The Joy Of Child Spacing While Giving Birth: One PHC’s Story

View of Rijiyar Lemu PHC. The facility serves the densely populated Rijiyar Lemu area in Fagge LGA, Kano. Photo credit: Nigeria Health Watch

Rijiyar Lemu Model Primary Health Center (PHC) along Kano — Katsina road on the outskirts of Kano city centre is unlike many other PHCs in Nigeria. Although the building is somewhat rundown and could do with some renovation, the PHC is large enough to accommodate several offices and there is a moderate staff force. Besides the regular outpatient and inpatient services, antenatal, immunization, maternity services and family planning services are also available. The PHC serves the densely populated Rijiyar Lemu area, which falls under Fagge LGA.

The PHC has a child spacing unit, one which has seen a steady increase in the number of women wanting to space their children. Referring to it as a ‘Child Spacing Unit’ instead of the widely used term ‘Family Planning Unit’ was deliberate. Family planning is still seen as foreign in many part of northern Nigeria, and it is seen as part of western culture. Therefore, the term ‘child spacing’ has been largely adopted by stakeholders when advocating for the use of family planning services. This is what Rijiyar Lemu Primary Health Centre has done.

The total fertility rate of Nigerian women is 5.53 children in their lifetime, this is higher than the global average of 2.4, and also higher than the fertility rate of other developing countries like Brazil, India, South Africa and Ghana. In other words, Nigeria’s population is growing faster than the world’s population. The Federal Government recently identified Nigeria’s population growth as one of the issues that needs to be addressed for the country to experience sustainable economic development. Controlling the population growth rate will benefit Nigeria, and there is no better way to do that than to have inclusive policies that will enable the use of contraceptives to increase. Nigeria’s modern Contraceptive Prevalence Rate (mCPR) is 10.8% for all married women and 10.4% for any method, according to the Multiple Indicator Cluster Survey (MICS) and the low demand for family planning services is one of the factors that hinders the drive to reach a CPR of 14.9% by 2020. The Federal Ministry of Health launched the ‘Green Dot’ initiative in 2017. The initiative was aimed at improving family planning services by providing various methods of contraception in health facilities across the country. Although the success of the scheme is yet to be determined, the initiative could get a great boost in demand if improved.

Image credit: Nigeria Health Watch

The use of contraception is lower in northern Nigerian states. With Kano at 6.3%, its neighbour Jigawa has the lowest contraceptive prevalence rate at 1.3% in this age group. Kwara State has the highest use of contraceptives in the northern states at 27.1%, followed by Kaduna State at 24.1%. This is in sharp contrast to many states in South-West where contraceptive prevalence rates are above 20%. According to MICS survey, Oyo State has the highest CPR in the country at 34.2%.

Simple Conversations that make a Difference
The journey to accepting birth spacing in Rijiyar Lemu PHC usually begins at the antenatal unit. In the past, demand for family planning services used to be very poor. Some days, they receive no patients and on other days, they would see about four women. The midwives therefore decided to take advantage of the women’s antenatal visits to emphasis the importance of family planning. In between the routine health talks on the nutritional needs of the women and their babies, the importance of continued antenatal visits, light physical activities, etc, they would stress the positive impact and joy of child spacing on their health and their children, as well as the economic benefits on the overall family. The women are also informed about the various birth spacing options available, and how each option works. This takes place on antenatal days which is usually on Tuesdays, and at any individual appointment a pregnant woman may have. An average of 120 women have antenatal visits every Tuesday and each woman goes home armed with the knowledge that she has the power to decide when to get pregnant.

Entrance to the child spacing unit at Rijiyar Lemu Phc. Photo credit: Nigeria Health Watch

Through these actions, Rijiyar Lemu PHC has helped create a positive perception of child spacing among the women, which has resulted in a high demand for family planning services among married women in the area, so much so that some women now request for birth control products in the delivery room after giving birth. Midwife Maimuna Saidu, says this simple strategy has helped create an appreciable level of awareness about the benefits of child spacing not just among the women, but also the men as their wives often share their knowledge with their husbands, who sometimes accompany their wives to the unit and get involved in deciding the option to be used. The involvement of men in sharing the decisions about child spacing is essential in order to increase the demand for contraception.

