Planning Healthy Ghanaian People
"People need to know more about family planning holistically,” said Emmanuel Boadi, Program Manager at Pathfinder International, a US-based NGO that does extensive work in the areas of family planning and reproductive sexual health in Ghana, in an interview with The Statesman. He added that the general perception of family planning is still related to population control.
“But it's not about stopping giving birth,” he said. “A young married couple may not yet be ready for children. They must decide together on the number of children they can afford to look after, and when they want to have them.”
He added that spacing is important because research has shown that “if the birth interval is too close it is unhealthy for the woman and child.” A minimum of two years between children is recommended, and three years is preferred.
Challenges in the new age of family planning and sexual reproductive health
Mr Boadi is an example of a new generation of family planner, one more interested in the health of families than population statistics. Since 1994, Ghana and much of the developing world has attempted to broaden the thrust of its family planning activities, beyond simple population control, to incorporate holistic family-oriented goals of total health. As one reproductive health expert put it, “With a maternal health approach policy makers are becoming more open, looking at a woman and her health rather than a demographic or economic argument.”
Yet, despite enormous accomplishments in decreasing birthrates and increasing the use of contraceptives, there is still a long way to go for Ghana. For example, there are grave disparities between regions, between city-dwellers and farmers, and between well educated wealthy women and their less privileged counterparts in terms of the use of modern birth control.
According to a recent USAID report on Ghana, “Unmet need remains high and women continue to have more children than they desire…there are important issues of inequity in the improvements in terms of bringing services to the poor and to the whole nation.” Unmet need is highest among young women, women in the countryside, women without secondary education, and poor women. The report explains that “fear of opposition and punishment has thus led to women using modern contraceptives in secret.”
It is not that women in rural areas don"t desire birth control. There remains a serious and growing unmet need in the countryside, and budgets for hospitals, doctors and nurses continue to grow for wealthier regions and sink for those with the greatest needs.
Women in the city have better access to contraceptives and family planning services, and are motivated to take them by cramped housing conditions and higher rates of workforce participation there.
Because of the lack of access to contraceptives and the legal and stigma issues around professional induced abortion, thousands of Ghanaian women die every year from botched abortions. When a woman does give birth, infant mortality rates are high and may actually be back on the rise.
Sexually transmitted diseases also remain a serious issue, and a difficult one to gauge the scale of. While the official AIDS rate is on the decrease, most Ghanaians do not know their status so the real rate is likely much higher.
Despite the move toward holism in family planning, on the ground there has been little in the way of integrating family planning and sexual health services other than advocacy for condoms, which provide the dual function of preventing disease transmission and pregnancy.
With the spread of HIV/AIDS and an increased focus on this one deadly disease, particularly since the advent of Millennium Development Goals that have no specific family planning targets, there has been less focus on other sexually transmitted infections, and there is a complete lack of national data on these. Even localized data is difficult to come by; it is collected at individual facility levels but not collaborated, analysed or reported. As a result, experts are unable to judge the extent of the SDI problem in Ghana.
On a more fundamental level, the problem of dependency on foreign aid persists. USAID provides a stark example of the danger of letting other countries control Ghana’s families. When the Bush administration tied family planning aid to the condition that no mention can be made of abortion, the Planned Parenthood Association of Ghana had its funding cut. According to a 2005 USAID report, its actions “certainly had a negative effect on family planning coverage in Ghana…more than half of PPAG’s 192 staff members were laid off, and more than 1,000 volunteers were without the structure that kept them motivated and supplied.”
Currently, most of Ghana’s family planning and sexual reproductive health spending comes from USAID, various UN departments, the UK Department for International Development, the World Bank, and Danida (from Denmark).
Ghana’s new strategy
The focus on population control has not been abandoned in Ghana, just expanded upon, with a shift in strategy. The population policy still targets a birthrate of 3.0 by 2020 (down from the current 4.4. births per woman), with a modern contraceptive usage rate of 50 percent of married women.
However, the broader goals of achieving healthy women, children, and families across the country has entailed a recognition of the importance of empowering women to take control of their lives and be leaders in their families. According to USAID, “Reflecting international trends and development priorities, the issue of gender equity has gathered significant momentum in Ghana over the past decade.”
