General
Source: CAI
In 1994, the Government of Ghana decided to reduce the Total Fertility Rate (TFR) from the then 5.5 children per woman to 3.0 in 2020 (2) as part of an overall plan to reduce poverty and create sustainable development in Ghana.
By 2008, the TFR was down to 4 children per woman, placing Ghana two years ahead of schedule.(3) However, the Northern Region and the Upper West Region were still behind target. In 2008, a woman in the Northern Region was expected to have 6.9 children on average and in the Upper West Region, 5 children.(4) Recent reports indicate that very little has changed since 2008, when the last Ghana Demographic and Health Survey (GDHS) was done.(5) Currently, the overall TFR for Ghana is estimated at 3.75.(6)
While persistent poverty in Northern Ghana is generally used to account for the high TFR in this region, a particular and important obstacle in reducing the TFR in these regions is the failure of modern contraception and family planning methods.(7) Ghana Health Services and the Ministry of Health have placed special emphasis on modern family planning methods throughout the country, specifically on distribution, quality and low prices.(8) Despite this, the Northern, Upper West and Upper East regions have the lowest usage of modern family planning methods, with 6%, 21% and 14% of the population respectively using modern contraception methods.(9) This CAI paper considers why these regions resist modern family planning methods, even in the face of increased availability and quality.
Unmet need for contraception
Most Ghanaian women indicate that they would prefer to have four children.(10) In rural areas, this is slightly higher at an average of 4.7 desired children.(11) The three northern regions of Ghana are largely rural, as opposed to the more urbanised southern regions of Ghana. Women in the Northern region want 6.6 children.(12) Even though most women in a rural environment indicate a desire for more children than their urban counterparts, the statistics mentioned above show that many of these women have more children than desired.
Women in rural areas also tend to have their first child on average two years earlier than their urban counterparts, at 20 years of age rather than the average 22.1 of urban women.(13) Women in rural regions marry at the age of 18.7 on average (as opposed to the urban average of 21.3) and in the Upper East Region, the average age of marriage is 17.8.(14) Men, on the other hand, tend to marry around the age of 25.(15) The GDHS tells us that 44% of all Ghanaian women are sexually active by the age of 18 and that, on average, rural women become sexually active earlier in their lives than urban women.(16) Education plays a large role in determining when people start to engage in sexual activity with those with no formal education starting two years earlier than those with any formal education.(17) A study in the Bolgatanga District, in the Upper East Region, found that only 38.6% of female pupils and 21.5% of male pupils were not sexually active.(18)
Modern contraceptive methods are not widely accepted and many of those without formal education are often ignorant of the benefits of contraception for birth control or as a prophylactic. This, of course, increases the chances among the youth of contracting STIs and unwanted pregnancies - the rate for adolescent pregnancy is 13.3%.(19) Consequently, illegal abortions account for around 15% of maternal deaths in Ghana.(20) (All abortions are illegal in Ghana, except those done to save the mother either from life-threatening physical injury or from the psychological trauma suffered from rape).
Furthermore, 35% of married Ghanaian women indicate that they don't want any more children and another 36% want to wait two years before having another child.(21) The 2008 GDHS calculates that Ghana currently has an unmet need for contraceptives of 35%.(22) In other words, there are women who would like to use contraceptives. Do they have access and confidence to do so?
Education and modern contraception
The Government of Ghana has made a concerted effort to educate its citizens about modern family planning methods via the media, particularly through radio, television and newspaper. This has had its greatest effect in the Greater Accra region, but very little impact in the rural northern regions.(23) Increased poverty and lower education rates decrease the ability of people to access the information the Government is spreading via the media. As a result, the northern regions of Ghana still display a low level of awareness about modern family planning methods. Information has also been spread by means of fieldworkers and health facilities. These, however, have respectively only been able to inform 10% and 13% of current nonusers about family planning methods.(24) This translates to four out of five current nonusers not being informed about modern contraceptive methods.
