The first Health Watch Forum of 2018, organised by Nigeria Health Watch with the support of partners, brought together a dynamic group of speakers and delegates to look at the issue of family planning from all angles. From government to civil society, different ends of the religious spectrum, policymakers to advocates, faith leaders to development partners, no perspective was left out. The town hall-style meeting discussed Nigeria’s current action towards meeting the Family Planning 2020 commitments agreed to by Nigeria in 2017 and examined how to engage men more to support family planning. The topic for the day was aptly themed, “The Elephant in the Room – Men as Change Agents in the Family Planning Discourse”
Nigeria’s rapid population growth and its potential consequences
Why is this discussion on family planning so important? Our population statistics clearly show that Nigeria is currently the most populous country in Africa, with an estimated population of just over 194 million people, making it the seventh most populous country in the world. In the last fifty years, the urban population in Nigeria has grown on average by 6.5% annually, without a corresponding increase in social amenities and infrastructure. It is estimated that by 2050, Nigeria’s population will reach 440 million making it the third most populous country in the world with about 70% of Nigerians living in cities. This means that in just over 30 years, there will be over double the current population, meaning that we have to double the number of schools, hospitals, doctors, nurses, teachers – just to stay where we are today!
Dr, Ifeanyi Nsofor, Nigeria Health Watch’s Director of Policy and Advocacy, who moderated the Health Watch Forum, laid the facts bare. “The landmass of the country is not increasing; we are struggling with basic infrastructure, yet the population continues to increase,” he said, adding, “We are facing a scenario where more people will be struggling over increasingly limited resources in the country- and history has taught us what happens when more people fight over fewer resources.”
The Health Watch Forum was structured around two sessions with speakers and panelists in both sessions, followed by two moderated Q&A sessions. There was a minimum protocol as the participants went straight into the two sessions of the day.
Session One: “How do we accelerate action to meet Nigeria’s FP2020 Commitments?”
Session Two focused on “How do we engage men to support their partners in seeking family planning Services?”
Including men in family planning services
Dr Diene Keita, Country Representative of the United Nations Population Fund (UNFPA), started on an optimistic note mentioning that “Nigeria is the first country in Africa to budget for family planning services”, but pointed out that a lot still needs to be done, highlighting that maternal deaths due to pregnancy and childbearing in Nigeria are an estimated 576 deaths per 100,000 live births, according to the 2013 National Demographic and Health Survey.
There was a broad consensus at the Forum that despite technological advances, men have not been targeted strategically enough for family planning services and that there needs to be a more deliberate focus on men. It was suggested that FP2020 should be used to increase gender balance when structuring family planning services, with men having a significantly increased role. The concept of family planning should be pushed as a resource planning tool and the best way to reduce maternal and child mortality, as well as a way to reduce high-risk births. In the Nigerian context, men are often the decision-makers in families and determine women’s access and use of family planning services.
How can men become change agents to drive an increase in the uptake of family planning services? Unfortunately, family planning is often seen as a woman’s role with men playing a peripheral role. Most messaging and services are currently targeted at women. The layout and services offered in primary health care centres are not suited to men and often the attitudes of the healthcare practitioners may appear hostile to men. “From my experience and that of others we know, the service providers sometimes allow their personal sentiments regarding male involvement in family planning to affect the information they give”, which can negatively affect uptake, confirmed Florida Uzoaru, Founder and CEO of Slide Safe. Other contributors at the forum proposed that family planning services should be remodelled to make men more comfortable in these spaces, and for the retraining of health workers, “At the Federal Ministry of Health, we have developed training manuals on family planning and are having a re-orientation programme for our health workers,” stated Dr Adebimpe Adebiyi, Director Family Health at the Federal Ministry of Health.
Engaging men directly will also help increase acceptance of family planning services. Effiom Effiom, Country Director of Marie Stopes International Nigeria (MSION), referred to an example where a Marie Stopes initiative that targeted men resulted in an increased uptake of family planning services in Katsina and Gombe states. He emphasized that it is unsustainable not to involve men in conversations about family planning and hope that progress will be made on the targets set.
The critical role of education to increase uptake of family planning services
An interesting insight was provided by Dr Diene Keita when she mentioned that in Mauritania and Niger, a concept called the “School of Husbands” exists as an informal forum for men to discuss reproductive health issues. Could this be an avenue that is explored in Nigeria? To increase uptake of family planning services, education, both formal and informal, could be the catalyst to expand male involvement. However, education should include adolescents and younger boys and not be restricted to men, noted Dr Laz Ude Eze, Executive Director of the Pink Oak Trust and a Family Planning advocate. He informed the audience that in Ebonyi State, by his estimation and following advocacy work he had done in the state,“over 40% of the young boys in secondary schools said they were sexually active“. This is unlikely to be limited to Ebonyi State.
