Against practice standards, Nigerian health workers, especially in public health institutions, ascertain the marital status of women to decide whether or not to give them contraception.
In 2019, Adesuwa (not her real name) made her way to a maternity centre, the only government-owned health facility around Aduloju/Bodija area of Ibadan, Oyo State, to get a contraceptive as she wanted a stronger conviction beyond condoms and calculating safe periods.
Against the standards of practice, health workers, especially in public health institutions, on ascertaining the marital status of women, decide whether or not to give them contraception.
Unmarried women are often denied contraception while for married women, their husbands’ consent is usually sought before contraception is issued. In some cases, unmarried women are advised to get married.
“Are you married?,” the nurse asked Adesuwa, 28. When she replied no, the nurse said she could not administer any contraceptive, advising her to go get married after asking how old she was.
Adesuwa went home without getting any contraceptive and continued with condoms and calculating her safe periods which is a traditional method of contraception.
One day in 2021, after sharing a pleasurable time with her lover, Adesuwa realised that the calculation of her safe period had not been accurate. She took an emergency pill but it was a little too late.
“I bought the pill, took it then I was waiting for my period, it did not happen so I felt there was a delay… “
When her menstrual flow for the next month was delayed, she believed it was the emergency contraceptive she had taken.
“After three weeks, I took a pregnancy test and I was positive. I spoke to a friend and we got Mifepak which was illegal to sell over the counter.”
Adesuwa, who was still not ready for a child, called a friend for help. Her friend recommended Mifepak (a drug used to induce abortion during early pregnancy). Mifepak is illegally sold over the counter in Nigeria.
“I bled after taking the medication. I felt it was over. I fell ill but thought it was malaria and went to get malaria medication. I had a uterus scan just to be sure and nothing was found; I felt better after taking the malaria medication.
“Later, I started having pain in my stomach; I could not lie or sit. I reached out to a doctor friend who recommended paracetamol for the pain. Although I threw up after taking it, I felt better and slept,” an emotional Adesuwa narrated.
As recommended by her doctor friend, she went to a laboratory with a friend to get another scan.
While waiting for her turn, the pain returned.
The scan revealed she had a ruptured ectopic pregnancy and had lost so much blood and needed urgent surgery.
“The attendant said I had a few hours to live.”
She was rushed to a hospital to evacuate the blood and ruptured fallopian tube.
“The foetus was still alive at the time of the scan but I had only one option which was to stay alive,” Adesuwa said, adding “I just wish our health workers can be logical, not sentimental.”
Adesuwa would not have had to deal with this life-threatening situation if the nurse had administered a contraceptive to her two years ago.
“It was ‘Detty December’ and I knew I wanted to have sex. I cannot take care of a child and so getting a contraceptive (injectables) was the only option,” Talata Salihu narrated her experience accessing contraceptives.
Ms Salihu chose a private facility because she did not want to be judged for her decisions.
“I went to a private facility (Marie Stopes) whose major work is around these issues and also because I was not sure I would not be judged at a public facility,” she said.
In Nigeria, unmarried women face discrimination and stigmatisation while trying to access family planning commodities except for condoms and emergency contraceptives that can be gotten over the counter.
Abortion is illegal in Nigeria. The anti-abortion law states that a pregnancy can only be terminated if there is a life at stake. So, contraceptives become the only other option for preventing unwanted pregnancies.
Interestingly, Nigeria’s 2018 demographic and health survey (NDHS) shows that the use of contraceptives in Nigeria is more prevalent among sexually active unmarried women than among married women with a contraceptive prevalence rate (CPR) of 37 and 17 per cent respectively.
Ironically, there is also a high percentage of unmet contraceptive needs among sexually active unmarried women as compared to their married counterparts; 48 and 19 per cent respectively.
Of the 37 per cent (CPR) among unmarried women, 28 per cent use modern methods of contraception while nine per cent use traditional methods; 12 per cent use modern methods while five per cent use traditional methods.
Modern methods of contraception include male and female sterilisation; injectables; intrauterine devices (IUDs); contraceptive pills; implants; female and male condoms; the standard days method; the lactational amenorrhoea method (LAM); and emergency contraception.
Implants, injectables and male condoms are the most used among the two groups of women, the survey further reveals.
A pleased Asari Ndem narrated how she got an IUD without a fuss at a private facility.
According to Ms Ndem, “it is important for women to access contraceptives especially for a country like Nigeria where we have an overpopulation problem. It is also a way of taking control of your body.”
She added that for a country that upholds purity culture, it is important to note that women are sexually active and they do not need to be married before they can access these commodities.
“Preaching abstinence rather than safe sex education is more harmful than useful to society,” she argued.
Aisha Sadiq, who is now married, narrated why she would not dare as an unmarried and younger woman to access or use contraceptives.
“I never tried to get contraceptive while I was unmarried. The idea of doing it was simply inconceivable. First of all, there was the fear that the neighbourhood pharmacist would report my purchase to my mother.
“Also there was the stigma attached to single girls who not only had the effrontery to engage in pre-marital sex but also had the audacity to buy contraceptives to protect unwanted pregnancies,” Ms Sadiq said.
Religion and Culture
Several studies suggest that cultural and religious beliefs as well as the culture of shame and stigmatisation in Nigeria dissuade most women, especially unmarried women.
