Study Design
FHI, in collaboration with the Ghana Statistical Service, surveyed 97 current providers in October 1994 to determine why they place age, parity, weight, spousal consent and marriage restrictions on particular methods. In addition, clinic records of the providers were reviewed to document the age and parity range of clients and whether spousal consent was obtained. Providers interviewed included auxiliary nurses, nurse-midwives and extension workers.
Results
Most Ghanaian providers imposed restrictions based on their own moral code. Most thought that by doing so, they were upholding social mores or protecting the health of the client. Unfortunately, they often exaggerated the dangers of contraceptives.
Of the providers interviewed:
- 26% said that marriage was a prerequisite for at least one reversible family planning method offered. The most common reason given for the marriage restriction was that family planning is only for married couples and that such restrictions discouraged indiscriminate sex among unmarried women.
- 55% said that they required a spouse's consent for providing one or more non-permanent methods. Family planning is seen as a decision for both partners. Without spousal consent, husbands might accuse wives of infidelity and blame the provider for any problems that occur.
- 76% said clients must meet minimal age requirements. Providers think that access to contraception leads to promiscuity among adolescents and young women. Age restrictions for injectables (mean minimum age was >30) were based on the mistaken belief that injectables can cause sterility.
- 74% indicated that they enforced maximum age limits because they felt hormonal contraceptives were a serious health hazard for older women. Also, all clients over 44 were assumed to be menopausal and so to have no need for family planning.
- 84% enforced a minimum parity rule because of concerns about delayed fertility or infertility. More than twice as many providers restricted access to injectables, for which no medical rationale exists, than IUDs, for which a case can be made for excluding nulliparous clients.
- 33% imposed weight restrictions for all hormonal methods because of concern about increased risk for cardiovascular disease. Restrictions for progestin-only methods were almost as common as those for combined pills, in spite of a lack of medical justification for restricting these methods.
Conclusions
Providers in this sample showed inadequate knowledge of the level of adverse effects of modern contraceptive methods. Their goal of protecting clients' health is admirable, but in exaggerating the dangers of contraception and limiting access, providers might have been doing more harm than good. Injectables were especially misunderstood. Most providers had erroneous notions of injectable-related infertility; age and parity requirements for injectables were particularly burdensome; and few providers recommended injectables to breastfeeding clients. These problems can be solved, or at least decreased, by provider education.
A more difficult problem is that providers want to impose their views on their clients and discourage sex outside of marriage. Providers should recognize that denial of family planning services may not prevent such behavior. Worse, it exposes women and men to unwanted pregnancies and sexually transmitted diseases.
November 1996
This work was funded by the FHI Contraceptive Technology and Family Planning Research Program through a Cooperative Agreement with the US Agency for International Development.
