted pregnancies (5). The first problem with this assumption is that, many times, children do not come as a product of rational decisions, but rather as a product of the passion of one moment. Therefore, because we have sex for reasons other than reproduction, we will produce babies without consistent contraceptive use. The second problem with the cost-benefit rationale is that it sets the cost of obtaining and using contraceptives very low. However, barriers to contraceptives are far greater than cost and distance to a family planning clinic. As revealed by interviews I conducted in Ghana, we have been successful in giving couples access to family planning, but we have failed to address other less tangible barriers.
Among the wide variety of barriers that exist in the field (6) many programmes have done little to explore or address issues such as misinformation surrounding contraceptives. Through interviews I conducted with women in Ghana, where the unmet need is s among the highest in the world at 34% (7), I found that the key element which holds women back from using contraception is misinformation; rumors, myths, and other pieces of faulty information prevent women, and especially young girls, from using contraception. If they believed that birth control will harm their body, health, or future fertility, they would not use it, even if a pack is placed directly into their hands. For example, the following woman working in a marketplace in the capital city, Accra said:
Sirina: you are afraid of the medicine. Okay, but what do you think will happen if you take it?
Woman: It will disturb you. Because if they say that if you use the medicine, it will destroy the womb. Because I am afraid of not having birth. If you don’t have birth, you won’t feel well in your self
Sirina: you don’t feel well as a woman.
Woman: yes! you are not feeling well. Some of them, they insult you if you don’t have births
Some even believed that abortion was safer than contraceptive pills because “it happened only once”, whereas contraception stifled fertility for an extended time. Abortions in Ghana, though legal, are highly restricted and largely unsafe.
Contrastingly, when the fear of infertility was taken away, many women jumped at the possibility to use family planning and limit their fertility. For example, one woman, who had thirteen children, was adamantly against the use of family planning because it went against God’s will. However, when she was asked, “would you use family planning if you were sure it was safe and it wouldn’t endanger your fertility?,” she answered: “oh of course.” This response was astounding because she seemed to have abandoned her religious reasons within a matter of seconds. When this question was included in all the subsequent interviews, the answer was almost always an emphatic “Yes!”
Furthermore, I found that women are badly in need of a method to control their fertility. One women was pregnant with her fifth child and had decided that she was going to take the “risk” of using family planning because she was so desparate to stop having children:
Interpreter: Well, she knew someone who had a problem with the family planning and they were trying to discourage her from it.
Sirina: But then why did she end up using it? I don’t understand why she would go for it.
I: That’s what I said that she wanted to give it a try and take the risk.
S: but if she took the risk she might not have been able to have babies again?
I: And she would have blamed herself for that. But she didn’t mind, she wanted to do it because she didn’t want any more [babies].
This widely found “intangible barrier” of misinformation meant that women had an ingrained belief that family planning was bad for fertility, and this belief played a large role in women’s reluctance to use it even when they wanted to control their fertility. Furthermore, it seems that when misinformation is removed women will act on their desire to have fewer children and will make a quick reversal of attitudes towards family planning. This can happen even without improvement in formal education or socioeconomic status. Other intangible barriers have a similar effect on women. For example, fear of maltreatment in clinics is potentially a huge hurdle. Despite Ghana’s Ministry of Health’s effort to train nurses and create youth-friendly clinics, these clinics are few and far between. For example, when I worked in a Family Planning Clinic, I witnessed the nurses “counselling” (scolding) a young client who wasn’t married before “getting into those things”. The girl was then forced to change her preferred method of contraception from the injection to the pill, because according to the nurse, that injection could make her sterile (it can’t), and she was sent away thoroughly embarrassed (8). Therefore, we can see that intangible barriers can be as significant or more than physicial availability of contraceptives.
Although intangible barriers are elusive to tackle, they are not insurmountable. For example, Iran, Bangladesh, and Thailand have all been able to ensure access to contraception for many women through community based distribution systems (10). In Iran, the increased governmental attention to family planning access and sexual education dropped the fertility levels (9) from 6.0 children/woman over her lifetime in the 1970s to 4.3 in the 1990s and then 2.1 in 2005 (10) – and inside a traditional culture. Case studies such as these raise questions about the validity of the accepted fertility behaviour theory; they show that fertility levels can drop and population growth can slow without improvement of other socio-economic variables. Therefore, it seems to imply that some factor, other than development, must influence fertility behaviours.
