Addressing reproductive health to impact MDG attainment

SUB-SAHARAN Africa is said to be the fastest growing region in the world, with a population of about 840 million and a growing rate of 2.4% per year, and is facing many global health and development challenges, especially its young population.

Experts say half of the population in the region are younger than eighteen years, thus the future of sub-Sahara Africa depends largely on the investments made in the education, health and employment opportunities of its youth, and how successfully these youth transition to a healthy and productive adulthood. This makes the realization of the Millennium Development Goals (MDGs), many of which relate to the youth, critical to meet the many needs of the youth across the African continent.

In Ghana, there have been many interventions in the health sector through national health policies, aimed at improving the health status of all Ghanaians, especially that of children, women and the youth. This feature seeks to look at Ghana's effort at improving sexual reproductive health of Ghanaians through family planning (FP).

According to Population Reference Bureau (PRB - a US-based organization) publication on -'Improving the Reproductive Health of Sub-Saharan Africa's Youth: A Route to Achieve the Millennium Development Goals', Ghana is among five most populous countries on the continent, together with Liberia, Mali, Nigeria and Senegal.

In these countries, children or youth between the ages of 15 - 19yrs transition from childhood to adulthood, a time of increased responsibility and independence, increased health risks, and also a period when the youth of both sexes generally complete or leave school and become sexually active.

PRB believes that as the youth make this transition, national investments in reaching the MDGs can help ensure that the youth are able to maximize their potential for healthy, and productive lives that contribute to alleviating the high levels of poverty that impede development.

This is also the belief of health experts in Ghana, thus efforts to attain a high rate of family planning is geared towards meeting the MDG targets as they pointed out to members of the media recently in Accra. Specifically, the Ghana Health Service (GHS), with support from the United States Agency for International Development (USAID) and Behavior Change Support (BCS), briefed members of the press on the state of FP in the country, highlighting problems and what needs to be done to achieve the desired results.

Family Planning
Family Planning (FP) involves planning of when to have children, and the use of birth control measures and other techniques to implement such plans. The Director of Family Health Division, GHS, Dr. Gloria Quansah-Asare said FP services include methods and practices to space births, limit the family size and prevent unwanted pregnancies.

She stated that FP methods currently available in Ghana for the short term include male and female condoms, spermicides, oral contraceptive pills (combined and Mini pill), monthly and three-monthly injectables, lactational amenorrhoea and emergency contraceptive.

The long term methods, which are reversible, include intra urine device, implants, natural family planning methods and the permanent methods, which are also irreversible, and include tubal ligation and vasectomy. She expressed worry that for the first time since the 1980s, FP use declined from 19% to 17% between 2003 and 2008, a contrast to the increase in FP use from 13% to 19% between 1996 and 2003.

Challenges/UnmetNeeds Unmet needs, according to Dr. Quansah-Asare, refers to women who do not want to get pregnant for the next two to three years or have any more children, but are not using any method, which is a challenge for achieving high family planning rate in Ghana.

According to her, this need is 34% currently, whereas that for rural areas is 10% higher, stressing that 'persistently high unmet need for family planning is 34 - 35%.' This is confirmed by the PRB report which indicates that unmet need usually results in unplanned and mistimed pregnancy, especially among the youth aged between 15 - 19yrs, with Ghana topping the chart in sub-Saharan Africa with a figure of 49%, Kenya - 47%, Zambia - 44%, Uganda - 42%, DRC - 33%, Ethiopia - 31%, Mali - 17%, Madagascar - 15% and Nigeria - 14%. 'In Ghana, one of the few countries where contraceptive use among adolescents has remained static in recent years, nearly 60% of adolescents report that their recent birth was unintended', the report said.

It said there were about 215 million women worldwide that have unmet need for contraception, and that among married women aged between 15 and 19yrs, it is 62% while that for married women aged between 30 to 34yrs is 33%.

