**2. Benefits**

Republic of the Congo, 8th and Egypt, 10th) with a combined population of 779 million will be the most populous nations in Africa [1]. Sub-Saharan Africa (SSA) has 11% of the world population but accounts for a pitiable 2% of global trade [3]. The population growth is largely driven by high

Demographically, there is population momentum across most of the countries, as more than half of the population are under the age of 15 years. What this means is that even if replacementlevel fertility is achieved, the population growth will continue for at least two decades because of the momentum built up in the age structure due to the past high fertility levels that has given rise to the greater number of couples who are having children. Social forces and pronatalist factors sustaining high fertility and which also impedes family planning (FP) programmes are well known [4, 5]. Added to this is the fact that in SSA husbands tend to want large families than their wives [6, 7]. Sub-Saharan African countries are still undergoing both demographic and epidemiologic traditions. Even though birth rate is declining, it is still in excess of death rates. Thus, the region has the highest rates of fertility globally with total fertility rates (TFR) that ranged from 4.8 children per woman in Kenya, 5.2 in Nigeria, 5.7 in South Sudan, and 7.6 in the Republic of Niger [1, 4, 8, 9]. It also has a high annual growth rate of more than 2.5% per year.

Again, the same continent is vulnerable to the "destructive forces" caused by nature as recent events have shown. The harsh adverse effects of global warming in the Sahel region, draught/ famine in the horn of Africa, deforestation, overgrazing with declines in soil fertility and incessant floods in West Africa has contributed in sustaining the vicious cycle of poverty and disease. As the number increases, the pressure on the environment (both built and natural) including natural resources and available fertile land for agriculture increases. Consequently, the net effect is increased in greenhouse gases (GHGs) with its attendant effects on public health.

Before 1970, majority of Africa countries had not viewed population growth as a major factor in their national development strategies because of their small population (34 of the 48 countries had a total population of less than 5 million) [8]. By the mid-1970s, the trend started to change with the rising number of national governments that reported having population policies aimed at reducing the rapid growth of their respective populations: 25% in 1976, 39% in 1986, 60% in 1996 and 64% in 2009 [9]. Previously, pronatalist governments that wanted to maintain or even increase population growth have gradually modified their stance and accepted provision of FP services as integral part of maternal and child health (MCH) which is a key component of primary health-care (PHC) system. Also, government policies regarding access to and availability of modern contraceptives have been an important determinant of reproductive behavior as well as maternal and child health. Many governments have given direct support providing FP services through state-owned health facilities. The provision of FP services is a key component of Safe Motherhood Initiative launched in 1987 in Nairobi, Kenya, to reduce maternal mortality in developing countries, where 99% of all maternal deaths occur [10]. In African region women have 1 in 42 lifetime risk (compared to 1 in 2900 in Europe) of dying prematurely in childbirth [11]. Provision of universal access to high-quality family planning and maternal health services and skilled attendance at delivery are key action strategies under the safe motherhood initiative [12]. Contraceptive use averts about 230 million births every year globally, and family planning (FP) is a primary strategy for prevention

of unwanted pregnancy [13].

70 Family Planning

fertility rate and rising cohort of women of reproductive age group (WRAG) (15–49 years).

The period 1970–1990 marked the golden era of family planning during which reproductive revolution occurred worldwide except in SSA. However, by the early 1990s, changes had begun to occur leading some experts to suggest that population and FP programmes started in the late 1960s in developing countries constituted one of the most important public health success stories of the twentieth century [14]. Benefits of FP were known ever since Beard in 1897 observed that ovarian follicles do not develop during pregnancy and that corpus luteum was responsible [17]. There are a variety of health benefits that are associated with the use of individual FP commodities; for instance, pills, injectable and implants have been associated with protection against uterine and ovarian cancers, benign cysts of the breast or ovaries and pelvic inflammatory diseases (PIDs). Pills can also reduce menstrual flow and dysmenorrhea and decreased prevalence of iron deficiency anaemia.

Family planning is a cost-effective public health and development intervention. Generally, planned pregnancies which are safer for the mother produce healthier children than unplanned pregnancy. FP allows individuals and couples to at least plan one aspect of their lives (reproductive life). The cost of averting unwanted birth is quite insignificant compared to the costs to the family and country of unwanted births [9]. Further, fewer public health interventions are as effective as FP programmes in reducing morbidity and mortality of mothers and infants and result in such a huge positive impacts [9, 18, 19].

