**4. Hormonal contraceptives**

Since the 1960s when oral contraceptives (OCs) were first marketed, they have symbolized modern contraception and have remained the most widely used hormonal method globally. OCs provide millions of women with effective, convenient and safe protection from pregnancy. Currently, more than 100 million women use OCs. Data on both ever use and current use of contraceptive revealed the continuing popularity of OCs [63]. Hormonal contraceptives can be classified into:

**1.** Oral pills

menstrual cycle when the woman is most likely to become pregnant. Fertility awareness is based on a scientific knowledge of the female and male reproductive systems and on the understanding of the signs and symptoms that occur physiologically in women's menstrual

Natural family planning provides women with alternatives for those who do not wish to use modern (artificial) methods. In low-income countries, women tend to adopt postpartum family planning methods only after resumption of sexual intercourse or menses [54–56]. In sub-Saharan Africa, both events can be delayed as typically women practice prolonged breastfeeding (up to 2 years) which lengthens their period of amenorrhea, and in Middle and West Africa, women abstain from sexual intercourse for extended periods of time after a birth [57]. Indeed, many African cultures discourage sex during breast-feeding because of misconception that semen pollutes the breast milk. However, recent report has shown that the mean duration of postpartum insusceptibility to pregnancy (combined period of amenorrhea and abstinence) is between 15 and 20 months in most SSA countries [58, 59]. The safety of these methods despite their use cannot be guaranteed. For instance, withdrawal method (coitus interruptus), one of the oldest methods of fertility control, the slightest mistake in timing of withdrawal may result in deposition of some amount of semen. Thus, the failure rate may be as high as 25% [51]. Many women erroneously believed that they were protected completely when amenorrhoeic. At the population level, amenorrhoea is related to low risk of pregnancy; the absence of menses does not guarantee protection from pregnancy for individual women (except during the time frame of lactational amenorrhoea). Despite these problems, till date they continue to be used alongside modern contraceptives as evidenced by Demographic and Health Surveys (DHS) conducted across Africa. **Table 2** shows the percentage of women who use modern and traditional methods of contra-

cycle to indicate when she is fertile or infertile. This is often referred to as safe period.

ception in 1992 and most recent DHS reports of some selected countries in SSA.

Burkina Faso 10 6 4 15 1.0 15 Ghana 20 10 10 23 5.0 22 Kenya 33 6 27 58 4.8 53.2 Malawi 13 6 7 59 1 58 Niger 4 2 2 14 2 12 Nigeria 6 3 4 15.1 5.4 9.8 Senegal 7 3 5 25.1 2.1 23.1 Tanzania 18 5 13 38 6 32 Uganda 15 4 9 39 4 35 Zambia 26 12 14 49 4.3 44.8 Zimbabwe 48 6 42 67 1 66

**Table 2.** Family planning methods currently used (percentages) by married women (15–49 years) [60, 61].

**Modern method**

**Any method** **Traditional method**

**Modern method**

**Country 1 2**

(1) Robey et al.; (2) data from recent DHS of various countries.

**Traditional method**

**Any method**

78 Family Planning

	- **a.** Injectable
	- **b.** Subcutaneous implants
	- **c.** Vaginal rings

Worldwide, an estimated 8% of all married women currently use the pill and rank third among all family planning methods currently used by married women. The use of pills accounts for about one-quarter of all contraceptive use among both married and unmarried women in sub-Saharan Africa [62]. Overall, about 15% of married women use family planning, and less than 4% use the pill.

In some countries in Africa, OC usage is among the highest in the world: 33% of married women in Zimbabwe, 21% in Mauritius, 1.8% in Nigeria, 18% each in Botswana and Cape Verde respectively [62]. The use of COCs has been associated with health benefits. It reduces menstrual blood flow and dysmenorrhoea and lowers the prevalence of iron deficiency anaemia [63–65]. Generally, when taken correctly, OCs offer highly effective contraceptive. Among perfect users (women who do not miss pills and follow the instructions correctly), only 1 in every 1000 women becomes pregnant in the first year [62]. Among typical users, about 60–80 women in every 1000 will become pregnant during the first year [66]. Appropriate health education and counseling of clients are the key ingredients to the successful use of OCs.