A Ghanaian doctor said that rumours, myths and misconceptions about contraceptives also pose challenges for their use, and contraceptive security issues, including reduced or dwindling funding, procurement of contraceptives and programme activities, especially generating demand. Often, negative attitudes and cultural norms inform misconceptions about contraceptives, as well as fear from unknown side effects, arising from lack of or inadequate education about side effects, as pointed out by Regina, a thirty year old lady.

She has a one and half year old child and was currently pregnant with her second child, which she indicated came as a surprise to her, because she wanted to space the second pregnancy a little longer. She relies on the natural method of FP because she does not really know the side effects she might experience with the other methods, though anytime she went on antenatal clinic, they were taught the importance of FP, methods available and the efficacy of each of them, as well as some likely side effects by the nurses.

According to her, her brother's wife used one of the methods and was experiencing serious side effects, and so she thinks it is better for her to use the natural method, admitting that 'if you miscalculate, you might get pregnant, like the pregnancy I am carrying now.'

Another twenty eight year unmarried lady, Faustina, said she also relies on the natural method of FP, and sometimes on the emergency contraceptive to avoid unwanted pregnancies. She also admitted that the method had failed her once, and thereafter she went in for the three-month injectable, which made her put on considerable weight, and so she had to stop using it. She noted that though she had wanted to try another method, her fiancée thought there could be unpleasant side effects, especially because she was yet to marry and have kids, saying 'the method has been working very well for me for a long time now, especially with careful calculation.'

Way forward/ BCS Project
Dr. Quansah-Asare pointed out that FP is a pivotal service in reproductive health, hence it should be made a component of reproductive health and safe motherhood. In her view, FP cuts across most components of reproductive health, such as 'post abortion care, comprehensive abortion care, STI/HIV/AIDS prevention and management, infertility prevention and management, adolescent and male services, and gender-based violence.'

She said all individuals and couples including adolescents are eligible for FP services to achieve the goal of FP, which is 'to assist couples and individuals of all ages to achieve their reproductive goals and improve their general reproductive health.'

According to her, the critical role of FP is evident in the fact that birth rates have been shown to decline when the option of FP is made easily available, which demands an urgent action to make FP provision an integral part of all efforts to reduce poverty, improve mothers' and children's survival and health. Also critical is the need for the large and well-documented unmet need for FP to be addressed, a reason for which the 'Life Choices' (LC) FP campaign was introduced and implemented in 2001 - 2002, in league with other interventions that contributed to the increase in FP from 13% to 19%, between 1998 and 2003.

To specifically address the falling pattern in FP usage, the GHS is reintroducing the LC under the BCS project. This project is a four-year USAID project on social and behavior change communication, supported by the John Hopkins Center for Communication Programs (JHU/CCP), with CARE and PLAN International, in partnership with the Ministry of Health (MOH) and GHS.

The BCS Project Chief of Party, Mr. Ian Osei said the overall purpose of the project is to assist the GHS at the national, regional and district levels, to support its effort to achieve health related goals through sustained and coherent social and behaviour change communication.

Since FP is one of the key health areas of the project, its objective is to increase the demand and use of modern contraceptive methods and address underlying social and behavioral barriers and issues, he noted. He identified barriers that need to be removed as lack of clarity on method choices, concerns about side effects, need for men's involvement, fear of social ostracism and lack of personal relevance among others. Thus, the specific audiences to be addressed include community members/population, opinion leaders and service providers.

According to him, the new LC would be in two phases, the first comprising the use of mass media to focus on the use of existing spots, music videos and press adverts, with the objective to raise the profile of FP in Ghana. The second phase would include activities at the level of mass media, health facility materials provision for GHS facilities, and focus on communities in the Greater Accra, Central and Western regions for a concentrated outreach.

Particularly, he appealed to members of the media to assist in any way possible through the various activities outlined in the LC campaign, since their involvement was critical to its success, and to 'engender national dialogue on FP, strengthen partnership and increase coverage and placement.'

Family Planning and attainment of MDGs
Experts believe that meeting the goal of FP would spur progress towards achieving all of the MDG targets in one way or the other. According to the Dr. Quansah-Asare, increased FP use positively impacts on all the MDG goals such that it reduces rapid population growth, high fertility and large family size that negatively impacts on national and household goals.

