Harnessing Africa's Baby Boom: Women Seize Power Over Their Fertility—and Future
Written by Sarah Newey | Published: June 21, 2022
Originally published by The Telegraph
Africa’s population is on track to double by 2050. Experts warn the continent’s high birth rate perpetuates poverty—so does the solution lie in family planning? Sarah Newey visits Ghana to find out. Pictures by Simon Townsley.
Senior and Junior are asleep in their mother’s arms, cozy beneath their pale pink beanie hats. Yet to be named, the pair are just a month old—with Senior nicknamed for arriving moments before her younger sister.
The twins are part of Africa’s baby boom, an unprecedented renewal which will see the continent’s population double in size by 2050, to an estimated 2.5 billion. Already 60 percent of the population is under the age of 25, making it one of the most promising and potentially volatile on Earth.
Experts say that if the health and education of this new generation can be secured, Africa’s “human capital” will soar, boosting economic growth by nearly 90 percent by 2050 and putting it on a development trajectory every bit as assured as India’s or China’s. Already, several African economies, including Ethiopia and Guinea, have enjoyed real GDP growth averaging more than six percent a year since 2013, according to World Bank data. But Africa’s future is far from certain. Without investment and nurturing, the current population boom is as likely to lead to bust as it is a dividend.
The cards are already stacked against Senior and Junior. At just 13, their mother, Augustina, is still a child herself and is woefully ill equipped to give them the support they need to flourish. Augustina met the twins’ 21-year-old father at a village party and two months later realized she was pregnant. At the time, she knew next to nothing about sex, let alone contraception. Her life has now changed beyond recognition. “I had heard a bit about family planning, but only that it was painful,” Augustina says. “Now, I’ve had to leave school. That’s been the worst part. I’m not really enjoying motherhood at all. It’s hard.”
Her story is not uncommon in sub-Saharan Africa, where roughly 10 percent of girls aged 15 to 19 have given birth at least once. In high-income countries, that figure is just 1.5 percent. Young mothers typically go on to have more babies and are less likely to complete their own education or have the money to invest in their children. In some parts of Africa, the average number of children per woman is four times the average in high-income countries.
Such high birth rates perpetuate poverty, say experts. But a large part of the solution lies in contraception and family planning. Invest in women’s health and empowerment, and they will invest in their families’ futures. Reduce population growth, and governments will have more to spend on each individual’s health and education. If every woman in Africa gave birth to her first-born just two years later, population growth would be nine percent smaller by 2100. If women had only the number of children they actually wanted, growth would drop by 30 percent.
“Family planning is a means to enjoy a healthier and better life—it is an essential cornerstone in the equation,” said Dr. Ayman Abdelmohsen, Global Operations Coordinator at UNFPA Supplies, the world’s largest provider of donated contraceptives. “Looking at it from the perspective of human development is essential; family planning is a capital investment in women and young girls—it is not just health care. Giving women knowledge leads to the realization that they have power over their own life and fertility.”
Despite the benefits for women and their communities, ensuring access to family planning is far from simple. In many African countries, the cultural, geographical, and political barriers appear insurmountable. On the other hand, that has been true in almost every other country on earth—right up to the point that they turned their birth rates around.
Augustina’s home, Ghana, in West Africa, could be on the brink of that transition. The economy, one of the strongest and most stable in Africa, has been growing for three decades, and the country now enjoys lower-middle-income status. Economic growth has driven poverty down to afflict less than 30 percent of the 28 million population, and slowly an educated middle class is emerging.
However, access to contraception remains low, especially in rural areas, and is used by just 22 percent of women over 15. While this is above the West African average of 16 percent, it is lower than many other middle-income countries. In places like Sri Lanka, Vietnam, and Nicaragua, uptake hovers at close to 50 percent, for example.
But change is coming. The Ghanaian government has shown signs that it is beginning to prioritize access to birth control as a means to embed growth and further reduce poverty. Working with NGOs, including Marie Stopes, new initiatives are being rolled out across the country to empower women and give them more choices.
Reaching children and teenagers like Augustina before they become pregnant is the priority. The outlook here is positive; the Ministry of Education looks set to get a comprehensive sex education syllabus onto Ghana’s school curriculums for the first time. “Catching adolescents [early] is really important,” says Anne Coolen, Marie Stopes Country Director. “We need to give young boys and girls the right information so they are prepared when they start having sex.”
Beyond the classroom, Marie Stopes runs eight drop-in clinics for contraception services and advice in Ghana and works with a much larger network of BlueStar private clinics across country.
In the heart of Tamale, a bustling city in northern Ghana, it’s market day, and the Marie Stopes clinic is packed with women of all ages, including 19-year-old Anisah. She’s having a contraceptive implant in her arm, after being told to use family planning by her older sister. “She told me I should use it to protect myself,” Anisah says. “It means I can have a good sex life and not worry about getting pregnant before I’m ready.”
Munitatu Abdallah, a midwife and clinic manager, will see between 20 and 30 women and girls today, many young women like Anisah, but also mothers and even grandmothers.
The clinics also provide safe abortion services. Poorly regulated street pharmacists often give women desperate to discreetly end a pregnancy dangerous medicines, and deaths are common. “I lost a sister, Fatahiya, to an unsafe abortion,” says Munitatu. “She didn’t tell us she was pregnant; she took drugs and then went to school. But she started feeling dizzy, and she later died in hospital. That’s why I do my job.”
