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When child spacing happens by chance, not by choice

5th December 2012
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Dorisiana Paschal’s youngest child is only ten months old and the 40-year-old mother of 11 suspects she is pregnant again. She has been having fevers lately and having been there many times before, there is no mistaking she could have conceived.

If Dorisiana’s fears are confirmed, this will be her 16th pregnancy. Four of her children died as infants.

“My fingers are crossed my sister. I just don’t know what will happen if I conceive,” the resident of Kishuro village in Muleba district tells me during a phone interview.

Dorisiana is among 222 million women in developing countries who do not have access to modern contraceptives. She just relies on fate for child spacing and usually finds out she is pregnant again a year or so after giving birth. She tells me one would think her children are twins given the short birth intervals between them.

According to the United Nations Population Fund (UNFPA)’s 2012 State of the World Population report, 867 million women of child bearing age in developing countries have a need for modern contraceptives. Of these, 645 million have access to them.

UNFPA’s Executive Director Dr. Babatunde Osotimehin says lack of access to contraceptives is inexcusable. “Family Planning is a human right. It must therefore be available to all who want it. But clearly this right has not yet been extended to all, especially in the poorest countries,” says Dr. Babatunde.

Lack of information

Dorisiana knows women who use contraceptives but has never dared use them herself. She has heard from those using them that they have side effects. “Those who use the pill or the injection say they have side effects. They say they cause high blood pressure.”

She is among millions of women in developed countries who according to UNFPA are unable to plan their families because they lack access to information, education and counseling on family planning. These women can not access contraceptives and face social, economic and cultural barriers including discrimination, coercion and violence in the context of their sexual and reproductive lives.

The little information Dorisiana has on contraceptives is just hearsays from fellow women in the village. She has never had a chance to hear from health experts. No one at the only health facility in the village has ever counseled her on family planning, let alone tell her the various methods on offer.

This is no surprise given that the dispensary in the village is run by Roman Catholic nuns. Whenever Dorisiana gives birth at the dispensary, the health workers only immunize her child and tell her to bring the baby for antenatal visits every month. Nothing more. Instead of counseling her to use family planning methods, the nurses (not nuns) usually scold Dorisiana, wondering why she does not go for sterilization.

The Roman Catholic church only encourages and supports natural family planning methods. These include abstaining during the fertile days in a woman’s menstrual circle and mucus monitoring among others.

It regards the use of barrier methods of birth control such as the condom and hormonal contraceptives such as pills and the injection as interfering with conception and hence considers their use to be a sin.

However, studies show that modern birth control methods are more effective compared with natural family planning methods.

A US-based Reproductive Health, Population and Gender specialist, Dr. Nancy Yinger, says 80 out of 100 newly wed couples not doing anything to prevent pregnancy will get pregnant in a year. And 40 per cent of those monitoring mucus will become pregnant.

Dr. Yinger who is a Senior Technical Advisor for Gender, Monitoring, Evaluation and Research for EngenderHealth’s RESPOND project, which stands for responding to the Need for Family Planning through Expanded Contraceptive Choices and Program Services, says people should be let to choose the number of children they want provided they do the right spacing. Child spacing is important to both mother and child and doctors recommend that women wait at least three years between births.

The health risks

If Dorisiana conceives as she suspects, both she and the baby could be at high risk of dying. Dr. Yinger says the risk of maternal deaths go up with more than four births.

An Obstetrician and Gynaecologist at the Mission Mikocheni Hospital in Dar es Salaam, Dr. Clementina Kairuki, shares the same sentiment. She says conceiving at this state not only jeopardizes Dorisiana’s health but that of the baby too.

Dr. Kairuki says a woman needs to recuperate before she conceives again. This helps her regain the minerals and vitamins she loses during pregnancy. A deficiency of these during pregnancy can have negative health implications for both mother and child.

Given her age, Dorisiana is at risk of developing pre-eclampsia, a development of high blood pressure and protein in the urine. It is the most common of the dangerous pregnancy complications. It may affect both the mother and the foetus and being older than age 35 is among the risk factors.

