How insecurity heightens neglect of contraceptives among Nigerian women

Ramatu, 39, stands by a stack of dirty clothes at the entrance of a mud hut as she coaxes her 22-month old son, Mustapha, to sleep against the backdrop of a cacophony of noise from grinding machines, transit motorcycles, and children playing around.

The location is an internally displaced persons (IDP) camp at Damangaza where thousands of men, women and children live after fleeing from bandits terrorising their parts of northern Nigeria. Broken bottles, heaps of refuse, clogged gutters, foul smell, and zinc shacks are the features of the camp situated on the outskirts of the Federal Capital Territory (FCT).

Despite the health hazard of living in such an environment, the majority of the women inhabitants have at least seven children each, with some of the children being between the ages of two months and three years.

Ramatu has 10 children, the youngest of whom is Mustapha. According to the mother, Mustapha and his immediate siblings were born “by chance”, having planned to stop having more kids many years ago.

The decision

Sometime in February 2013, Ramatu decided to adopt a contraceptive method to avoid adding to her seven children. Her best bet for unlimited contraceptive use is a health centre in Biu, the community in Borno State where she resided before it came under attack in 2015.

Ramatu had decided to enroll in a family planning method after attending a medical outreach in the community on the benefits of family planning. Prior to this, she had been pregnant 11 times but four of them died as infants, contributing to the over one million children lost to maternal-related deaths.

She recalls her eagerness to commence contraception almost immediately after the outreach but her husband was against the idea. “After much persuasion, he gave his approval,” she said.

Ramatu began the journey of contraception and was consistent for two years before tragedy struck. Her community, Biu, was attacked by the Boko Haram Islamist sect. The villagers had been warned of an imminent attack by the dreadful sect, but they paid no heed until the night it happened.

On that day in January 2015, Ramatu and her family had just had dinner and were retiring to bed when the sect unexpectedly stormed their village.

“We left our community with almost nothing after many of them stormed our homes, killed and injured some people, and also burnt down many houses,” she said.

That night, some of the fleeing residents walked several kilometres through thick bush to find shelter in neighbouring communities, while others decided to leave the state the next day.

At daybreak, Ramatu’s family and others began the journey to Abuja, Nigeria’s capital city where they found shelter at various IDP camps, including Damangaza camp.

The camp houses over 1,000 families, many of them from Borno, Adamawa or Yobe – three states most affected by the activities of Boko Haram in the North-Eastern part of Nigeria.

Rural banditry, criminal and communal violence, and flooding are other factors that continue to displace hundreds of thousands of people in Nigeria. At least 2.7 million people have been displaced from their homes in Nigeria, according to data obtained from the internal displacement monitoring centre.

A few of these displaced persons took residence in established camps, most of which are in and around Maiduguri, while others sought refuge in neighbouring states, Abuja and Lagos. Some also moved to neighbouring countries like Niger Republic and Cameroon.

Contraceptives now luxury

Ramatu fondly remembered when she easily accessed family planning services at the Biu health centre, until her life changed in a twinkle of an eye. But having fun with her husband is what nature demands.

Since she settled at the IDP camp, accessing contraceptives has been a major challenge. Ramatu said no health facility provides contraceptives for women in the camp and she cannot afford them on her own. This had brought about for her three children, a development she described as “Allah’s plan.”

“Allah is the giver of children, so if he keeps giving us children we do not have a choice but to accept them,” she said.

The large family of 12 is barely surviving on the little money Lawal, Ramatu’s husband gets from menial jobs. “It will be impossible to divert funds for contraceptives,” she said.

Due to lack of access to contraceptives, Ramatu may never enjoy the physical, emotional, psychological, and empowerment benefits associated with family planning.

Women and children suffer the most consequences of the insecurity ravaging Nigeria, the National President of Nigeria Association of Women Entrepreneurs (NAWE), Vera Ndanusa, said.

Ms Ndanusa said women, especially those in rural communities, give birth to children almost every year because they lack access to modern contraceptives.

She said such women fail to space childbearing enough for their bodies to recuperate after giving birth.

“Women and children in IDP camps are mostly neglected and left to fend for themselves. This affects every aspect of their lives, including lack of adequate child spacing using modern contraceptives,” she said.

She warned until the government pays deliberate attention to family planning in IDP camps and insecurity-ravaged communities, “we will not get out of the woods.”

