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This is part II of a two-part blog. To read part I of this piece, click here.
Changing opinions and behaviors around family planning in Senegal may happen slowly.
Islam is the predominant religion in Senegal, practiced by approximately 94% of the population. Most Muslims in Senegal seek guidance on all social, religious, and cultural matters from their marabouts or spiritual leaders. The Senegalese government and the ISSU project are working closely with Muslim leaders to ensure that they are directly involved in discussions regarding family planning. According to the project’s baseline survey, more than three-fourths of urban men and women think that religious leaders should talk more openly about family planning. More than 90% of those surveyed also think that “God is the only one who should decide the number of children a couple has.”
Imam Abdou Khadre Diallo and other religious leaders in the mosque in Djida Thiaroye Kao talked about a speech made by Senegal’s President Abdoulaye Wade. Wade had spoken during the conference about the acute need for family planning, not only to improve maternal and child health, but also to contribute to gains in economic development and to reduce poverty, and many heard the address on the radio. The religious leaders, all of whom had been trained by the ISSU project to serve as community educators, agreed that family planning was essential for maternal and child health but felt that their communities would accept the idea of spacing births—not limiting the number of children couples have.
On Friday morning, we visited the urban center of Guédiawaye, population 280,000. Guédiawaye’s chief medical officer, Dr. Alioune Gaye, told us that the city is a place of migration, drawing people from rural areas in Senegal and from neighboring countries drawn by the allure of Dakar—but not wealthy enough to be able to afford life in the capital. Guédiawaye is a predominately poor, overcrowded urban area with a weak educational system. Guédiawaye has significant problems with sanitation, including flooding and standing stagnant water. Few homes are connected to city sewer services.
At a neighborhood mosque in Guédiawaye, the religious leaders told us that they had been following the debates about President Wade’s speech. According to these religious leaders, Islam accepts the voluntary limitation of births. An article, “Limitation des naissances prônée par le Président : Des Imams avalent la pilule de Wade,” published by the Senegalese paper Le Quotidien, suggests these Imams “swallowed Wade’s pill.” These leaders, trained by the ISSU project, said that couples should limit the number of children they have when they do not have the resources to take care of their children. “We end up producing too many fighters, singers, and dancers” when people can’t plan the number of children they want to have, Imam Niang said.
Toward the end of that day’s site visit, we went to the health post of Fith-Mith, which serves a population of about 16,000. Journalist Nick Loomis captured some of the debate now happening in Senegal and at this health post in an article for Voice of America News.
The clinic’s head nurse, Mariam Mbaye Sy, talked about the challenges. “All of these women have been waiting here since seven this morning,” she said, gesturing to benches full of women, babies, and children. Sy was excited about the new systematic screening and being able to offer all women family planning counseling and services. “They don’t always think to ask about it, but making it more visible will have an impact. Women do want to use family planning. We just have to make it easier for them.”
Statistics at the Fith-Mith health post in Guédiawaye, and at other urban health centers in Dakar, are not yet encouraging. Only 17% of the urban poor use modern contraception, compared to 30% of the urban rich.1 These rates are higher than the overall use of modern contraception in Senegal, but the population of urban areas is growing quickly.
The three-day International Conference on Family Planning, which wrapped up earlier this month, brought together family planning activists, academics, and advocates. Hundreds of millions of dollars have been invested in family planning programs over the last 25 years. But globally, more than 215 million women in developing countries who say they want to limit or space births are not using modern contraceptives. We know that the consequences of unmet need are startling. Every day, nearly 1,000 women and girls die in pregnancy or during childbirth. For every one woman who dies, at least 20 more suffer from a disability related to maternal causes. The World Health Organization estimates that modern contraception use prevents 188 million unintended pregnancies each year, resulting in 150,000 fewer maternal deaths. If the unmet need for modern contraceptives were met—particularly among the 215 million women in need in developing countries—another 90,000 women’s lives would be saved each year. How can we meet the unmet need?
Too many people still lack access to basic health care. Others can access basic care but encounter gaps in availability of modern contraceptive methods. Others may have limited knowledge of contraceptive methods. Too many women face enormous social and cultural barriers to actually plan their families and ensure that every pregnancy, and every birth, is wanted. Meeting the unmet need requires continued investments in new contraceptives, long-term attention to education, especially of girls and women, and ongoing international discussions of health and human rights. But it also means investing in existing technologies and tried-and-tested ways of getting contraceptives to those in need.
Family planning also needs advocates—and activists. The movement needs the passion of the activists who mobilized international resources to address the HIV epidemic. The international family planning conference galvanized media attention, and President Wade’s speech got people in Senegal talking—and sometimes disagreeing—about family planning. But what happens after the conference?
Making family planning acceptable means changing social norms, making it okay to talk about family planning and to decide how many children to have. The global health community needs to work with local activists, especially young people, to capitalize on their energy and enthusiasm. As the young men told us on the streets of Pikine, “We don’t want to sit around drinking tea all afternoon; we want to be useful.”
As we saw firsthand in the urban areas near Dakar, social and cultural barriers to family planning use can only be addressed locally. And as we heard firsthand, local activists—from health workers to mayors to Imams and other religious leaders—are willing to do their part.
Communities ultimately have the solutions to their problems.
1. Family planning findings from a baseline survey of married women and men in four cities in Senegal, conducted in 2010 by the Centre de Recherche et Développement Humain (CRDH) in close collaboration with the Measurement, Learning & Evaluation Project (MLE) and the Initiative Sénégalaise de Santé Urbaine (ISSU). Urban poor is defined as the lowest wealth quintile.
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