The child spacing unit has been designed to ensure that the women, some of whom come with their husbands, receive counselling in privacy. The room is partitioned with wooden plywood to ensure privacy. Couples are given detailed explanations about the different family planning product in the outer room and are able to choose their preferred method. The inner room has a bed that is used by the health workers for consultations with the women.

Inside the inner room of the child spacing unit where family planning procedures take place. Photo credit: Nigeria Health Watch

Ms. Rukaiya Isiyaku is one of the three staff members running the unit and providing services to women. She mentioned that the unit has most contraception commodities, from Intra Uterine Devices (IUDs) to oral tablets and injectables and the whole process from counselling to service delivery is free as the commodities are supplied by the local government health office. Interestingly enough, condoms although available, are very rarely used. A clear indication that ultimately women bear the responsibility for contraception. The women that Ms Isiyaku assists are most comfortable with injectables as their use is less invasive and there is a reduced tendency for doses to be skipped. Oral pills which need to be taken daily are also used, however their use comes with the risk of missed doses or the loss of interest from consistent use. The Rijiyar Lemu PHC child spacing unit has been attending to an average of 20 women a day over the last two years.

Jummai Yunusa Abubakar is a resident of Rijiyar Lemu and one of the women receiving child spacing services from the PHC. Three years ago, Jummai became pregnant just three months after giving birth, a situation she said that made her and her husband very worried. She rushed to the PHC to seek advice and was informed about child spacing options. After giving birth, she requested to be placed on a contraception and this enabled her to take proper care of her daughter by breastfeeding her for 20 months, before getting pregnant with her now 6-month-old baby, Aliyu. Jummai said her three-year-old daughter is healthier and stronger than her older brother, because she had the opportunity to be breastfed for a longer period, unlike her son who had to be weaned within few months after delivery. After seeing the benefits, she plans to continue using child spacing products until Aliyu is at least two years old.

Family planning provider Rukaiya Isiyaku holding some of the family planning products in the procedure room of the child spacing unit. Photo credit: Nigeria Health Watch

To reach potential users like Jummai, the Kano State government must create a platform for health workers to periodically carry out sensitisation activities in local communities.

Rwanda’s family planning success is a testament to the fact that the use of community health workers is very effective. Rwanda’s leadership has been highly supportive of family planning; in recent years, the country has invested in its network of Community Health Workers (CHWs), run communications campaigns to drive demand and behavioural change, as well as providing training on long-acting and permanent contraceptive methods. There has been a dramatic rise in the country’s contraceptive prevalence rate for modern methods between 2000 and 2015, from 4% to 48% and a drop in total fertility rate from 5.8 in 2000 to 4.2 in 2015.

The strategies behind these successes will be shared with stakeholders at the 5th International Conference on Family Planning (ICFP) in Kigali, from November 12th — 15th 2018, the largest conference in the world that focuses on family planning. Every other year since 2009, the ICFP brings together the family planning community to share best practices, celebrate successes, and chart a meaningful roadmap to improve the lives of women and girls.

Family planning seems to have found a foothold in Rijiyar Lemu area, thanks to the innovative approach of the staff at the local PHC. However, targeting only women may not be sustainable in the long run, as men are usually the ultimate decision makers in most Nigerian family settings. Outreach campaigns to sensitise the men and create awareness on the benefits of child spacing could provide a greater boost to this initiative. These campaigns should also target influential individuals like religious and traditional leaders, who have significant influence in local communities.

The wider discussion and learnings from the PHC in Rijiyar Lemu, highlights the importance of continuously reinforcing the message about child spacing. With Nigeria projected to be the third most populous country in the world by 2050, further pressure will be put on the country’s already stretched resources. PHCs are at the frontline of health care delivery in Nigeria and initiatives like the Green Dot and other family planning services need to receive the required financial support, ensuring they are well equipped to deal with increase demand. Other examples of the successful scaling up of family planning services include the 72 hours makeover of PHCs carried out by The Nigeria Urban Reproductive Health Initiative in states like Bauchi and Kaduna, enabling capacity to be increased for family planning services.

Women like Jummai who get pregnant soon after giving birth are indicative of the demand for child spacing (family planning) services and these highlights the need for continuous community sensitization campaigns about child spacing services.