Beneficial but unavailable

Nigeria’s population, according to the country’s National Bureau of Statistics (NBS), is estimated to be 206 million, a number expected to double in less than 25 years if Nigerian women continue to reproduce at the current rate.

To slow down the unsustainable population growth and reduce the high maternal and child mortality rate, the Nigerian government at the 2012 London Summit on Family Planning (FP) made a commitment to scale up the promotion of family planning to Nigerians.

This was to be done by making contraceptive consumables available to those who need them and when they need them.

Contraceptives, family planning

Contraceptives are methods, devices, or drugs used to reduce or prevent unwanted pregnancies and unsafe abortions. They come in three different forms: the long-acting reversible contraception, the short-acting reversible contraception and permanent methods.

The long-acting reversible contraceptives (LARC) are methods of birth control that provide effective contraception for an extended period without requiring user action. They include injections, intrauterine devices (IUDs) and subdermal contraceptive implants. On the other hand, the short-acting contraceptives (SARC) have to be used in short time intervals such as in the case of condoms, and daily intake of pills.

The benefits of family planning are obvious: it allows women to space childbirth and replenishes vital nutrients lost during the process. It also allows the organs of mothers to return to normal.

According to the World Health Organisation (WHO), among the 1.9 billion women of reproductive age group (15-49 years) worldwide in 2019, 1.1 billion need family planning. And of this figure, 842 million are using contraceptive methods, and 270 million have an unmet need for contraception.

The global health body said contraceptive use is much lower in developing countries such as Nigeria, and that one in 10 women has an unmet need for family planning.

Contraceptive use in Nigeria

In Nigeria, Africa’s most populous nation, only 16.6 per cent of women are currently using modern contraceptives, according to the National Demographic and Health Survey (NDHS) 2018.

Despite the low use, the Nigerian government failed to include a budget line for family planning in the 2022 budget.

Contraceptive is one of the best ways to prevent maternal mortality and more than 90 per cent of maternal deaths are preventable if women do the right thing, the director of family health at the Federal Ministry of Health, Salma Kolo, said.

Ms Kolo said at least 40,000 women in Nigeria lose their lives to pregnancy-related issues annually. She also said over one million children under the age of five die as a result of losing their mothers to pregnancy delivery complications.

“Maternal-related illnesses kill more than COVID-19 virus. Between 40,000 to 50,000 women die from pregnancy/delivery causes yearly,” she said.

According to Ms Kolo, if a mother dies of childbirth complications, the chance of the child surviving is slim.

“To end this menace, women especially those in rural communities must embrace family planning,” she said.

But for women like Ramatu living in insecurity ravaged communities and IDP camps, unplanned, unwanted, and poorly spaced pregnancies have become their new reality.

Findings by PREMIUM TIMES show that this is largely caused by a lack of access to family planning services and supplies and the absence or overburdened health facility.

Forced out of their homes

For Linda Samuel, a mother of two and resident of Anguwan Zawo Gonin-Gora in Kaduna State, life has not been the same since her community was attacked by bandits. Ms Samuel said the night of the incident is unforgettable for the residents as their lives changed ever since.

“We heard gunshots from afar which is normal but suddenly, the shots became louder and that was when we knew they had invaded our community,” she said.

“We ran to a neighbouring community for cover,” she added.

Days after the dust had settled, the residents were advised to return to the community, even as they counted their losses. But it didn’t end at that, the bandits attacked again.

“The constant attack on this community has made it difficult for many women to keep up with contraceptive use,” she said.

She started using contraceptives a few months before the community was attacked. She is scheduled to take the injection every two months but this has become impossible due to insecurity in the community.

“Sometimes, we hear gunshots from nowhere which makes us leave our home to neighbouring communities. These unplanned movements prevent me from taking the injection because it’s impossible to go back home when the attack is still on,” she said.

Amina Umar, who also fled from Boko Haram attacks, said she stopped accessing family planning services since she got to the IDP camp at Damangaza. Although she already has nine children, how to survive is more important than looking for contraceptives at the moment, she said.

Ms Umar, the second of three wives, had found shelter at the IDP camp after their village in the Chibok area of Borno State came under attack many years ago. Before fleeing the community, she had only five children but she has added four more in the last six years.

Chibok is popular for an attack launched by Boko Haram between April 14 and 15, 2014, where 276 female students were kidnapped from the Government Secondary School in the town. At least 110 of the girls are still believed to be with their abductors.