To this effect, a minimum age of marriage of 18 years was enacted in 1998, and the Ministry of Women and Children’s Affairs was created in 2001. Government has made efforts to “increase female enrolments and completion rates at all levels in the educational system.” The goal is to raise stronger, more informed women who can take charge of their reproductive health as well as other issues affecting them.
These changes have recognised the need of women to be able to make decisions about their fertility and experience safe motherhood. This involves not only choosing when to start having children, but also how many and when. Experts now agree that a minimum of two years between births, and preferably three years, is optimal for the health of mother and child.
More recently, Ghanaian family planners have come to realise the importance of involving men in reproductive health. Men are still the main decision makers in most Ghanaian families and communities, so if men are unsupportive of family planning all that women learn is ineffective.
The effort to include men must also reach out to traditional leaders and lineage heads. Family planners are beginning to recognize the need to listen to, and be responsive to, the needs identified by communities, and this is usually done through chiefs and their interpreters.
Family planning service, to be effective, cannot follow the same model for every community. Approaches must be adapted to local realities and needs. Training approaches need to involve both health workers and community members.
Current thinking among some major donors also recognizes that resources need to be “controlled by local groups…small, external resources are therefore needed as incentives for community action rather than as replacements for it.” In other words, outsiders can provide assistance and guidance, but control of family planning must be placed into competent local hands.
Adolescent Sexual Reproductive Health
A further challenge is that both parents, and local leaders, can buy into the concept of family planning and sexual reproductive health, only to see their teenage girls suffer unwanted pregnancies or, in some cases, damaging illegal abortions. “Family planning was designed for couples in the 60s,” explained Mr Boadi; it did not take into account the reality that teenagers are at a very high risk for sexually transmitted infections and unwanted pregnancies.
With more than half of the country’s population under the age of 24, NGOs like the Planned Parenthood Association of Ghana and Pathfinder International have decided to focus on this previously neglected segment to help alleviate this common scenario.
Government has cooperated, creating the Adolescent Health and Development Programme, and introducing family life education into school curriculum.
Mr Boadi noted that a great deal of moral reservations among adults had to be overcome in order to reach youth with family planning and reproductive sexual health education. This work was done mainly in partnership with Christian and Moslem leadership using verse from the Bible and the Koran to support family planning. UNFP has been quoting the Koran that there is no prohibition on family planning, that it does not contradict the ways of Islam.
Pathfinder has been working on family planning issues in Ghana since the 1960s, at first by funding other NGOs and more directly since 2001. With funding from the Bill & Melinda Gates Foundation, Pathfinder has been heavily focused on sexual reproductive health for youth aged 10-24 years, especially 15-24, in partnership with PATH (Program for Appropriate Technology and Health), and UNFP.
UNFP has taken on the role of advocacy and coordination to create an enabling environment for youth-focused sexual reproductive health activities, policies, and legislation. This involved convincing Government, traditional leaders, community leaders, district officials, and health workers to accept the need for young people to have access to these services.
PATH followed UNFP’s advocacy with behavioral change communication, raising awareness and generating demand for family planning and sexual health services among youth. In this role PATH has worked with vocational and basic schools to integrate sexual reproductive health, including assertiveness and the ability to say no to sex and planning for the future, into the curriculum.
“Once they know this they stay away from unprotected sex, pregnancy, and disease,” Mr Boadi explained.
Pathfinder has taken the role of trying to build the capacity of organizations working with young people to provide sexual reproductive health services. This includes training health workers and NGO staff in good governance, data collection, management information systems, proposal development skills, and efficient and transparent accounting systems.
In some cases Pathfinder has responded to identified specific needs such as for computers, strategic planning, and other professional skills. The NGO has also directly trained youth from church groups and other youth organizations. “They must take it upon themselves as future leaders of this country,” Boadi said.
In all of these varied activities, the emphasis is on providing youth-friendly services, including facilities that attract people on a continuous basis to access sexual reproductive health services. “It is very difficult for youth to go for these services when a problem arises,” Mr Boadi explained.
He said that in the past the attitude of services providers toward youth was very negative. “They would say to youth 'why do you have this problem?’ and send them away,” he said. “Girls as young as 13 can get pregnant and nobody wants this but the girl and baby need antenatal care.”