The lack of knowledge becomes more evident among the youth. Around 46% of all males and 48% of all females between the age of 15 and 19 years said in a 2007 survey that they were not confident about using male condoms.(25) In the same age group, only 28% of the females and 21% of the males had detailed knowledge about pregnancy prevention or sufficient knowledge to distinguish common myths about sexual activity from facts.(26) Informed estimates state that around 80% of the females and 63% of the males in this age group do not use any modern contraception when engaging in sexual activity.(27) As has already been stated, most people in this age group are already sexually active. In the northern regions of Ghana, about half the population is under 15 years of age and teenage pregnancy has been highlighted as a major health and social issue.(28)
The 2009 survey of pupils in the Bolgatanga District highlighted some further problems with information surrounding condoms. Most males interviewed put a condom on only after first having penetrated their partner, thus decreasing its effectiveness as a contraceptive.(29) There was also widespread confusion about how many times a condom could be used.(30) Many thought that a condom could be used more than once. Next to nothing was known about female condoms.(31) The survey noted that misinformation about family planning methods and modern contraception increased with a decrease of school attendance and in more rural settings.(32)
Attitudes towards contraception
The northern districts of Ghana are mostly rural, with 85% of the Upper East region living in rural areas.(33) In 2006, these districts had an illiteracy rate of over 76% (34) and in the Upper East Region, only half of those who ever attend school get their primary level, with only 5.2% ever attaining a technical, vocational or commercial degree.(35) Many of the people in these regions are simply unable to access the information made available by the Government.
In addition, health care facilities are significantly fewer in these areas. Of the pupils who took part in the Bolgatanga survey, 80% said that they had never been to a family planning centre.(36) Many of the participants also displayed a distrust of health facilities, mentioning that health practitioners did not explain what was wrong with them and often prescribed unidentified medication.(37) To further compound matters, many felt very uncomfortable talking about their sex lives, often citing taboo as a reason for not being able to communicate about sex.(38) Health workers in these regions, therefore, have a lot of difficulty in raising awareness about modern family planning methods.
This distrust was also displayed with regards to modern methods of contraception. Many pupils felt that condoms were 'not designed for Africans' and that they were only partially effective.(39) A worrying factor is the predominant belief that women should not carry condoms or suggest their use to their partner.(40) Such behaviour is associated with social stigma and many women are strongly discouraged from having contact with male condoms. Only 36.7% of males and 23.6% of females displayed an awareness of other methods of contraception such as pills and injections.(41) Coupled with poor information about condom use, these factors severely undermine the effectiveness of the most popular form of contraception in the area: the male condom.
Apart from misinformed attitudes about contraception, pupils displayed potentially dangerous opinions about sex and STIs. Around one in five female pupils and one in four male pupils felt that sex was an obligation.(42) Just under 15% of both males and females felt that a woman was not allowed to refuse her partner sex, saying that physical violence should be used against a woman who does not want to have sex.(43) Many failed to identify cases of sexual violence and only one in twenty females interviewed indicated that they would report an incident of sexual violence to the police.(44) Many felt that sexual violence was usually the woman's fault.(45)
While HIV & AIDS was indicated to be the most feared STI, most interviewees harboured several false beliefs about the disease.(46) Many believed that they could identify a person infected with HIV & AIDS.(47) Many also believed that one could get HIV/AIDS from kissing or coming into contact with an infected person.(48) Apart from HIV & AIDS, some interviewees / study participants displayed partial knowledge of gonorrhoea and syphilis, but could not mention or identify any other STIs.(49) The poor information around STIs combined with a general distrust of modern contraceptive methods increases the risks many of the people in these areas are open to when being sexually active.
Concluding remarks
The Northern Region and the Upper West Region likely suffer from the same misinformed attitudes as the Upper East Region, given the similarities in their rates of education and poverty. Studies such as the Bolgatanga school survey (50) are helping us understand where the Government of Ghana's current drive to reduce the TFR is encountering obstacles. Despite the major successes that Ghana has displayed in the south with its National Contraceptive Security Strategy,(51) the northern regions of Ghana, specifically the Northern, Upper East and Upper West, are lagging behind. This is due to high rates of poverty and poor levels of education. Because of both of these factors, many of the people in these areas are unable to access the information and facilities made available by the Government of Ghana. Fortunately, several drives are currently underway to increase the literacy rate in these areas.(52)
NOTES:
(1) Contact Aidan Prinsloo through Consultancy Africa Intelligence's Gender Issues Unit ( This email address is being protected from spambots. You need JavaScript enabled to view it. This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
(2) Government of Ghana:National Population Council, National Population Policy: at a glance, revised ed. 1994, http://www.npc.gov.gh.
(3) Kpakpah, M., Statement, at the Commission on Population and Development (forty fourth session), General debate on National Experiences in Population Matters: Fertility Reproductive Health and Development, 13 April 2011, New York: United Nations.