Mr. Tweedie also said re-positioning FP through the LC is 'necessary for achieving and sustaining the MDGs.'

MDG 1 targets eradication of extreme poverty and hunger in Ghana, and in this regard, it has been established that many countries that lowered their birth rates have eradicated or greatly reduced poverty, she said. She observed that risk of poverty was higher in families with many children, whereas a 'demographic dividend' occurred when family size falls rapidly, and ensure there were relatively more people of working age with fewer dependent children.

For instance, Thailand, South Korea and Taiwan all have successfully managed to take advantage of their demographic bonus to raise the living standards of millions of their citizens. Rapid population growth undermines basic education in a vicious cycle, and limits the educational prospects of girls. Thus MDG2 aims to achieve universal primary education in Ghana, by reducing family size through FP.

This, the female doctor said would ensure that all children gain access to primary education, and lower pupil/teacher ratio for quality education.  MDG 3 seeks to promote gender equity and empower women, which means that FP would give women the ability to control their own fertility that is fundamental to their empowerment, and obtaining equality with men in many aspects of life.

As Dr. Quansah-Asare puts it, 'women without access to FP are likely to be younger, when they have their first child, and less able to space or limit subsequent births, and the early initiation of sexual activity and unintended pregnancies curtails the education for many girls.' She said MDG 4 aims to reduce child mortality, which is strongly associated with high fertility rate, because many closely-spaced children, common in large families, leads to increase in child deaths.

MDG 5 is to improve maternal health and achieve universal access to reproductive health by 2015, because maternal mortality is the second largest cause of female deaths in Ghana, caused by hemorrhage, unsafe abortion and hypertensive disorder among others. However, FP can reduce maternal deaths by 35%, by simply preventing unintended pregnancies and thereby reducing the number of women unnecessarily, exposed to all the risks of pregnancy, delivery and unsafe abortion.

Particular, fulfilling the high unmet need for FP in Ghana would avert almost 4000 maternal deaths over a ten year period, said the health expert, adding 'this means in just a year, 400 Ghanaian families would be spared the heartache and catastrophe of losing their mothers and wives to maternal-related death.'

The PRB report supports this point by saying that the target indicators for MDG 5 include the contraceptive prevalence rate, adolescent birth rate, and the unmet need for FP, because 'adolescent child bearing is risky for mothers and their infants.' It added that achieving this MDG, will therefore rely greatly on meeting the contraceptive needs of adolescents, delaying the first birth, ensuring antenatal care and skilled attendance at birth, and preventing unsafe abortion.

MDG 6 aims to combat HIV/AIDS, malaria and other diseases in Ghana. Dr. Quansah-Asare noted that rapid population growth negatively impacts on the already overstretched health systems and facilities, which is worsened by the high incidence of exodus of doctors and nurses to other countries. Thus, contraception services, specifically male and female condoms, would help prevent HIV.

Regarding MDG 7, which aims to ensure environmental sustainability, she noted that population growth worsens the environmental problems, which has been left vulnerable by climate change, adding that population pressures were adding to the difficulties in forests, biodiversity, flooding in urban areas due to rapid migration among others. Thus, FP compliance would help address this situation by reducing population growth and the pressure on these elements.

Conclusion
The issue of reproductive health is very important to the development of individuals, families and the nation at large, especially concerning attainment of the MDGs. To particularly meet the MDG target date of 2015, requires that all Ghanaians contribute towards this agenda.

This is necessary to address the needs of women and children, all youth and improve the health of families that would go a long way to increase Ghana's work force, and contribute to the eventual aim of achieving middle income status.

To this extent, health workers must also seek to avoid negative tendencies that turn away especially the youth, from accessing FP services, whereas parents and guardians must educate their children and other dependents on the need to avoid unintended pregnancies.

Teachers, religious bodies and civil society groups must also put in efforts to guide the youth in making the right choices that would improve their health, and help attain their lifetime goals, towards achieving national goals. Long Live the GHS, Long Live Ghana, Long Live Africa!