To change this situation, Pathfinder has focused on improving health facilities and training professionals in youth service and outreach. The organization has worked with 65 health facilities in 20 districts across five regions, 51 of them run by the Ghana Health Service, 10 from the Christian Health Association, and 4 Planned Parenthood Association of Ghana facilities.
In order for facilities to be accessible to young people, an environment of confidentiality and privacy must be created using sound-proof consultation rooms. This situation has improved drastically in the past 13 years, 83 percent of healthcare facilities now have a private exam room, up from 59 percent in 1993.
In addition to training medical professionals, Pathfinder has also trained youth peer educators. “Young people listen to their own peers more than others,” Mr Boadi said. These youth leaders have been trained to talk to their peers about the need to use protection during sex, or practice abstinence.
In an innovative spin on this tactic, Pathfinder also uses what it calls a “non-traditional condom distribution strategy” in response to the great challenge young people face in buying condoms at a pharmacy due to social stigma. Instead, condoms are distributed by trained adults in places where young people tend to gather, such as tailors, barbershops, internet cafés, and saloons. For example, a barber who is trained in sexual health issues can hand out free condoms to youth and explain their importance in a private, safe manner.
Pathfinder has also worked with the Nurse and Midwife Council of Ghana to integrate adolescent sexual reproductive health into nurse and midwifery training. “It is less expensive to ensure that nurses are already oriented to youth issues than to wait until they are graduated,” Boadi said.
As a result of these efforts, this subject matter is now an examinable course in these professions. So far, 250-300 graduating midwives have received family planning training, and follow-up studies have showed a very high retention rate of this knowledge.
Outcome/Results:
In addition to reduced fertility rates, Ghana’s family planning infrastructure and service availability have improved drastically in the past decade. Ninety-six percent of facilities now offer family planning five or more days a week.
Sixty percent of Ghana’s 5,000 family planners have been trained in interpersonal communication and management of contraceptive side effects by Government, NGOs, and educational facilities. Yet, according to a recent review, “Although more family planning providers have received in-service training on counselling, there are mixed results in terms of improved quality of care.”
As a result, a general fear of contraceptives remains despite the availability of several modern methods that are generally considered safe by experts.
However, it can be said that family planners have succeeded in becoming more proactive in reaching families, even in remote areas. In the words of one staff member of PPAG, “In the 70s and early 80s, when you talked about family planning, it was ‘go to the clinic and get a pill,’ but in the past 10 years, we have moved to the community.”
Health providers have also succeeded in becoming more holistic in their approach to family planning. Rather than simply distributing contraceptives, practitioners and trained volunteers are now providing comprehensive information about birth control options, benefits of child spacing, and other aspects of family planning.
What next?
The greatest remaining challenges are reducing dependency on foreign aid, creating better linkages between family planning and sexual health, and ensuring that all Ghanaians have access to services. Government has taken strides in recent years to increase budgetary support for this work, but the bulk of funding still comes from abroad.
This dependency on foreign aid is in part what allows well-intentioned and useful initiatives like the MDGs to categorize priorities at the expense of a truly holistic approach, one that accounts for STIs, including HIV/AIDS, as part of the overall family planning mechanism.
In this vein, there is currently a burgeoning movement in Ghana to remove the stigma on people living with HIV/AIDS, and sexual health workers are struggling to convince Ghanaians to fear the disease, not the victims. To this end, there is a national policy in place that is attempting to remove all discriminatory laws against PLWHA and ensure that they too have fair access to health and family planning services.
With all the focus now on youth and families, there remains a large, high-risk community that has received little or no outreach on sexual health issues: the gay community. The reason for this is the same reason that youth were neglected for so long: morality.
“For moral reasons we may not want to reach out to the gay community,” Mr Boadi explained. “We may not want it but it is there; we can’t pretend it’s not.”
He argued that it is better to provide sexual education to this group than “leave them in the dark,” and noted that a new USAID project will be working with gays and lesbians in all of Ghana’s 7 southern Regions.
Eventually, this work will expand into northern Regions as well, forming networks within the gay community as it goes. “A large number of people are coming out,” said Boadi. “It is really happening, not only in cities but in districts.”