Overcoming the stigma around abortions is difficult. A nationwide Marie Stopes awareness campaign—Time to Talk—successfully broached the subject earlier this year, encouraging women to use contraception so they can avoid the necessity of an abortion. “We also offer post-abortion counseling,” says Munitatu. “98 percent of women who have an abortion at the clinic start using family planning afterwards. If everyone used family planning, it would reduce the need for anyone to have an abortion.”
The clinics are effective and popular, but distances in Ghana are huge, and only a minority of women can reach them. To overcome geography, Marie Stopes also operates outreach teams—comprised of a health nurse, midwife, and driver—who travel along pothole-ridden dirt roads to remote regions.
For Ashitotu, their arrival in the remote village of Mianwali in central Ghana could not come soon enough. “My husband died, so I had to marry his brother,” she says, sitting in the shade outside a small community building with her nine-month-old daughter, Nkusimi, on her knee. “He ran away after he made me pregnant. He hasn’t answered my calls or met Nkusimi, but I know that if he ever comes back, he’ll want to have sex. I don’t want another baby. Things are very difficult. I have five children to look after. I can’t have another one.”
At 34, Ashitotu is being offered access to contraception for the first time. Short-term methods in the form of injections and condoms are available at Ghana Health Service clinics, but Ashitotu wants something longer lasting. Though she originally thought about an implant—a hormonal plastic rod inserted into an arm, which works for three years—she has decided instead to have a “coil” or intrauterine device (IUD) fitted. They prevent pregnancy for up to 12 years.
“It’s important that women have access to longer-term options,” says Sheilla Mensah, the Marie Stopes midwife performing Ashitotu’s procedure. “These methods allow women to space their pregnancies, as they can have them removed when they like. It also helps them to save money.”
Sheilla puts on her headlamp and begins the procedure, as Ashitotu lays on the blue bleach-stained sheets. The whole process is over within 15 minutes, but will give Ashitotu peace of mind for over a decade. “It wasn’t really painful,” she says afterwards. “It was so quick. I don’t care if people gossip about me, because what I have been through is much worse than any side effects.”
Marie Stopes operates eight outreach teams across Ghana, providing over 35,000 women like Ashitotu with long-lasting contraception each year. To make the service sustainable, it is also training the nurses and midwives of the Ghana Health Service, through four capacity building teams, to take over in the long term. This is increasingly a necessity, as the government has made its intentions to move to ‘Ghana beyond aid’ clear, and international funding here is drying up.
“Donors are increasingly pulling out of service delivery and looking towards other countries [because of Ghana’s economic status],” says Anne Coolen. “We are building on strategies with the Ghana Health Service and the government to make sure they are ready. It feels like a turning point for Ghana.”
Another distribution system being tried here goes by the name of Marie Stopes Ladies. It’s based on the old Avon cosmetics model where commission-driven “Avon Ladies” sold makeup door-to-door. But in this case, contraception—and even the pills required for first trimester abortions—are on offer. Rahmatu is one of the ladies. A trained midwife, she opens up her home in the evenings to women wanting to discreetly access contraception. Under the cover of darkness, more women in this deeply conservative part of northern Ghana feel comfortable to visit Rahmatu without becoming the topic of local gossip.
30-year-old Asana had an implant fitted by Rahmatu last year. “If I had to go to a hospital, I wouldn’t use family planning,” she says, sitting in the dimly lit courtyard. “At the hospital, it is an open place and everyone will know that you want to use family planning. News will spread like wildfire. The gossip is worse among those who don’t use it—they judge you and begin to look at you like you’re promiscuous.”
Perception matters in Ghana, where women who want to use contraception are often too embarrassed to ask for it. Working with Muslim and Christian religious leaders, village chiefs, and men in communities is starting to turn the tide of opinion, and Marie Stopes believes that as more women use birth control, demand will increase exponentially. To ensure this happens, the combination of options is important; there’s no ‘one-size-fits-all’ approach to delivering contraception or reaching all women. Teenagers are different to 30-year-olds, rural women have different lives to urban. But the approaches require investment, and as the country develops, that increasingly needs to come from the government.
If Ghana rises to the challenge, the future looks bright. Even in the most conservative cultures, change can happen quickly; in Iran, in 1984, women had an average of over six children each. 15 years later, this had dropped to fewer than three—the fastest-ever decrease in babies per woman.
Globally, the impetus on governments to improve access to family planning is also on the rise. “It is a topic that is so critical for the future of women, adolescents, and children, but also so critical for peace and security in the world,” Kristalina Georgieva, CEO of the World Bank, told The Telegraph in November, at the replenishment event for the Global Financing Facility, the largest investment fund to focus solely on women’s and children’s health. “We are not going to beat the war against extreme poverty unless we address the needs of those who are left out. The future development of countries depends first and foremost on the quality of their people, the health and education they receive.”
Back in Augustina’s town, there are positive signs. Since Marie Stopes re-trained the midwives at the small, franchised clinic, giving them the confidence to both tell women about and provide family planning, there has been almost a 400-percent increase in uptake in services. New outreach schemes—to tell women in churches, schools, and their homes—are also helping to turn opinion.
But although Augustina is supported by her parents, uncle, and the twins’ dad, life is still uncertain. “I would like to go back to school, but I don’t know if that will happen,” she says. “I feel like I should get a job. My dad says I have to marry the man, but maybe I’ll get married when I’m 20. I don’t know.”
What she does know about, however, is her dream for the twins. “I want them to be Ministers of State when they grow up. I will tell them about family planning. My life has become very hard. I don’t want them to end up like me.”
© Sarah Newey/Simon Townsley/Telegraph Media Group Limited