**9. Knowledge, attitude and practice of family planning**

The dividends accrued from improvements in reproductive health are cumulative and key to achieving sustainable development goals (SDGs) by improving maternal health, reducing child mortality and eradicating extreme poverty. Family planning brings transformational benefits to the women, families, communities and nations [16]. In the twenty-first century, the maternal mortality in the continent is still unacceptably high. The lifetime risk of maternal mortality of women in SSA is 1 in 39 live births, the highest when compared to other regions.

Despite recent increases in contraceptive use, sub-Saharan Africa is still characterized by high levels of fertility with TFR of 5 (number of births per woman) and a considerable unmet need for contraception [76]. Sub-Saharan Africa is still undergoing demographic transition (i.e. a shift to low death rate and birth rates). This is largely due to high birth rates with low contraceptive use. It is estimated that 90% of abortion-related and 20% of pregnancy-related morbidity and mortality together with 32% maternal deaths could be prevented by the use of effective contraceptive [9, 77]. In SSA, about 14 million unintended pregnancies occur each year, with about half occurring among women aged 15–24 years [78, 79]. The low level of utilization of contraceptives is due to several factors, the health systems and the framework within which family planning (FP) services are delivered, and suboptimal service factors [79]. Others are barriers at the individual level: risk perception, lack of or insufficient knowledge needed to make desired decision or choices, male partner disapproval and economic and geographic access to service facility. Knowledge of FP is crucial to make informed choice. Also noted are barriers to utilization of FP: commodity stock-out, limited provider skills and limited number of methods [80]. Even though contraceptive methods and services are frequently geared towards women, men are the primary decision-makers on family size and their partners' use of family planning methods [8, 81, 82].

Men's fertility preferences and attitudes towards family planning seem to influence their wives' attitudes towards the use of modern contraceptives [83]. This translates to the fact that the importance of male involvement in any family planning programme cannot be overemphasized. Information and knowledge on contraceptive methods are necessary tools to informed choices and utilization. Better informed and knowledgeable women are able to seek for desired information and also know where to access appropriate services. On the other hand, lack of knowledge together with cultural, social and religious factors is a major impediment to service utilization [81, 84, 85].

At the community level, since individuals leave in communities, it definitely can influence personal health-seeking behavior, as there are intersections between personal beliefs and attitudes and community norms. Previous studies revealed that women may choose to accept family planning or indeed choose a particular method because of the methods adopted by those in the community [86]. Again, recently, several studies have explored the role of contextual factors in contraceptive use in African countries [87–90]. Beyond individual and family factors, the context in which women live does influence their contraceptive decisions. The growing body of literature has identified a number of contextual factors that influence the use of contraceptive: presence and quality of reproductive health services, macroeconomic factors, community fertility norms, female autonomy and availability of physical infrastructure [91]. Previous studies [26, 76, 92] and reports of Demographic and Health Surveys [61] in SSA reported a near universal knowledge on family planning among women of reproductive age group. Unfortunately, this has not translated into increased utilization of contraceptive methods as evidenced by low contraceptive prevalence rates (CPRs). This can well be demonstrated by contraceptive prevalence in the world and by region of Africa (**Figure 2**) [93] with West Africa having the lowest prevalence rate among married or in-union women (15–49 years old) in 2015.

**10. Unmet needs for family planning**

17

Western Africa

Southern Africa

Northern Africa

Middle Africa

Eastern Africa

Africa

World

Sub-Saharan africa

Least developed countries

23

28

33

The decline in fertility in SSA has been slow than expected and has stalled in some countries [94, 95]. The total fertility rate varies from 4.8 children per woman in Kenya to 7.6 in the Republic of Niger [8, 9] and the lowest contraceptive prevalence of 22% among married women [96] and globally the highest level of unmet need for FP of about 25% [96]. Worldwide, over 222 million women have unmet need for contraceptive [97], and about 34 million women in Africa had unmet need for FP in 2009 [98]. The demand for contraceptives, with improved access and uptake, is the key public health intervention to improve maternal health outcomes, thereby reducing maternal mortality. Increasing contraceptive use has many demographic dividends, and unmet need denies women these benefits and violates their reproductive health rights. Studies have shown that several obstacles have hindered women access to FP services: unavailability of services, cultural and religious barriers, lack of knowledge and rural residence [99, 100]. Additionally, weaknesses in the existing FP programmes coupled with the fact that in SSA FP programmes tended to offer select methods (as a matter of convenience) or as a means of promoting the most effective and long-lasting methods [78]. Reasons for not

64

26

Contraceptive use Unmet need

24

22

13

12

83

15

24

22

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53

40

**Figure 2.** Contraceptive prevalence and unmet need for FP (percent) in the world and African region.

40

The low usage and CPRs could be attributed to negative attitude directed at the methods and other factors discussed earlier. Thus, the promotion of modern contraceptive use will require multifaceted interventions across all the levels of society. Specifically, addressing some or all of these barriers to the use of modern FP will importantly contribute to family, community and national socio-economic development. Particularly, contraceptive use needs to be promoted in West Africa on both health and economic grounds.