Just like Ms Umar, Catherine, a mother of six had taken shelter at Tse Yandev IDPs camp in Makurdi, Benue State, following a midnight attack on her community. 30 years old Catherine, lived in Yelewata in Guma LGA of the state until they were attacked by suspected herders in 2018.

The attack, which left many people dead and others injured, prompted the majority of the residents including Catherine to move to the Tse Yandev camp where over 2,000 persons now call home.

She had four children before moving to the camp and gave birth to two more due to her inability to access contraceptives at the camp.

“Life m in the camp is for survival and feeding the family, not for buying contraceptives,” she said.

The chairman of the Association for the Advancement of Family Planning (AAFP), Umar Jabbi, said insecurity in some communities has reversed the gains already made in modern contraceptive use. Mr Jabbi said until the issues of banditry attack is addressed, more women will continue to ignore the use of contraceptives.

“Distance, a major barrier”

The nearest health centre for Saadatu to access family planning services is about three kilometres from her home. Saadatu, a mother of four, resides in Unguwar Salihu in Goronyo LGA of Sokoto State.

She said although she was on contraceptives for a while, she stopped taking the injections due to the distance of the health facility to her community. Asides from paying for the services and transportation, Saadatu said the incessant attacks in the community and neighbouring villages have made it dangerous to ply that route.

“When I got married, my husband and I agreed to go for family planning after two children but life happened. Right now, we are too scared to stay in our houses but we are even more scared to leave our homes to far distances,” she said.

Similarly, 35 years old Inno Yusuf, residing in the same community as Saadatu, said the banditry attacks restricted their access to healthcare services generally. Ms Yusuf, a mother of five, said “Allah gives children, we pray for provisions to take care of them.”

She said if the community had its own health centre, it would be easier for women to access adequate services. “Many women in this community are interested in it, but distance, insecurity and financial constraints are discouraging them,” she said.

Mustapha Jumare, the Project Director, Initiative for Integrated Grassroot Empowerment and Support (IIGES-PAS) in Kaduna State, said the banditry attacks especially in rural communities have made it difficult for women and children to access health services, including family planning.

Mr Jumare said the attacks also contribute to the low shortage of commodities in some parts of the country as health workers are afraid of visiting banditry-prone areas.

“Unless the issue of insecurity in the country is addressed, Nigeria may not achieve its 2030 goal on family planning,” he said.

Implications for women empowerment

While the world focuses on the health benefits of investing in access to contraception for women, the economic benefit is being overlooked. A research by the Centre for Global Development, demonstrates that access to contraception is not only correlated with but can even cause Women’s Economic Empowerment (WEE), and drive economic growth.

When women fail to practice family planning, it has a lot of negative effects on WEE, Ms Ndanusa, the national president of NAWE, said.

She said contraception not only helps women get into the workforce and attain greater heights in their professional fields, it also allows them to plan for a better future by investing in education.

“A large number of women meant to contribute to the workforce are not in the workforce, so the nation is losing a lot,” she said.

“We are losing the income these women would have been generating.”

For Ramatu and other women that lack control over childbearing, it is almost impossible to make any contribution to the country’s economy. “All they do is produce children and this is because they lack the economic power to stop the man,” Ms Ndanusa said.

The executive director of FP2030, Samukeliso Dube, said for women to manage their health and contribute positively to the economic growth of the country, they have a right to determine when and if they want to have children.

“When looking at climate change, fighting hunger and poverty, it is better to invest in family planning because it will fight those other ills,” she said.

The National President of the Nigerian Economic Society (NES), Ummu Jalingo, said women empowerment tends to increase the national income of a country. Ms Jalingo said when a woman is empowered, she gets more resources and puts them to better use which leads to more income.

She said women must be given the privilege to make decisions about their bodies and when they want to have children. “In terms of security and crises, women and children are mostly the worst hit and this impacts negatively on the economy,” she said.

She said WEE is one such characteristic that can influence a woman’s experience of pregnancy, delivery, and postnatal care.

Reducing poverty through family planning

Melinda Gates, the co-founder of the Gates Foundation, had earlier described contraceptives as one of the greatest anti-poverty innovations the world has ever known. Ms Gates said access to birth control boosts economic productivity by allowing women to earn an income and leads to smaller families with more resources to spend on children’s health and education.

“Contraceptives empower women. And empowered women … well, they transform societies,” Ms Gates said.

For Ramatu, Amina, Linda and Saadatu, there is a pattern; they are without jobs but have many children, and rely solely on their husbands for financial provision. To attain their full potential as women, the importance of family planning cannot be over-emphasised.