A weakened body system is another risk since body organs such as the heart, liver and others get overworked during pregnancy. Having had more than five children, Dorisiana also risks a uterine rupture if she conceives again. This is a tear in the wall of the uterus. Studies show that uterine ruptures cause high maternal and neonatal mortality in many rural settings in the world.

A woman is likely to suffer excessive bleeding after five births and Dorisiana is highly susceptible given that her uterus is already loose. Dr. Kairuki refers to the term medically as uterine atony, which she says is the loss of tone in the uterine muscle. The OBGYN says in the case of uterine atony, the uterus fails to contract hence leading to acute bleeding. This she says is the leading cause of maternal deaths.

Every year, close to 8000 women die during pregnancy and child birth in Tanzania as a result of conditions that could have been prevented or treated.

 

Desire to close factory

When Dorisiana was pregnant with her youngest child, she was put on bed rest for nine months. Her cervix was too loose to carry the baby to term. The doctor suggested she delivers at Rubya Hospital. “But labour started when I was at the dispensary and luckily, I delivered safely.”

Giving birth fifteen times at such short intervals is no easy task at all. Dorisiana says she has suffered a lot and thinks she already has enough children. She now wishes she could close the factory but she does not have money to undergo sterilization.

“Due to what I have been through, I would have already gone for sterilization but I can’t afford the 60,000/- they charge at Ndolage Hospital,” she says, the determination and seriousness in her voice very clear.

She no longer fears her husband to whom the family size does not matter as long as he can put food on the table. In Dorisiana’s village, it’s the younger generation that seems to be dancing to the tune of family planning. They stop at four or five children. “But as for us with older husbands, they insist on having more children provided they can feed them as they have enough land for cultivation. But it is us women who bear the brunt,” says a concerned Dorisiana, whose husband Paschal is 64.

Most women her age have between seven and nine children and most don’t have a choice when it comes to family planning. Those using contraceptives do so secretly.

The nations total fertility rate, that is the average number of children per woman is five, which is considered very high.

They say education is the key to life but Paschal, Dorisiana’s husband, is yet to see the evidence of this. All the children in the village who went to secondary school are idle in the village. This is why he was not motivated to send their two older daughters to secondary school after primary education. Their 21-year-old daughter is now married with two children and the second born (18), works as a maid in Dar es Salaam.

The third born recently completed primary education and Paschal has no plans to take her to secondary school if she is not selected to join a public school.

Government’s commitment

During the London Family Planning Summit in July, USD 2bn was garnered in funding commitments from developing countries and USD 2.6bn from donor nations. This funding aims to make voluntary family planning available to an additional 120 million women and adolescent girls in developing countries by 2020. However, additional resources are needed to give access to all women who need the service.

Women who need contraceptives in Tanzania are many and their needs are yet to be made. The unmet need stands at 25 per cent. When addressing the London Summit, President Jakaya Kikwete said; “We are determined and committed to do better in the coming years. We have set ourselves a target of getting 60 per cent of contraceptives prevalence coverage by 2015.”

This means increasing the number of women under contraceptives from 2.4 million in 2010 to 6.6 million by 2015. And President Kikwete is confident that this is possible given the high number of women whose contraceptive needs are yet to be met.

He promised that the government would ensure family planning programmes are implemented fully.

An estimated USD 88.2m will be required between 2010 and 2015 to meet the contraceptives commodities and supply costs.

“The government already has a family planning budget line for commodities. It’s also benefiting from contributions of health partners such as DFID, USAID and Australia AID among others,” said President Kikwete adding; “We therefore look forward with great anticipation to the outcome of this Summit. We would like to see the financing gap closed so that we can provide the targeted 4.2 million women with the contraceptives they not only need but deserve.”

He said the support from partners has made a huge difference and that it accounted for the achievement the country has made so far. Things would be worse without their support.

Even if Doris is lucky to get her period this month, her future still hangs in the balance for she can not afford to have a tubal ligation. She needs assistance without which she could be just another statistic in the maternal deaths figures. Remember, no woman should die giving life!

SOURCE: THE GUARDIAN