**Figure 2.** Contraceptive prevalence and unmet need for FP (percent) in the world and African region.

### **10. Unmet needs for family planning**

unintended pregnancies occur each year, with about half occurring among women aged 15–24 years [78, 79]. The low level of utilization of contraceptives is due to several factors, the health systems and the framework within which family planning (FP) services are delivered, and suboptimal service factors [79]. Others are barriers at the individual level: risk perception, lack of or insufficient knowledge needed to make desired decision or choices, male partner disapproval and economic and geographic access to service facility. Knowledge of FP is crucial to make informed choice. Also noted are barriers to utilization of FP: commodity stock-out, limited provider skills and limited number of methods [80]. Even though contraceptive methods and services are frequently geared towards women, men are the primary decision-makers on family size and their partners' use of family

Men's fertility preferences and attitudes towards family planning seem to influence their wives' attitudes towards the use of modern contraceptives [83]. This translates to the fact that the importance of male involvement in any family planning programme cannot be overemphasized. Information and knowledge on contraceptive methods are necessary tools to informed choices and utilization. Better informed and knowledgeable women are able to seek for desired information and also know where to access appropriate services. On the other hand, lack of knowledge together with cultural, social and religious factors is a major impedi-

At the community level, since individuals leave in communities, it definitely can influence personal health-seeking behavior, as there are intersections between personal beliefs and attitudes and community norms. Previous studies revealed that women may choose to accept family planning or indeed choose a particular method because of the methods adopted by those in the community [86]. Again, recently, several studies have explored the role of contextual factors in contraceptive use in African countries [87–90]. Beyond individual and family factors, the context in which women live does influence their contraceptive decisions. The growing body of literature has identified a number of contextual factors that influence the use of contraceptive: presence and quality of reproductive health services, macroeconomic factors, community fertility norms, female autonomy and availability of physical infrastructure [91]. Previous studies [26, 76, 92] and reports of Demographic and Health Surveys [61] in SSA reported a near universal knowledge on family planning among women of reproductive age group. Unfortunately, this has not translated into increased utilization of contraceptive methods as evidenced by low contraceptive prevalence rates (CPRs). This can well be demonstrated by contraceptive prevalence in the world and by region of Africa (**Figure 2**) [93] with West Africa having the lowest prevalence rate among married or in-union women

The low usage and CPRs could be attributed to negative attitude directed at the methods and other factors discussed earlier. Thus, the promotion of modern contraceptive use will require multifaceted interventions across all the levels of society. Specifically, addressing some or all of these barriers to the use of modern FP will importantly contribute to family, community and national socio-economic development. Particularly, contraceptive use needs to be pro-

moted in West Africa on both health and economic grounds.

planning methods [8, 81, 82].

82 Family Planning

ment to service utilization [81, 84, 85].

(15–49 years old) in 2015.

The decline in fertility in SSA has been slow than expected and has stalled in some countries [94, 95]. The total fertility rate varies from 4.8 children per woman in Kenya to 7.6 in the Republic of Niger [8, 9] and the lowest contraceptive prevalence of 22% among married women [96] and globally the highest level of unmet need for FP of about 25% [96]. Worldwide, over 222 million women have unmet need for contraceptive [97], and about 34 million women in Africa had unmet need for FP in 2009 [98]. The demand for contraceptives, with improved access and uptake, is the key public health intervention to improve maternal health outcomes, thereby reducing maternal mortality. Increasing contraceptive use has many demographic dividends, and unmet need denies women these benefits and violates their reproductive health rights. Studies have shown that several obstacles have hindered women access to FP services: unavailability of services, cultural and religious barriers, lack of knowledge and rural residence [99, 100]. Additionally, weaknesses in the existing FP programmes coupled with the fact that in SSA FP programmes tended to offer select methods (as a matter of convenience) or as a means of promoting the most effective and long-lasting methods [78]. Reasons for not using contraceptive are quite unfounded as contraception is a safe medical intervention. It is estimated that mortality risk of unplanned and unwanted pregnancy is 20 times the risk of any modern contraceptive method and 10 times the risk of a "properly" performed abortion [101].