SUB-SAHARAN Africa is said to be the fastest growing region in the world, with a population of about 840 million and a growing rate of 2.4% per year, and is facing many global health and development challenges, especially its young population.

Experts say half of the population in the region are younger than eighteen years, thus the future of sub-Sahara Africa depends largely on the investments made in the education, health and employment opportunities of its youth, and how successfully these youth transition to a healthy and productive adulthood. This makes the realization of the Millennium Development Goals (MDGs), many of which relate to the youth, critical to meet the many needs of the youth across the African continent.

In Ghana, there have been many interventions in the health sector through national health policies, aimed at improving the health status of all Ghanaians, especially that of children, women and the youth. This feature seeks to look at Ghana's effort at improving sexual reproductive health of Ghanaians through family planning (FP).

According to Population Reference Bureau (PRB - a US-based organization) publication on -'Improving the Reproductive Health of Sub-Saharan Africa's Youth: A Route to Achieve the Millennium Development Goals', Ghana is among five most populous countries on the continent, together with Liberia, Mali, Nigeria and Senegal.

In these countries, children or youth between the ages of 15 - 19yrs transition from childhood to adulthood, a time of increased responsibility and independence, increased health risks, and also a period when the youth of both sexes generally complete or leave school and become sexually active.

PRB believes that as the youth make this transition, national investments in reaching the MDGs can help ensure that the youth are able to maximize their potential for healthy, and productive lives that contribute to alleviating the high levels of poverty that impede development.

This is also the belief of health experts in Ghana, thus efforts to attain a high rate of family planning is geared towards meeting the MDG targets as they pointed out to members of the media recently in Accra. Specifically, the Ghana Health Service (GHS), with support from the United States Agency for International Development (USAID) and Behavior Change Support (BCS), briefed members of the press on the state of FP in the country, highlighting problems and what needs to be done to achieve the desired results.

Family Planning
Family Planning (FP) involves planning of when to have children, and the use of birth control measures and other techniques to implement such plans. The Director of Family Health Division, GHS, Dr. Gloria Quansah-Asare said FP services include methods and practices to space births, limit the family size and prevent unwanted pregnancies.

She stated that FP methods currently available in Ghana for the short term include male and female condoms, spermicides, oral contraceptive pills (combined and Mini pill), monthly and three-monthly injectables, lactational amenorrhoea and emergency contraceptive.

The long term methods, which are reversible, include intra urine device, implants, natural family planning methods and the permanent methods, which are also irreversible, and include tubal ligation and vasectomy. She expressed worry that for the first time since the 1980s, FP use declined from 19% to 17% between 2003 and 2008, a contrast to the increase in FP use from 13% to 19% between 1996 and 2003.

Challenges/Unmet Needs
Unmet needs, according to Dr. Quansah-Asare, refers to women who do not want to get pregnant for the next two to three years or have any more children, but are not using any method, which is a challenge for achieving high family planning rate in Ghana.

According to her, this need is 34% currently, whereas that for rural areas is 10% higher, stressing that 'persistently high unmet need for family planning is 34 - 35%.' This is confirmed by the PRB report which indicates that unmet need usually results in unplanned and mistimed pregnancy, especially among the youth aged between 15 - 19yrs, with Ghana topping the chart in sub-Saharan Africa with a figure of 49%, Kenya - 47%, Zambia - 44%, Uganda - 42%, DRC - 33%, Ethiopia - 31%, Mali - 17%, Madagascar - 15% and Nigeria - 14%. 'In Ghana, one of the few countries where contraceptive use among adolescents has remained static in recent years, nearly 60% of adolescents report that their recent birth was unintended', the report said.

It said there were about 215 million women worldwide that have unmet need for contraception, and that among married women aged between 15 and 19yrs, it is 62% while that for married women aged between 30 to 34yrs is 33%.