In a study titled ‘When Do Nigerian Women of Reproductive Age Initiate and What Factors Influence Their Contraceptive Use? A Contextual Analysis’, Ekholuenetale et al found that religious practices may influence contraceptive use.
“The north, which is predominantly Islam, has the lowest prevalence rate (one-fifth), against (one-third) which is recorded for the catholic faith (predominantly resident in the south east) and 41.4% recorded for other Christians (predominantly South westerners). This suggests that there may be some religious practices supporting or discouraging contraceptive use,” the report stated.
Another study by Phillips Obasohan titled ‘Religion, Ethnicity and Contraceptive Use among Reproductive age Women in Nigeria’, found that contraceptive use among women of reproductive age in Nigeria significantly varied by ethnicity.
“The possible reason for this is the cultural belief of most of these women that God has placed Children in the womb of a woman and until they are given birth to, you do not stop,” the report stated.
Perhaps a more interesting part of accessing contraceptives in Nigeria is the misinformation around the phenomenon.
Adaugo Ibezim narrated how two years ago she wanted to get an IUD and confided in her friend who in turn told her that the device will decay in her body.
Ms Ibezim got scared and has since resorted to emergency contraceptives which are not ideal and are meant for emergency situations only like the name suggests.
Ministry of Health’s Response
Salma Ibrahim, Director Family Health Department at the Federal Ministry of Health, corroborates the findings of these researches. She told PREMIUM TIMES that barriers to accessing contraceptives especially for married women include the inability to make unilateral decisions; that is, they cannot make decisions without the consent of their partners or family members.
She added that indeed there is a huge gap in unmet demand for the sexually unmarried as rightly indicated by the NDHS 2018.
However, “most times unmarried females try to access contraceptives from public health facilities, there is fear, anxiety, which mostly is due to cultural issues and healthcare providers are in most case judgemental and it creates stigma and discrimination which makes young people uncomfortable accessing these services.”
“When this happens, they resort to buying over the counter from drugstores and pharmacies,” she said, adding that this act violates the standard of practice put in place by the federal government to enhance access to family planning commodities.
“Additionally, lack of access could lead to unwanted pregnancy which is most times accompanied by unsafe abortions; negative psychological effects; children who parents are unable to cater for.
“There should be equity in access whether you are married or unmarried, there should be no form of bias in providing services to clients. This is an area we feel is still a weak link to the service we are providing,” Ms Ibrahim noted.
If the discrimination and stigmatisation associated with accessing contraceptives continue, Nigeria may again not meet its target of 27 per cent increase in uptake of family planning commodities by 2030.
Although there is no legislation yet to sanction or punish health workers who violate these standards, as a way forward, Ms Ibrahim said the ministry has continued to provide training and build the capacity of health workers, ensuring that public health facilities provide youth-friendly services.
Also, she said, the health ministry was partnering with traditional and religious leaders to encourage and influence the uptake of family planning commodities.
The use of contraceptives and the family planning initiative all over the world is essential to manage the exponential increase in population. According to statistical projections, if Nigeria continues in its current direction, there will be a 100 per cent increase in its population by 2050 – 400 million people.
Despite this projection, Nigeria made no budgetary allocation for family planning in its 2022 budget. The Federal Ministry of Health only made a one per cent provision for family planning after groups spoke against the budget.
In Lagos State, the economic capital of Nigeria, discriminatory access is also rife when it comes to family planning commodities.
“Yes, even if the unmarried is older in age. Reasons for this have to do with our culture and individual beliefs. A lot of family planning providers are biased and can be very judgemental which is an act of discrimination that affects acceptance and uptake,” Folashade Oludara, Director Family Health and Nutrition at the Lagos health ministry said while commenting on discrimination faced by unmarried women.
She said contraceptives should be easily accessible and affordable.
“There must be providers with appropriate technical counselling and good interpersonal skills.”
Lagos State has seven Youth Friendly Centres and four Young Mom’s Clinics that are functional, to curb the discrimination, she said.
Ms Oludara said a few of the centres are stand-alone but the majority are within the health facilities due to funding and space constraints.
She said there are no sanctions for defaulters because patients do not report directly.
“Discriminatory access to contraceptives in Nigeria, especially for unmarried women, contravenes the principle of inclusiveness and the provision of universal access in a bid for universal health coverage,” Stanley Ukpai, the director of programmes at Development Research and Projects Centre (DRPC), said.
“Unmarried women are a key index that still contribute to the population growth, hence their exclusion is a faux pas in the process of population management through family planning services.”
He said the effect of this discrimination will be seen in the rise in unmet needs for contraceptives, low contraceptive prevalence rate, increase still in the prevalence of maternal mortality and neonatal mortality.
“Excluding unmarried women who are active from contraceptive use may impair us from reaping demographic dividends. When women are purposely denied contraceptives, their rights to decide on when to conceive and how many they can have are affected. The rates of abortion may rise and this has effects on the probability of mortality,” Mr Upkai said.
Mr Ukpai added that aside from the effect on mother and child health, it also affects the economy of the country.
“Our GDP is still struggling and Nigeria is still trying to come out of the recession from two years ago. If we continue to grow unmanaged, this has implications,” he said.
“If the landmass is receding, like we hear in the case of Lake Chad, and population keeps rising, there will be restiveness which will lead to competition for scarce resources which will, in turn, lead to insecurity.”
Mr Ukpai recommended that the government become more intentional in ensuring equal access to these commodities, especially for younger people.