The concept of unmet needs for contraceptive dates back to the 1960s, the "KAP-Gap" era, and was used as a rationale for investment in family planning programmes [102]. It is the proportion of currently married, fecund women who do not want any more children but are not using any form of family planning (unmet need for limiting) or currently married women who want to postpone their next birth for 2 years but are not using any form of family planning (unmet need for spacing) [103]. Unmet need is essentially a conflict between what a woman wants and what she does about it. She might want fewer fertility but fails to take action needed to prevent pregnancy. The total demand for family planning is the proportion of married women with unmet need and married women with met need for family planning. In other words, it is the sum of contraceptive prevalence plus unmet need for family planning. Currently, the total demand for FP (sum of unmet need and current contraceptive use) is around 44% in SSA [104]. Also, unique to the continent is the fact that predominantly the unmet need is for spacing rather than for limiting births. Thus, it shows the importance attached to child spacing in Africa and a reluctance to commit to a final cessation of childbearing [9]. It also shows that demand for contraception (to space) exists within this population that can be explored. In countries where growing numbers of women want to avoid a pregnancy but contraceptive use is low, unmet need is higher. Rwanda, Senegal, Togo and Uganda all have unmet need of about 30% or higher [104]. The main objective for the study of unmet need is to estimate the potential demand for FP [102].

Basically, its purpose is to identify women who are currently exposed to the risk of unintended pregnancy but who are not using any method of contraceptive. In theory, these women either do not want any more births (limiting) or want to postpone the next birth for at least 2 more years (spacing). The computation of unmet need is complex and can vary depending on which categories of women are included in the definition [104]. When this is summed up with current contraceptive use, it provides a picture of total potential demand for FP in a country (**Figure 3**).

as a user of natural methods. Currently, in the DHS questionnaire, there is no follow-up questions specific to natural methods resulting in possibility of under reporting in some developing countries [106]. Despite these drawbacks, measurement of unmet need has endured as a good analytical tool till date. Its importance cannot be overemphasized: the estimate is useful as it helps to reveal the size and characteristics of the potential market for contraceptives, allows for projection of how much fertility could decline if additional needs for FP were met. Reducing unmet need for FP is key to helping couples achieve their reproductive rights and achieving demographic goals. The lessons here are to understand the variations in unmet need across the continent. Respective national governments will need to understand uniqueness of unmet needs in order to strengthen family planning programmes to reduce unmet need. Studies have revealed that strong programmatic interventions not only reduce unmet need and increase contraceptive

58

28

Using contraception Not using contraception (unmet need)

30

30

35

17

85

19

13

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Family Planning Services in Africa: The Successes and Challenges

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26

16

54

use but also increase the proportion of women using modern contraceptives [107].

The challenges to family planning programmes are many, varied and require attention at the highest policy level in order to realize the huge demographic, socio-economic and development

**11. Challenges**

12

15

10

**Figure 3.** Potential demand for family planning.

15

22

31

23

4

Burkina Faso

Cote d'Ivoire

Chad

Ghana

Nigeria

Kenya

Malawi

Rwanda

Uganda

Zimbabwe

Experts have also raised the following concerns on its measurement:


Today, the major source of data for measuring unmet need globally is the Demographic and Health Surveys (DHS) and for which data is available in most countries in SSA. Many countries have had two or four rounds of such surveys between 1990 and 2014. The DHS questions administered to women asked whether they are doing anything to avoid a pregnancy. If the woman reports the use of a natural method and does not simultaneously use a more effective method, she is counted

**Figure 3.** Potential demand for family planning.

using contraceptive are quite unfounded as contraception is a safe medical intervention. It is estimated that mortality risk of unplanned and unwanted pregnancy is 20 times the risk of any modern contraceptive method and 10 times the risk of a "properly" performed abortion [101]. The concept of unmet needs for contraceptive dates back to the 1960s, the "KAP-Gap" era, and was used as a rationale for investment in family planning programmes [102]. It is the proportion of currently married, fecund women who do not want any more children but are not using any form of family planning (unmet need for limiting) or currently married women who want to postpone their next birth for 2 years but are not using any form of family planning (unmet need for spacing) [103]. Unmet need is essentially a conflict between what a woman wants and what she does about it. She might want fewer fertility but fails to take action needed to prevent pregnancy. The total demand for family planning is the proportion of married women with unmet need and married women with met need for family planning. In other words, it is the sum of contraceptive prevalence plus unmet need for family planning. Currently, the total demand for FP (sum of unmet need and current contraceptive use) is around 44% in SSA [104]. Also, unique to the continent is the fact that predominantly the unmet need is for spacing rather than for limiting births. Thus, it shows the importance attached to child spacing in Africa and a reluctance to commit to a final cessation of childbearing [9]. It also shows that demand for contraception (to space) exists within this population that can be explored. In countries where growing numbers of women want to avoid a pregnancy but contraceptive use is low, unmet need is higher. Rwanda, Senegal, Togo and Uganda all have unmet need of about 30% or higher [104]. The main objective for the study of unmet need is to estimate the potential demand for FP [102].