A Ghanaian doctor said that rumours, myths and misconceptions about contraceptives also pose challenges for their use, and contraceptive security issues, including reduced or dwindling funding, procurement of contraceptives and programme activities, especially generating demand. Often, negative attitudes and cultural norms inform misconceptions about contraceptives, as well as fear from unknown side effects, arising from lack of or inadequate education about side effects, as pointed out by Regina, a thirty year old lady.

She has a one and half year old child and was currently pregnant with her second child, which she indicated came as a surprise to her, because she wanted to space the second pregnancy a little longer. She relies on the natural method of FP because she does not really know the side effects she might experience with the other methods, though anytime she went on antenatal clinic, they were taught the importance of FP, methods available and the efficacy of each of them, as well as some likely side effects by the nurses.

According to her, her brother's wife used one of the methods and was experiencing serious side effects, and so she thinks it is better for her to use the natural method, admitting that 'if you miscalculate, you might get pregnant, like the pregnancy I am carrying now.'

Another twenty eight year unmarried lady, Faustina, said she also relies on the natural method of FP, and sometimes on the emergency contraceptive to avoid unwanted pregnancies. She also admitted that the method had failed her once, and thereafter she went in for the three-month injectable, which made her put on considerable weight, and so she had to stop using it. She noted that though she had wanted to try another method, her fiancée thought there could be unpleasant side effects, especially because she was yet to marry and have kids, saying 'the method has been working very well for me for a long time now, especially with careful calculation.'

Way forward/ BCS Project
Dr. Quansah-Asare pointed out that FP is a pivotal service in reproductive health, hence it should be made a component of reproductive health and safe motherhood. In her view, FP cuts across most components of reproductive health, such as 'post abortion care, comprehensive abortion care, STI/HIV/AIDS prevention and management, infertility prevention and management, adolescent and male services, and gender-based violence.'

She said all individuals and couples including adolescents are eligible for FP services to achieve the goal of FP, which is 'to assist couples and individuals of all ages to achieve their reproductive goals and improve their general reproductive health.'

According to her, the critical role of FP is evident in the fact that birth rates have been shown to decline when the option of FP is made easily available, which demands an urgent action to make FP provision an integral part of all efforts to reduce poverty, improve mothers' and children's survival and health. Also critical is the need for the large and well-documented unmet need for FP to be addressed, a reason for which the 'Life Choices' (LC) FP campaign was introduced and implemented in 2001 - 2002, in league with other interventions that contributed to the increase in FP from 13% to 19%, between 1998 and 2003.

To specifically address the falling pattern in FP usage, the GHS is reintroducing the LC under the BCS project. This project is a four-year USAID project on social and behavior change communication, supported by the John Hopkins Center for Communication Programs (JHU/CCP), with CARE and PLAN International, in partnership with the Ministry of Health (MOH) and GHS.

The BCS Project Chief of Party, Mr. Ian Osei said the overall purpose of the project is to assist the GHS at the national, regional and district levels, to support its effort to achieve health related goals through sustained and coherent social and behaviour change communication.

Since FP is one of the key health areas of the project, its objective is to increase the demand and use of modern contraceptive methods and address underlying social and behavioral barriers and issues, he noted. He identified barriers that need to be removed as lack of clarity on method choices, concerns about side effects, need for men's involvement, fear of social ostracism and lack of personal relevance among others. Thus, the specific audiences to be addressed include community members/population, opinion leaders and service providers.

According to him, the new LC would be in two phases, the first comprising the use of mass media to focus on the use of existing spots, music videos and press adverts, with the objective to raise the profile of FP in Ghana. The second phase would include activities at the level of mass media, health facility materials provision for GHS facilities, and focus on communities in the Greater Accra, Central and Western regions for a concentrated outreach.

Particularly, he appealed to members of the media to assist in any way possible through the various activities outlined in the LC campaign, since their involvement was critical to its success, and to 'engender national dialogue on FP, strengthen partnership and increase coverage and placement.'

Family Planning and attainment of MDGs
Experts believe that meeting the goal of FP would spur progress towards achieving all of the MDG targets in one way or the other. According to the Dr. Quansah-Asare, increased FP use positively impacts on all the MDG goals such that it reduces rapid population growth, high fertility and large family size that negatively impacts on national and household goals.