**1.** Health-care facilities **2.** Commercial outlets

**3.** Community-based systems

Family planning services and contraceptive commodity supply were started through assistance by the US Agency for International Development (USAID) and other international donors to national governments across Africa. Later on, non-governmental organizations (NGOs) came in to supply and/or donate FP commodities. Initially, the services were provided at health-care facilities in state, district and provincial capitals. During these "infantile" periods, access to family planning methods was under strict control of medical practitioner even in health facilities. During the period clients have to pay a token to access service which also was a huge barrier to many potential users. Firstly, the woman has to meet the eligibility criteria [33], they must be married and husband must give verbal (seen by the doctor) or written consent and be seen by the doctor as soon as she starts her menses. This was a good starting point for FP services delivery, but the burden and disadvantages of this "solo" practice became obviously inconvenient to the clients, long waiting time and other logistics. There was an urgent need to overhaul the system in order to improve access and service utilization. The World Health Organization (WHO) has published international guidelines on medical eligibility criteria that have proven to be invaluable [34].

Family Planning Services in Africa: The Successes and Challenges

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Studies have shown that if given an adequate training, paramedical staff (nurses and midwives) could insert intrauterine devices (IUDs) and provide injectable contraceptives to high clinical standards and even lay staff, after a short training, could also dispense pills, and over-the-counter sale of pills without prescription was justifiable [9, 35–37]. Facility-based service provision is highly restrictive in terms of geographic access; this means that alternative approaches are in dire need in order to make the commodities easily accessible. However, studies have shown that the use of FP methods falls only modestly with increasing distance or travel time to the nearest source of contraception [38]. But in SSA where poverty index is high, physical accessibility becomes predictable and risky especially during raining season, and transport is available only once or twice (during market days) in a week; these are the real challenges to contraceptive use. The provision of services through government facilities follows the PHC approach: all the three tiers (primary, secondary and tertiary) of health-care systems. The incorporation of contraceptive services into PHC facilities is an approach to boost contraceptive prevalence rates especially in SSA [39] where this has remained persistently low. In order to improve service availability and increase coverage, private health facilities later got involved. This involvement varies widely across the continent, being 40% in Kenya and more than 50% in Uganda but low (<20%) in areas where national government programmes are strong such as Namibia and South Africa. However, majority of these private facilities are Urban-based and thus serve the needs of urban elites.

Commercial outlets such as pharmacies, drug retail shops and patent medicine or street vendors and bazaars also constitute major significant outlets in which contraceptives (e.g. pills, condoms) can be obtained. Social marketing schemes run by NGOs or international organization are popular where advertising, logistics and product prices are highly subsidized in order to promote utilization. It is most effective when pills, condoms or both are fairly common methods; demand for contraception is well established coupled with a well-developed

The health and socio-economic benefits of healthy motherhood including the use of contraception are known. Contraceptive use promotes small family size, improves child survival and reduces sibling competition for scarce family and maternal resources [20, 21]. When used correctly and consistently, contraceptive use in developing countries have been shown to decrease the number of maternal deaths and also prevent more than half of all maternal deaths if full demand of birth control is met [12, 22]. Spacing children can reduce mortality among under-fives by 10% and among pregnant mothers by 32% [23–26].

At macro-level, national population growth is slower which reduces strains on the environment, natural resources, education and health-care systems. FP reduces the risk of maternal mortality per birth (i.e. number of maternal deaths in 100,000 live births per year) [27] as a result of pregnancies too early, too many, too close and too late (4Ts of maternal mortality) [28–30] all of which are prevalent in SSA. The effective use of contraception can help couples achieve the desired number of children they want, prevent the number of unwanted pregnancies and reduce the risks of sexually transmitted infections (STIs) and thus overall improvement in maternal and child health and the nation.

Contraceptive use allows couples to realize their full potentials, and the woman can better fulfill her roles as a wife, mother, wage earner and community member. The man can better expand his roles as husband, father and family caregiver [30]. All these go a long way in curtailing population explosion, reduce dependency ratio (youth), better the health indices for the country and improve socio-economic conditions. This will also assist Africa to make progress in achieving all the sustainable development goals (SDGs).