Basically, its purpose is to identify women who are currently exposed to the risk of unintended pregnancy but who are not using any method of contraceptive. In theory, these women either do not want any more births (limiting) or want to postpone the next birth for at least 2 more years (spacing). The computation of unmet need is complex and can vary depending on which categories of women are included in the definition [104]. When this is summed up with current contraceptive use, it provides a picture of total potential demand for FP in a country (**Figure 3**).

Experts have also raised the following concerns on its measurement:

• Women's personal opposition to family planning.

not and thus not at risk of pregnancy [105].

methodological issue.

84 Family Planning

• The term does not necessarily reflect actual or potential interest in method use.

• It does not reflect how women perceive themselves to be at risk of pregnancy.

• Failure to differentiate between married women who are sexually active and those who are

• Underreporting of natural methods [106] in large-scale surveys which is a long standing

Today, the major source of data for measuring unmet need globally is the Demographic and Health Surveys (DHS) and for which data is available in most countries in SSA. Many countries have had two or four rounds of such surveys between 1990 and 2014. The DHS questions administered to women asked whether they are doing anything to avoid a pregnancy. If the woman reports the use of a natural method and does not simultaneously use a more effective method, she is counted as a user of natural methods. Currently, in the DHS questionnaire, there is no follow-up questions specific to natural methods resulting in possibility of under reporting in some developing countries [106]. Despite these drawbacks, measurement of unmet need has endured as a good analytical tool till date. Its importance cannot be overemphasized: the estimate is useful as it helps to reveal the size and characteristics of the potential market for contraceptives, allows for projection of how much fertility could decline if additional needs for FP were met. Reducing unmet need for FP is key to helping couples achieve their reproductive rights and achieving demographic goals.

The lessons here are to understand the variations in unmet need across the continent. Respective national governments will need to understand uniqueness of unmet needs in order to strengthen family planning programmes to reduce unmet need. Studies have revealed that strong programmatic interventions not only reduce unmet need and increase contraceptive use but also increase the proportion of women using modern contraceptives [107].

#### **11. Challenges**

The challenges to family planning programmes are many, varied and require attention at the highest policy level in order to realize the huge demographic, socio-economic and development dividends of low fertility levels. This will also make SDGs achievable. Continued political will and support are prerequisite for sustainability and acceptability of FP programme:

**13. Recommendations**

**Conflict of interest**

**Author details**

Alhaji A Aliyu

**References**

needed to address unmet needs for FP.

I declare that l have no conflict of interest in writing this chapter.

Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria

Available at: http://www.africahealth2010.aed.org (Accessed 2/7/015)

www.worldwatch.org/features/population (Accessed 26/6/017)

project. Studies in Family Planning. May/June 1995;**26**(3):121-139

Medicine and Biomedical Research. 2015;**14**(2):13-21

[1] WHO/USAID. Repositioning Family Planning: Guidelines for Advocacy Action.

[3] Frederick TS. Population, Family Planning and the future of Africa. Available at: http://

[4] Binka FN, Nazzar A, Philips JF. The Navrongo community health and family planning

[5] Arends-Kuoenning M, Hossain MB, Barkat-e-Khuda. The effects of family planning workers contact on fertility preferences. Studies in Family Planning. Sep. 1999;**3**(3):183-192 [6] Aliyu AA, Shehu AU, Nasir MN, Sabitu K. Contraceptive knowledge, attitudes and practice among married women in Samaru community, Zaria-Nigeria. East African Journal of Public

[7] Bankole A, Singh S. Couples' fertility and contraceptive decision-making in developing countries: Hearing the men's voice. International Family Planning Perspective. 1998;**24**(1):15-24 [8] Aliyu AA, Dahiru T, Oyefabi AM, Ladan AM. Knowledge, determinants and use of contraceptives among married women in Sabon Gari, Zaria- northern Nigeria. Journal of

[9] Cleland J, Bernstein S, Ezeh A, Glasier A, Innis J. Family planning: The unfinished agenda.

Address all correspondence to: alhajimph@gmail.com

[2] World population data sheet 2016

Health. 2010;**7**(4):354-357

Lancet. 2006;**368**:1810-1827

Important shift in political commitment and priorities together with good governance, adequate funding is needed to sustain FP programmes. Efforts need to be intensified to encourage partner communication and engagement in order to improve FP practice. Further, research is

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