Mr. Tweedie also said re-positioning FP through the LC is 'necessary for achieving and sustaining the MDGs.'

MDG 1 targets eradication of extreme poverty and hunger in Ghana, and in this regard, it has been established that many countries that lowered their birth rates have eradicated or greatly reduced poverty, she said. She observed that risk of poverty was higher in families with many children, whereas a 'demographic dividend' occurred when family size falls rapidly, and ensure there were relatively more people of working age with fewer dependent children.

For instance, Thailand, South Korea and Taiwan all have successfully managed to take advantage of their demographic bonus to raise the living standards of millions of their citizens. Rapid population growth undermines basic education in a vicious cycle, and limits the educational prospects of girls. Thus MDG2 aims to achieve universal primary education in Ghana, by reducing family size through FP.

This, the female doctor said would ensure that all children gain access to primary education, and lower pupil/teacher ratio for quality education.  MDG 3 seeks to promote gender equity and empower women, which means that FP would give women the ability to control their own fertility that is fundamental to their empowerment, and obtaining equality with men in many aspects of life.

As Dr. Quansah-Asare puts it, 'women without access to FP are likely to be younger, when they have their first child, and less able to space or limit subsequent births, and the early initiation of sexual activity and unintended pregnancies curtails the education for many girls.' She said MDG 4 aims to reduce child mortality, which is strongly associated with high fertility rate, because many closely-spaced children, common in large families, leads to increase in child deaths.

MDG 5 is to improve maternal health and achieve universal access to reproductive health by 2015, because maternal mortality is the second largest cause of female deaths in Ghana, caused by hemorrhage, unsafe abortion and hypertensive disorder among others. However, FP can reduce maternal deaths by 35%, by simply preventing unintended pregnancies and thereby reducing the number of women unnecessarily, exposed to all the risks of pregnancy, delivery and unsafe abortion.

Particular, fulfilling the high unmet need for FP in Ghana would avert almost 4000 maternal deaths over a ten year period, said the health expert, adding 'this means in just a year, 400 Ghanaian families would be spared the heartache and catastrophe of losing their mothers and wives to maternal-related death.'

The PRB report supports this point by saying that the target indicators for MDG 5 include the contraceptive prevalence rate, adolescent birth rate, and the unmet need for FP, because 'adolescent child bearing is risky for mothers and their infants.' It added that achieving this MDG, will therefore rely greatly on meeting the contraceptive needs of adolescents, delaying the first birth, ensuring antenatal care and skilled attendance at birth, and preventing unsafe abortion.

MDG 6 aims to combat HIV/AIDS, malaria and other diseases in Ghana. Dr. Quansah-Asare noted that rapid population growth negatively impacts on the already overstretched health systems and facilities, which is worsened by the high incidence of exodus of doctors and nurses to other countries. Thus, contraception services, specifically male and female condoms, would help prevent HIV.

Regarding MDG 7, which aims to ensure environmental sustainability, she noted that population growth worsens the environmental problems, which has been left vulnerable by climate change, adding that population pressures were adding to the difficulties in forests, biodiversity, flooding in urban areas due to rapid migration among others. Thus, FP compliance would help address this situation by reducing population growth and the pressure on these elements.

Conclusion
The issue of reproductive health is very important to the development of individuals, families and the nation at large, especially concerning attainment of the MDGs. To particularly meet the MDG target date of 2015, requires that all Ghanaians contribute towards this agenda.

This is necessary to address the needs of women and children, all youth and improve the health of families that would go a long way to increase Ghana's work force, and contribute to the eventual aim of achieving middle income status.

To this extent, health workers must also seek to avoid negative tendencies that turn away especially the youth, from accessing FP services, whereas parents and guardians must educate their children and other dependents on the need to avoid unintended pregnancies.

Teachers, religious bodies and civil society groups must also put in efforts to guide the youth in making the right choices that would improve their health, and help attain their lifetime goals, towards achieving national goals. Long Live the GHS, Long Live Ghana, Long Live Africa!

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