Elsevier

Contraception

Volume 78, Issue 1, July 2008, Pages 73-78
Contraception

Original research article
Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it

https://doi.org/10.1016/j.contraception.2008.03.002Get rights and content

Abstract

Background

Unintended pregnancies continue to burden many countries in sub-Saharan Africa. Our aim was to estimate the number of unintended pregnancies in the region and model the impact of expanding use of contraceptive implants at the expense of short-term hormonal birth control methods.

Study Design

For the 42 countries in mainland sub-Saharan Africa, we estimated current levels of unintended pregnancy, prevalence of hormonal contraceptive use and number of unintended pregnancies stemming from early discontinuation and typical method failure rates. Using a decision-analytic model, we estimated the potential impact of more widespread use of the contraceptive implant.

Results

Every year in sub-Saharan Africa, approximately 14 million unintended pregnancies occur and a sizeable proportion is due to poor use of short-term hormonal methods. If 20% of the 17.6 million women using oral contraceptives or injectables wanted long-term protection and switched to the contraceptive implant, over 1.8 million unintended pregnancies could be averted over a 5-year period.

Conclusion

Poor patterns of short-term hormonal contraceptive use (high discontinuation rates and incorrect use) contribute significantly to the problem of unintended pregnancy in sub-Saharan Africa. More availability and widespread use of highly effective methods, such as the contraceptive implant, will improve reproductive health in the region.

Introduction

All throughout sub-Saharan Africa, millions of women would like to avoid pregnancy. In surveys conducted since year 2000 in 25 sub-Saharan African countries, about one-quarter of reproductive-aged women state they do not want any more children and about one-third want to wait at least 2 years before having a child [1]. In these same surveys, nearly 90% have knowledge of at least one form of modern birth control, yet only one-third have ever used one. Moreover, when asked about the planning status of their last birth, between 10% and 65% of women report the event was unintended, depending on the country and age group of the respondent. With demonstrable evidence of unmet need for contraception, exceeding 30% in some countries in sub-Saharan Africa [2], abortion rates in the region are high, particularly in East Africa [3]. Thus, despite 14 years since the United Nations International Conference of Population and Development in Cairo [4], the risk of unintended pregnancy in sub-Saharan Africa remains high and unsafe. Indeed, pregnancy is the most dangerous health event for women in sub-Saharan Africa; the lifetime risk of death due to pregnancy in the region is approximately 1 in 16 [5].

The problem of unintended pregnancy in any region, particularly sub-Saharan Africa, is not easily or quickly solved since the vast majority of unintended pregnancies probably occur because of inaccessibility or avoidance of birth control practices; for example, in one analysis of 16 developing countries, approximately 72% of unintended pregnancies occurred because of those reasons [6]. Making contraceptive services easily accessible to all women is a necessary first step toward eliminating unintended pregnancy and bringing new users into family planning programs would have the greatest impact. Expansion, however, requires tremendous resources; in 2015, sub-Saharan Africa will need $1.3 billion just to keep pace with a growing population and incremental increases in use of contraception [7].

An important proportion of unintended pregnancies in developing countries, approximately 28%, may be easily preventable, since they occur among women who are already engaged in family planning. Such women experience unintended pregnancy because of failure or discontinuation of their birth control method [6]. Provision of better, easier-to-use birth control options for women in sub-Saharan Africa can have important benefits. The current mix of methods, dominated by short-term hormonal methods (injectables and oral contraceptives), may be inadequate to move the region to the next level of improved reproductive health.

We undertook this project to estimate the magnitude of unintended pregnancy in sub-Saharan Africa and to estimate how this burden could be alleviated with better access to contraceptive implants. Norplant® was first introduced into African family planning programs in the 1980s and newer implants (Jadelle® and Implanon®) are currently available in many countries. International donor agencies may soon be able to purchase a less expensive implant from China which could improve developing country access to this technology. Some countries in sub-Saharan Africa appear to be in good position to expand contraceptive uptake and improve reproductive health with more widespread use of the implant [8].

Section snippets

Materials and methods

We used information from a variety of sources to estimate the magnitude of the problem of unintended pregnancies in the 42 mainland countries of sub-Saharan Africa. First, from the United Nations Secretariat [9], we obtained medium-variant estimates of the number of births, by maternal age group, in each country; the information is reported as the estimated number of births over a 5-year period (2005–2010). From the Demographic and Health Surveys (DHS), we obtained information on the percent of

Results

According to medium-variant estimates [9], the 42 mainland countries of sub-Saharan Africa will experience over 150 million births in the 5-year period (2005–2010) (Table 1). Overall and across all age groups, approximately 28% of these births will be unintended, totaling roughly 42 million. As expected, younger age groups contribute disproportionately to this total, given higher fertility rates; women under age 25 bear 44% of the total estimated number of unintended births in the region. With

Discussion

Our calculations showed that unintended pregnancy is a major problem in sub-Saharan Africa and wider availability and use of the contraceptive implant (at the expense of short-term hormonal methods) can help alleviate it. If only a fraction of current users of short-term hormonal methods had the option of choosing an implant, the reduction in unintended pregnancies could be tremendous. Implants, like intrauterine devices, offer women long-term, reversible and highly effective protection that

Acknowledgments

Support for this research was provided by Family Health International (FHI) with funds from the US Agency for International Development (AID/CCP-A-00-95-00022-00), although the views expressed in this publication do not necessarily reflect those of FHI or other participating institutions.

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