On a busy day at Kwapong Health Centre in rural Ghana, Dr. Beatrice Nyamekye put contraceptive implants in the arms of six women and gave eight or nine more a three-month course of hormone injections to prevent pregnancy. A few asked for condoms or oral contraceptives, but most wanted something that lasted longer.
“They love the implants and the injections more than anything,” says Nyamekye, the community health nurse. “It takes the worry out of it, it gives them privacy, they don't even have to discuss it with their husbands or partners.”
The hustle and bustle at Kwapong clinic is the same across Ghana, and much of sub-Saharan Africa, where women have the world's lowest access to contraception: Just 26 percent of women of reproductive age in the region use a modern method other than rhythm or insertive methods, according to the United Nations Population Fund, which works on reproductive and maternal health.
But that is changing, as more women have access to quick, cheap and discreet methods that allow them to gain reproductive autonomy: Over the past decade, the number of women using modern contraception in the region has almost doubled, to 66 million.
“We are making progress and it is growing. In the near future, a huge number of women will have access,” Esi Asare-Pura said. I am responsible for advocacy activities for the Ghana office of MSI, a reproductive health non-profit organization.
Three factors are driving this change: more girls and women are getting educated. They have more knowledge about contraception, knowledge that often spreads through social media to the remotest corners of communities. And they have greater ambitions in terms of careers and experience, which they are more likely to realise if they delay having children.
Second, the range of available contraceptive options has expanded as generic drug manufacturers bring more affordable hormonal injections and implants to the market.
And third, improved roads and planning mean contraception can reach rural areas like this one, a nine-hour drive from the port in the capital, Accra, where goods are shipped in from manufacturers in China and Brazil.
Improved access brings tangible benefits to women. Faustina Sahene, who runs the operation at the bustling MSI clinic in the town of Kumasi, says women from the country's large Muslim minority appreciate the implants and IUDs because they allow them to space out pregnancies without openly challenging their husbands' desire to have many children.
She also encourages this among young, unmarried women, who may be overly optimistic about their current partner's promise to provide for the child and not realise how pregnancy would limit their options.
“Having children can interfere with your education, your career and even your sexual pleasure,” Saaheneh said before escorting another patient through the door of her examination room.
Across the region, doctors have largely been stripped of control over access to contraception, despite resistance from medical associations that fear losing a reliable source of income. In many countries, community health workers go door-to-door to distribute contraception and give Depo-Provera injections on the spot. Corner shops increasingly sell self-injectors, allowing young women to buy the shots without the risk of critical questioning from nurses or doctors.
In Ghana, nurses like Nyamekye are letting women know there are cheaper, more discreet options. When she stopped off at a roadside hair salon recently, she chatted with women waiting to have their hair braided on a wooden bench. She asked just a few questions, and lively conversations began. One woman said getting implants might make her gain weight (Nyamekye agreed that was possible). Another said she might stop by the clinic for an injection, but her braider teased her about the rapid progress she was making with her new boyfriend.
Sub-Saharan Africa is both the world's youngest and fastest growing region, with its population projected to nearly double to 2.5 billion by 2050.
The Kwapong clinic has a room for adolescent girls, where movies play on a big TV and specially trained nurses are on hand to answer questions for the timid girls who sneak in in their pleated uniforms. After talking with the nurse, 15-year-old Emmanuel, who had just started having sex with her first boyfriend, opted for the injection. She planned to tell only her best friend. The injection was a better choice than the pill, the only option she knew before visiting the clinic, because she was afraid her uncle, with whom she lived, might find the pill and know what it was for, she said.
Nyamekye says that 10 years ago in Kwapong, women's only options were condoms or the pill, or that once a year MSI would come to town with a bus-based clinic, staffed by midwives, and line up women to insert IUDs.
Despite current progress, the United Nations reports that 19% of women of reproductive age in sub-Saharan Africa will have unmet contraceptive needs in 2022, the last year for which data is available. This means that even if they want to delay or limit childbirth, they are not using modern methods.
Supply problems also persist: in the last three months, supplies have not arrived from Accra, leaving the Kwapong clinic short of everything but pills and condoms.
It's a sign of how difficult it is to get contraception to these places in a system where international health organizations, governments, pharmaceutical companies and shipping companies have more say than women themselves over which contraceptives they can choose.
The vast majority of family planning products in Africa are procured by the United States Agency for International Development or the United Nations Population Fund (UNFPA), with support from the Bill & Melinda Gates Foundation. The model dates back more than half a century, when wealthy countries were trying to curb rapid population growth in poorer countries.
Leading global health organizations have invested in expanding access to family planning as a complement to reducing infant mortality and improving girls' education, but most African governments have excluded family planning from their national budgets, despite the enormous benefits it brings to women's health, education levels, economic participation and well-being.
Countries with limited budgets typically choose to spend on health services deemed more essential, such as vaccines, rather than reproductive health, because they generate more immediate benefits, said Dr Ayman Abdelmohsen, director of family planning in the technical division at the United Nations Population Fund (UNFPA).
But recently, in response to efforts by the United Nations Population Fund (UNFPA) to encourage lower-income countries to shoulder more of the costs, 44 governments have signed up to a new funding model committing to increasing their reproductive health contributions each year.
Still, there was a funding shortfall of about $95 million worldwide last year to buy the products. Donors now foot the bulk of the bill, but funding for 2022 is nearly 15% lower than in 2019 as global health budgets shrink because of the climate crisis, the war in Ukraine and other new priorities. Support for African government programs has also stagnated as African countries struggle with rising food and energy prices.
The good news is that prices for new contraceptive methods have fallen dramatically over the past 15 years, thanks in part to promises of bulk orders brokered by the Gates Foundation, which hoped that long-acting methods would appeal to many women in sub-Saharan Africa. For example, the price of hormone implants made by Bayer and Merck fell from $18 a pop in 2010 to $8.62 in 2022, while sales rose from 1.7 million to 10.8 million over the same period.
But affordability remains a challenge for low-income countries, where total government spending on health care averages $10 per person per year. While pills and condoms are more expensive in the long run, the upfront cost of long-acting products is a barrier.
Just getting contraception to clinics isn't enough: health workers need to be trained to insert IUDs and implants, and someone has to pay for that, Dr. Abdelmohsen said.
Hormonal IUDs remain in short supply in Africa and cost more than $10 each, said Dr. Anita Zaidi, who heads gender equality efforts at the Gates Foundation. The nonprofit is investing in research and development of new, longer-acting products and is also looking for manufacturers in developing countries who can make existing products more cheaply.
The foundation and others are also investing in new efforts to track data such as which companies are making which products, which countries are ordering them, and when they're delivered, so that clinics don't run out of stock. They also want to track more precisely what methods African women want, and why those who say they want to use contraception don't. Is it a cost issue? Access issue? Cultural norms, such as health-care providers being reluctant to deliver to unmarried women?
Gifty Auah, 33, who works at a small roadside beauty salon in Kwapong, gets regular injections every three months. She gave birth to her first child while she was a student. “When I got pregnant at 17 it was unplanned. Family planning wasn't as easy as it is now,” she says. “I had to go to town and pay. It was very expensive.”
She had to leave school because she became pregnant, and if she had had the options she does now, her life might have been different. “If I had been in the situation I am in now, I would not have been pregnant,” she says. “I would have moved forward in life, studied, and would have been a judge or a nurse by now.”
