Nigeria has been adjudged one of the nations on earth with a high fertility rate. At 5.32 births per woman, she was ranked 21 on the UN World Population Prospects report for the period 2005-2010.1 It makes one wonder if the gospel of fertility control being preached in other nations is in anyway filtering across into our country. There abound a wide range of fertility control measures worldwide.
Nigeria has been adjudged one of the nations on earth with a high fertility rate. At 5.32 births per woman, she was ranked 21 on the UN World Population Prospects report for the period 2005-2010.1 It makes one wonder if the gospel of fertility control being preached in other nations is in anyway filtering across into our country. There abound a wide range of fertility control measures worldwide.
Methods of fertility control range from the natural methods through the familiar Pills and Condoms to the less familiar types such as the long lasting and reversible ones like the Implants and Intra Uterine Systems. The list does not end there; the traditional African methods are relevant in our environment whereas, the most effective permanent measures that are Vasectomy and Tubal Ligation do not enjoy much popularity on this part of the planet.
It would be imperative at this start to highlight the subtle differences that exists in the many terminologies that abound in the reproductive health domain. Contraception means any measure that prevents conception – in essence, fertilization. It prevents the egg from meeting the sperm in the first place and in certain religious sects, this is a more palatable way of viewing the big picture. Family planning is when a couple desires to have a child at a particular time. However, the reality is that not every person wishing fertility control has or wishes to have a family. Birth control is a term that has caused more controversy than ever intended by those who coined it. It refers to all measures, with the ultimate goal of preventing pregnancy and birth. Birth control measures therefore act at any point before conception, post fertilization through implantation to birth. Simply put, Birth control includes contraceptives, emergency contraception and abortion which still carry significant stigma in the Nigerian society (even though it is in the very fiber of the Nigerian reproductive health fabric - a subject for one of my future write up). At this point, most readers would have decoded why I used the term fertility control in the title of this article. It is because; it is a more acceptable term in the arsenal of the reproductive health gurus. It maintains neutrality and is easy to understand. It refers to men and women, taking responsibility for and controlling their fertility. Needless for me to say that Nigerian women and men controlling their fertility is of paramount importance to us as a nation because it is one key factor that will alleviate the burden of our national reproductive health crises.
Join me to take this walk down the life of the average Nigerian man and woman. We start our journey from their teens: what did our parents ever tell us about our changing bodies? Nothing. Discussions about contraception - my God, that was and still is a taboo! Any formal help from the schools? There was none. Informally from each other, these teens glimpse half-truths of what is. So how did we learn? Well, we simply learnt on the job. Culturally, discussions about anything that so much as mimics sex education should not be. Yet, these boys and girls move from their teens through adolescence, to adulthood and all of a sudden are faced with sexual and reproductive, responsibilities they were never equipped for in the first place. Fertility control is one of such responsibilities. What choices are there? How do we surmount the cultural barriers in our psyche that limits our assessing these options even when they are available?
I will over the next couple of paragraphs, highlight the trends of fertility control, dispelling the myths, highlighting the Nigerian challenges and laying bare the truths in a simple way that will better inform our readers and help them in seeking help. This is very important because these challenges and the unspoken word that is fertility control help to fan the embers of maternal mortality and morbidity which is a huge health burden in Nigeria. In Nigeria, the UN’s World Health Organisation says one in every 13 women die during childbirth, making it the country with the second highest rate of maternal mortality in the world. Hence any preventable pregnancy will help reduce these figures.
I will start with the challenges which one could classify into two broad groups. The physical challenges such as poor infrastructure, availability and accessibility and the non-physical challenges posed by our belief systems, culture and way of life. Mind you, there are no clear cut boundaries between these classifications if anything; they overlap more often than not presenting the even tougher dilemmas of ‘the grey area’ challenges.