A newer theory of fertility decline, the opportunity model (11), says that women and couples will use contraception if they understand fertility regulation is an imaginable possibility. That is, if they believe they can use contraception without harmful side effects, they will want to use it and demand its availability! Think about it this way, before the internet we didn’t demand a connected web of information through which we could communicate almost instaneously. This demand was created by making such technology an imaginable possibility. Now that it is in our realm of possibility, almost nobody can live without it. In the early years of the internet, skeptics claimed that people would have to learn too many new skills to make use of it. However, Marc Andreesen, the creator of the first browser, replied “People will change their habits quickly when there is a strong reason to do so, and people have the innate urge to connect with other people- when you give them a new way to connect with other people, they will find it objectionable not to be able to”(12). Similarly, many academics have said that people would not adopt family planning because it would require too much behaviour change. However, I would argue that family planning opens doors to new options for women, and when they have access to contraceptive methods, along with correct information backed up with safe abortion, they will find it objectionable not be able to control their family size. In our work studying fertility preference and behaviours in Ghana, this pattern was clear; it seemed that women who learned that family planning was safe and easy to use, in other words who believed family planning was an imaginable possibility, would demand it and start to use it. Considering this theory we assume that the number quoted for unmet need is grossly underestimated because women with many intangible barriers may not realise that they have an option to control their fertility and thus may not express this desire.
This sheds new light on why family planning programmes in the past have not been as successful as expected. We need to redefine the way we think about barriers and tailor programmes to address these issues. If we are able to do this, we will be able to give women control over their own fertility, and by doing so slow rapid population growth. We cannot afford to ignore rapid population growth as this sole factor can ruin all our plans for the Millenium Development Goals and exhaust our world’s resources (13). If we ignore this issue, we are ignoring women’s rights and the rights of the future generations to come. We should encourage the international community to re-direct their attention towards family planning and understand its relevance in the underlying issues of health and development.
Sirina Keesara
Sirina.Keesara(a)ucsf.edu
References
1. Robinson WC; Ross JA. The global family planning revolution: three decades of population policies and programs. Washington, D.C., World Bank, 2007
2. Khan, Shane, Vinod Mishra, Fred Arnold, and Noureddine Abderrahim. Contraceptive Trends in Developing Countries. Calverton, Maryland, USA: Macro International Inc. 2007. DHS Comparative Reports No. 16.
3. Sedgh, Gilda et al. Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. New York: Alan Guttmacher Institute, 2007: Occasional Report No. 37. Accessible at http://www.guttmacher.org/pubs/2007/07/09/or37.pdf
4. Notestein F.W. Economic problems of population change. Proceedings of the Eighth International Conference of Agricultural Economists. London, Oxford University Press. 1953
5. In Gary Becker’s Nobel Prize winning book, Treatise on the Family, he uses economic principles to explain decisions and actions that pertain to the dynamics of the family. He includes on chapter about the Demand for Children in which he terms children as a high cost commodity and explains childbearing as a parent’s rational decisions about their “consumption” of children. ( cite his book)
6. Campbell, M.M. Sahin-Hodoglugil N. & Potts, M. Barriers to Fertility Regulation: A Review of the Literature. Studies in Family Planning, 2006: 37, 87-98
7. Gribble, Jay. Family Planning in Ghana, Burkina Faso, and Mali. Population Reference Bureau. April 2008. access on December 30th, 2009 at http://www.prb.org/Articles/2008/westafricafamilyplanning2.aspx
8. Keesara, Sirina. Barriers to Fertility Regulation for Ghanaian Women. Presentation at 137th annual APHA conference. Accessible at: http://apha.confex.com/apha/137am/webprogram/Session27587.html
9. Fertility levels are measured by Total Fertility Rate (TFR), the number of children that a woman (women, or a woman – hjave or has) would have in her /or their lifetime if fertility rates are constant. Replacement lvel fertility, in which each woman has the number children only replace the population is 2.1.
10. Gubaju, Bhakta, GUBAJU, BHAKTA. Fertility Decline in Asia: Opportunities and Challenges The Japanese Journal of Population. March 2007; 5:1
11. Campbell M, Bedford K.The theoretical and political framing of the population factor in development Phil. Trans. R. Soc. B 2009 364, 3101-3113.
12. Friedman, Thomas. Chapter 2. The World is Flat: A Brief History of the Twenty-First Century.
13. All Parliamentary Group on Population Development and Reproductive Health, “Return of the population Growth Factor: Its Impact on the Millenium Development Goals” (HMSO, London, 2007). www.appg.popdevrh.org.uk Accessed on December 27th 2009












The entrance of the open clinic in Tel-Aviv
Iman Aghbariyya during her work in the open clinic