(4) Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro, Ghana Demographic and Health
Survey 2008: Key Findings. Calverton, Maryland, USA: GSS, GHS, and ICF Macro, 2009. http://www.measuredhs.com.
(5) 'Northern region women are the most fertile in Ghana – Population Officer', Ghana News Agency, 11 May 2011, http://www.ghananewsagency.org.
(6) United Nations, Department of Economic and Social Affairs, Population Division, World Population Prospects: The 2008 Revision, New York, 2009 (advanced Excel tables). http://data.un.org.
(7) Kpakpah, M., Statement, at the Commission on Population and Development (forty fourth session), General debate on National Experiences in Population Matters: Fertility Reproductive Health and Development, 13 April 2011, New York: United Nations.
(8) The Ministry of Health, Agencies and Partners, Meeting the Commodity Challenge: The Ghana National Contraceptive Security Strategy 2004-2010, Accra: Reproductive and Child Health Unit, 2004. http://www.rhsupplies.org.
(9) Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro, Ghana Demographic and Health
Survey 2008: Key Findings. Calverton, Maryland, USA: GSS, GHS, and ICF Macro, 2009. http://www.measuredhs.com.
(10) Ibid.
(11) Ibid.
(12) Ibid.
(13) Ibid.
(14) Ibid.
(15) Ibid.
(16) Ibid.
(17) Ibid.
(18) Rondini, S. and Krugu, J.K., 2009. Knowledge, attitude and practices study on reproductive health among secondary school students in Bolgatanga. African Journal of Reproductive Health, 13(4), pp.51-66, http://www.bioline.org.
Upper East Region, Ghana
(19) Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro, 2009, Ghana Demographic and Health
Survey 2008: Key Findings. Calverton, Maryland, USA: GSS, GHS, and ICF Macro. http://www.measuredhs.com.
(20) Ghana Statistical Service (GSS), Ghana Health Service (GHS), and Macro International. 2009. Ghana Maternal Health Survey 2007. Calverton, Maryland, USA: GSS, GHS, and Macro International. http://pdf.usaid.gov.
(21) Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro, 2009, Ghana Demographic and Health
Survey 2008: Key Findings. Calverton, Maryland, USA: GSS, GHS, and ICF Macro. http://www.measuredhs.com.
(22) Ibid.
(23) Ibid.
(24) Ibid.
(25) Hessburg, et al., Research report: Protecting the next generation in Ghana: new evidence on adolescent sexual and reproductive health needs, New York: Guttmacher Institute, 2007. http://www.guttmacher.org.
(26) Ibid.
(27) Awusabo-Arare, K., Abane, A.M., and Kumi-Kyereme, A., 2004. Adolescent sexual and reproductive health in Ghana: a synthesis of research evidence, Occasional Report No. 13, New York: Guttmacher Intitute, http://www.guttmacher.org.
(28) Rondini, S. and Krugu, J.K., 2009. Knowledge, attitude and practices study on reproductive health among secondary school students in Bolgatanga. African Journal of Reproductive Health, 13(4), pp.51-66, http://www.bioline.org.
(29) Ibid.
(30) Ibid.
(31) Ibid.
(32) Ibid.
(33) Ibid.
(34) Aryeetey, E., and Kwakye, E., 'National Functional Literacy Programme', Policy Brief 9: Interregional Inequality Facility,London: Overseas Development Institute, February 2006. http://www.odi.org.uk.
(35) Rondini, S. and Krugu, J.K., 2009. Knowledge, attitude and practices study on reproductive health among secondary school students in Bolgatanga. African Journal of Reproductive Health, 13(4), pp.51-66, http://www.bioline.org.
(36) Ibid.
(37) Ibid.
(38) Ibid.
(39) Ibid.
(40) Ibid.
(41) Ibid.
(42) Ibid.
(43) Ibid.
(44) Ibid.
(45) Ibid.
(46) Ibid.
(47) Ibid.
(48) Ibid.
(49) Ibid.
(50) Ibid.
(51) The Ministry of Health, Agencies and Partners, Meeting the Commodity Challenge: the Ghana National Contraceptive Security Strategy 2004-2010, Accra: Reproductive and Child Health Unit, 2004. http://www.rhsupplies.org.
(52) Aryeetey, E., and Kwakye, E., 'National Functional Literacy Programme', Policy Brief 9: Interregional Inequality Facility,London: Overseas Development Institute, February 2006. http://www.odi.org.uk.