The first challenge to surmount is “my people perishing for lack of knowledge”. Poor public enlightenment and the culture of not speaking about all things that has to do with the region between our legs as Nigerians does not help. We make use of these parts of our anatomy so why pretend like they do not exist? Why not get to understand and speak about them more to enhance optimal performance and quality of life for our men and most importantly, our women? Starting from the homes, parents need to sex educate their adolescent children; schools need some sort of reproductive health curriculum; jingles in our local languages in our markets and post natal clinics for example , will go a long way to providing the adequate information on contraception.
The second challenge is the “male child syndrome” .Did I hear you ask what this means? Take a case scenario where a lady has had 4 children and the last one was by an emergency Caesarean section because she had very poorly controlled raised blood pressure. She has been advised not to have any more pregnancies but she just has to have more children. She will not have any contraception because her 4 children are all girls. She needs to try one more time just to see if she can have a boy. Even when a few good men do not complain, the women are convinced that someday they would be booted out of their homes if they do not produce the heir. Some men out rightly say to the lady that she must produce a boy. Medically, we know the evidence abound that a woman will only give birth to what her husband gives her (male or female depends on the sperm; this is a topic for another day). So, this poster lady may end up trying 3 more times making 7 children and yet no boy or she eventually gets her boy. This male child syndrome is closely tied to the “polygamy factor”. This is because should it be a polygamous setting and another wife has a boy; this lady in question is ready to get to number 10 to prove to her fellow wife that she too can have a boy. She does not care if she dies in the quest. She will not have any contraception unless she has a male child.
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Next is the “my husband does not want me to have contraceptive challenge”. When I discussed with one of these women, she said her husband believes that pregnancy is the trap that catches the unfaithful wife. In his opinion, once a woman has contraception on board, she becomes free to bed hop with no repercussions! Such a man is innately programmed to keep the contraceptive word unspoken.
“My friend said it was bad for her” challenge is another major huddle. If one contraceptive measure does not suit one lady, it does not mean it will not suit the next. There is no one size fits all contraception. I should emphasize it here and now that women should be individualized according to their age, their marital or single status, other underlying health problems or life style habits and hobbies to enable a holistic approach to them choosing a contraceptive measure.
“I cannot cut my manhood/ my tubes” is a mental and cultural block I find fascinating. This brings to mind a lady I once saw in my consulting room after her 6th child. She was not very fortunate to benefit from other measures because she was over 40 years and hypertensive, had bled uncontrollably in the past with implants and the Mirena IUS made her put on weight. She was a good candidate for tubal sterilization or for her husband to have a vasectomy. You could have seen the shock on my face when this very educated couple told me that they wished to go to their graves with every single part of their anatomy; she declined sterilization and he declined a vasectomy. With due respect to the population of women empathic Nigerian men, I would point out here that the average Nigerian man who has a high polygamy potential would find it very difficult to consent to vasectomy. This has often been put forward to health care practitioners out of ear shot of listening wives.
“I do not want anything in my body” is a common response from many women to the idea of an IUCD, IUS or an implant. One would think these women are referring to cocaine pellets with the vehemence they say this. However, this is a mental block challenge we need to surmount. I agree that it may sound unpalatable having some foreign object in one’s body, but so is a knee replacement or a pacemaker device and yet people all over the world plus in Nigeria would have it without blinking twice. The fact that one condition appears with a clear for all to see immediate fatality and another is a potentially fatal avenue down the path of morbidity and mortality, affects choices. Why not give it a try and see if it works for you. If it does not, there is always another option to try. Putting up this mental block does not help. These are long acting contraceptive measures that are very effective. However, insertion and removal especially in the case of the implant beneath the skin requires some skill
“Availability of facilities and cost” challenge. Another doctor friend of mine has to make orders from abroad for the Mirena IUS for her patients who request it. It is therefore expensive and affordable only to the elite. This grieves my heart because, it is no rocket science deduction that the woman in the market place, those in the rural areas and the financially challenged in our society constitute the bulk of our maternal mortality and morbidity statistics. They ultimately, should be able to have access to these facilities for us to win the fertility control battle.