Although there is a Population and Family Life education curriculum developed for schools, it is not being implemented in all schools. Clear gaps in knowledge seem to exist in young and older adolescents. “As much as a whole lot of students in the campus populations know about condoms, utilization does not match ownership and ownership does not match knowledge“, Dr Laz Ude Eze further noted. An insight shared by Dr Fatima. B Muhammed from the Society of Family Health’s Adolescent 360 programme was that young people have no one they trust to give them the information they need about sexual health, and inevitably this leads to teen pregnancies. Schools should not have to shoulder all the responsibility; sexual education should start in the home. The language used in family planning needs to be sensitive otherwise it stigmatizes and discourages young people from coming forward and seeking sexual and reproductive health education. Florida Uzoaru brought a further perspective when she mentioned that “At Slide Safe we started talking about sex education on social media because it provides anonymity.”
The religious dimension to family planning
Discussions about family planning often include the religious dimension and surprisingly the Forum saw consensus in the messages from different sides of the aisle! What should religious institutions be doing to increase men’s acceptance and uptake of family planning services? Sa’adatu Hashim, the Amirah of the Federation of Muslim Women Association in Nigeria (FOMWAN) in Kano mentioned that they have been actively targeting women but there is a need for male motivators who can go back into the communities to educate men and tell them about the dangers of having too many children.
She strongly felt that beliefs had to change, and passionately stated that “men are our problem, men have to be involved in family planning!” She went on to say, “We do not view family planning as child spacing alone, we view it as having a manageable family. Where is the justice in what we are doing now? Men should see other women as their daughters.” She mentioned that FOMWAN was working with other stakeholders to engage men, such as the Emir of Kano who seemed quite open to finding a solution to the growing number of children on the streets. She finished by asserting, “If you know you cannot take care of many children, marry one wife”.
Religious leaders are critical gatekeepers in family planning discussions because they can be very influential in the decision making of men. Therefore engaging them on the importance of family planning is key. “At NURHI2, we met with religious leaders and produced a document written by them, reflecting their views on family planning”, said Mrs Charity Ibeawuchi, Senior Technical Advisor, Advocacy for Nigeria Urban Reproductive Health Initiative (NURHI).
Reverend Isaac G. Gbadero, the Senior Pastor of First Baptist Church in Zaria noted that progress was made where other methods were being used to engage men, including interfaith town hall meetings where men and women were invited, and counselling sessions on sex education and family planning for young people going into marriage. The question on most people’s minds could be why clarity on the issue of family planning is not obvious in popular religious commentary. “Most clerics are hypocrites. I always tell our clerics, if you don’t practice it, don’t preach it” asserted Reverend Gbadero, adding, “As religious leaders, we must lead by example because people follow our words as well as our actions.”
Cut your coat according to your cloth; The economics of family planning
The message that resonated most was probably the economic argument. How does having many children affect the money in your pocket? This messaging needs to be very subtle or it risks alienating the intended audience, as it would appear that one is putting an economic value on something that is unanimously understood to be priceless – a child. “Hard facts resonate with everyone. Financial consequences of not planning families have more value in conveying the message to men,” stated Dr Ejike Oji, Chairman, Association for the Advancement of Family Planning, at the Forum.
The economic argument also includes empowering women, as there is an obvious upside to men investing in their wives and daughters. When a woman is engaged in a productive venture, it reduces the time she spends having babies and once she starts bringing in money, the family is better off and it may help to reduce gender-based violence, and there is less financial pressure on the men in the family. The economic argument to control family size is a strong one, we need to make arguments that resonate with men. “When men know the economic value of family planning and child spacing, they champion the cause” Dr Oji further stated. According to Dr Adebimpe Adebiyi, “You plan your family, you end poverty”. Family planning is now about having the number of children you can afford, and this message needs to be taken to people in the rural areas and other less engaged populations.
Keeping the momentum going
The discussions during the Health Watch Forum were often animated, and speakers and delegates spoke their minds freely. We need to have more of these “crucial conversations” if we are to really move forward in tackling the challenges that lie ahead in Nigeria. “We must take family planning as a serious development strategy for Nigeria to move forward”, stressed Ibeawuchi. It is critical that discussions about sexual health take place in families, communities and the wider Nigerian society. The momentum to take action in the room was clearly palpable. How do we now translate this to the wider Nigerian population, especially the role of men as change agents in increasing the uptake of family planning services? “Tell people we are in trouble”, Dr Ejike Oji, Chairman, Association for the Advancement of Family Planning stated in his closing remarks, with a sense of great urgency.
“We all hope for rain because we want to have children, but we fear the lightning because we know that thunder is coming” – Sa’adatu Hashim, Amira of FOMWAN, Kano.