Traditional measures should never be underestimated. Ever seen the lady with colourful beads round her waist? I have seen them. While some are purely esthetic, others are supposed to have fertility control powers. I have often wondered; do they actually work? I beg to be forgiven because my doubt may stem from my background as a medical doctor however, I am open to being educated by anyone who reads this article and is willing to provide me the hard evidence showing efficacy of the varied traditional fertility control agents in use. I have gone to the extent of asking my mother and other older ladies what traditional fertility control their generation had. Ironically, apart from polygamy which one pointed out and which made sense to me, the others are a joke. Yes, polygamy was a way of fertility control albeit unintentionally in most cases. Take the example of one man, four wives. He takes turns to sleep with each woman. One of these ladies may perpetually be unfortunate to have the man take his turn with her when she is not ovulating. Should this bedding rota not change due to some unprecedented event like one wife travelling, or is sick or just delivered, some women may end up with the barren label.
Finally, fertility control should like most reproductive health issues be treated as a burden borne by two: both males and females. This is because firstly, contraception requires both parties to discuss it but needs the woman to decide what she wants in the final analysis. In my experience, a lady x comes to the hospital, seeking a birth control method. You take the time to explain all the measures, and then she tells you, I need to ask my husband what he wishes to do! Seriously, lady x, is it your husband who carries these pregnancies or is it you? Are you the one with heavy periods who can benefit from Mirena IUS reduction of menstrual loss or is it he the man, saying you should take the pills instead of the Mirena IUS. My friend recently wanted a sterilization at caesarean section (3 previous normal deliveries and this fourth one a c/s) however, her husband told her, not to try it. She later said to me, ‘for peace to reign in the home, I had to give up on the idea’
A LOOK AT FERTILITY CONTROL MEASURES IN A BIT MORE DETAIL
Natural contraceptive methods
The goal is to avoid the sperm reaching the egg. Natural family planning calculates the time in a woman’s monthly cycle when it is safe to have sexual intercourse with a reduced risk of pregnancy. If the instructions are properly followed, natural family planning methods can be up to 99% effective, depending on what methods are used. This means that one woman in 100 who use natural family planning will get pregnant in one year. It will be less effective if it's not used according to the instructions – it takes commitment and time to achieve 99% effectiveness.4
It requires couple co-operation, about 3-6 months to first study the pattern of a woman’s cycle and teaching by someone who has the expertise. Other fertility indices like body temperature and cervical mucus consistency use increases efficacy.
Your menstrual cycle lasts from the first day of your period until the day before your next period starts. The length of a woman’s menstrual cycle can vary. Anything from 24 to 35 days is common, although it could be longer or shorter than this. The average length of the menstrual cycle is 28 days. Ovulation occurs roughly halfway through your menstrual cycle, usually around 10 to 16 days before the start of your next period. Ovulation could happen earlier or later than this, depending on the length of your cycle.4 It is unsafe to have unprotected intercourse during this ovulation period bearing in mind that the sperm could live for 7 days after sex; so you must make allowance for this.
I must point out here that periods of stress, illness or certain drug use can alter a woman’s cycle. A lady once asked me in Nigeria how with this hot temperature in our country, she will be able to tell any subtle temperature difference. It is advised that early morning temperature should be taken and there is an average 0.5-1 degree centigrade rise at ovulation. The multiplicity of environmental and psychological fluctuation makes this method a challenge but for those who are dedicated, they do achieve good results.
Barrier contraceptive methods
The female diaphragms and the cervical caps are physical barrier methods that do not allow the sperm to come into contact with the female egg and fertilize it. 2% of women aged 16-49 use diaphragms, caps, sponges or female condoms. 3 Their popularity as forms of contraception has declined with the availability of more effective methods. However, they still offer options to those who are unable to use other forms through personal preference or contra-indications, or for those who desire a female-controlled form of contraception. However, they are not very common to get in Nigeria, once used, they cannot be reused and they need proper teaching to enable effective use plus some are noisy.
The female barrier methods have never been very popular in Nigeria. The male condom continues to enjoy leading popularity. It also requires correct application on an erect penis to be effective. It is bound to fail if it is only worn half way through the sexual act just prior to ejaculation. One set back is that it leaves contraception solely in the hands of the male. Many a male patients have told me that their satisfaction is not optimal with condom use. Most of this is a thing of the mind and today there are very sensitive materials with some latex free ones (useful in cases of latex allergic persons) used in condom production.
The failure rate of condoms in couples that use them consistently and correctly during the first year of use is estimated to be about 3%. However, the true failure rate is estimated to be about 14% during the first year of typical use. This marked difference of failure rates reflects the error of usage. Some couples fail to use condoms every time they have sexual intercourse. Condoms may fail (break or come off) if you use the wrong type of lubricant (for example, using an oil-based lubricant with a latex condom will cause it to fall apart). The condom may not be placed properly on the penis. Also, the man may not use care when withdrawing. 5
The ability of barrier methods to prevent not just pregnancy but also to provide protection against sexually transmitted infections when used properly makes it a double edged arsenal in the reproductive health battle ground of Nigeria.
Hormonal pills and patches methods of contraception
These stop the sperm from meeting the egg or act by stopping egg production in the first place. Their common factor is that they contain active hormones. They more often contain the two hormones estrogen and progesterone in which case they are called combined oral contraceptive pills (COCP)/ patches. Others contain just progesterone and are called progesterone only pills (POP) or mini pills. They change your body's hormonal balance so that your ovaries do not ovulate (produce an egg).They cause the mucus made by the neck of your womb to thicken and form a mucous plug. This makes it difficult for sperm to get through to fertilize an egg. They make the lining of your womb thinner. This makes it less likely that a fertilized egg will be able to attach to it.6
There are varied brand names in the market and I will refrain from mentioning any here because a detailed consultation at the closest family planning clinic to ensure that a woman is assessed to check if she is fit for a particular type of hormonal contraception is a must before use. It is not appropriate like we do in Nigeria to run into the next chemist store and ask for pills xyz which my best friend is taking. This is because apart from the daily need for drive and compliance with taking these medication, other factors considered are age, migraines, smoking, heart diseases, weight gain, acne, just to mention a few.
Nonetheless, it is important to know that patches are replaced weekly for 3 weeks and then there is a 4th patch free week before you start the cycle again. Pills could be continuous daily ones or ones where you have a pill free week before starting all over again
Long-acting reversible contraceptive methods (LARC)
Reversible long acting methods could be hormonal or non-hormonal. The duration of action of these methods ranges from 3 months to 10 years depending on the type. If you want reliable contraception that you do not have to remember every day, a method that takes out the hassle and gives spontaneity to sex, then these methods may suit you. They are over 99% effective but however, they do not protect against sexually transmitted infection like barrier methods do. Some of them on the flip side actually predispose to ascending infections of the pelvis spreading rapidly should a woman be exposed.
The hormonal injection
These are deep intra muscular injections that are easily given by the nurse or doctor. They contain the hormone progesterone in an oily base that makes it active for up to 2-3 months; preventing pregnancy .It requires follow up compliance every 2-3 months to be effective and may cause irregular bleeding with the first one or two injections. However, with sustained use, it can completely stop a woman’s period. When this injection is stopped, it may take over a year for usual levels of fertility to return.
The copper coil or IUCD (Intrauterine contraceptive device)
Is a small ‘T’ shaped device that sits within the womb, having threads at the end which the woman should feel every month post each period to ensure the coil’s correct positioning. It has no hormones but often has very small quantity of copper wound around both arms of the ‘T’. There are several different types and it requires only a few minutes for trained doctors or nurses to put it in position.
It is effective for between 3-10 years. If at any time a woman opts to have it removed, it can be taken out in a matter of minutes and fertility returns to normal very quickly once removed. It is not age limited; however, because of the existence of the threads which are in the vagina that can predispose to infections ascending the female reproductive tract rapidly, it should be the exclusive preserve of those in a strictly faithful monogamous set up. Hence its use in young, single unmarried ladies who have a higher risk of multiple sexual exposures is not encouraged.
The copper coil use may make some women develop heavier and more painful periods. In extremely rare cases, should this method fail, it increases the risk of a woman having pregnancy in the tubes.
The hormonal coil or Mirena IUS (Intra uterine system)
Is very similar to the copper coil however, the difference is that it is hormone impregnated. While sat within the womb, it releases small amounts of progesterone directly into the lining of the womb where it is needed to avert pregnancy. Insertion and removal is similar to the copper coil and it lasts 5 years. It can also be removed at any time and fertility also returns to normal early. Other side effects are similar to that of the copper the only difference being that unlike the copper coil however, the Mirena IUS, reduces heavy periods and women may experience a reduction in bleeding volume within 3-6 months of fitting it.
The hormonal sub dermal implant (SDI)
This is inserted in the upper arm just underneath the skin. It is a small white rod, approximately the size of a regular match stick. This tiny rod contains the hormone progesterone which it releases into the system. It is effective for 3 years if properly fixed. Though fitting this rod takes only a couple of minutes, it requires more training and skill than other methods to fit and remove. It can be removed at any time, has no age limitations and fertility returns to normal soon after removal.
Apart from the fact that it has been known to cause erratic, heavy and prolonged or infrequent bleeding in women using it, another thing to consider is that it may require a minor surgical procedure to have it removed. Increased keloid forming populations like ours, have also expressed some reservations to having implants
Permanent contraceptive methods
Sterilization
So my dear readers; have you completed your family? Does a woman have a debilitating illness? Then a permanent procedure is the next best thing. Sterilization of either male (vasectomy) or female (tubal ligation/blockage) is not reversible so you should be completely sure you do not wish to have any more children or be ready to live with no children should your circumstances change. These require trained doctors to cut or block the tubes that transport eggs and sperm respectively. It could either be an open surgical procedure or key hole surgery. Certain methods of permanent tubal blockage could even be done as office procedures (Essure is one such example). For earlier pointed out reasons, these are not very popular in our country. A patient once asked me, ‘doctor, what if I marry a second wife, how will I impregnate her?’ Yet another said to me ‘Doctor, if you cut my manhood, how will I perform?’ The second question is easier for me to answer because vasectomy does not cause erectile dysfunction if done properly. However, the first question is a matter of choice, which doctors cannot answer – only the patients can answer this. We as health care providers need to give all the information in detail that will enable the client make an informed choice.
In conclusion, I thank you my dear readers for sticking with me till now as I conclude this write up. We have highlighted our society’s major challenges to fertility control. We now know what is available out there and we are armed with the basic information to stimulate our curiosity to search for more information. Get searching on the internet and start asking your doctors question. Begin preaching to your friends and family. Spread the word; let us begin to modify our cultural bias and together, we can begin to say the word that is fertility control. We as Nigerians will each take our fertility and that of the next generation seriously and by extension help to alleviate the stigma that is maternal mortality and morbidity that ranks us low on the reproductive health terrain.
REFERENCES
1. The UN ranking is sourced from the United Nations World Population Prospects. Figures are from the 2006 revision of the United Nations World Population Prospects report, for the period 2000-2005 and 2005–2010. http://data.un.org/DataMartInfo
2. World Health Organisation http://www.who.int/gho/maternal_health/countries/en
3 Contraception and Sexual Health 2008/09, Office for National Statistics (2009)
4. The NHS Natural family planning and fertility awareness http://www.nhs.uk/Conditions/contraception-guide/Pages/natural-family-planning.aspx
5. Barrier methods of contraception http://www.emedicinehealth.com/birth_control_barrier_methods/page2_em.htm
6. Combined hormonal contraception
http://www.patient.co.uk/medicine/Combined-hormonal-contraceptives.htm
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The views expressed in this article are the author’s own and do not necessarily reflect the editorial policy of SaharaReporters
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