African Journal of Reproductive Health

 

Revue Africaine de Santé de la Reproduction

ISSN -- e:2141-3606   p: 1118-4841

Published by Women's Health and Action Research Centre (WHARC)

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Book Review

 

Sociocultural Aspects of Family Planning and HIV/AIDS in Nigeria

 

Author: Lawrence A. Adeokun

Publishers: ABBI Books, Ibadan

Year of publication: 2009

Page extent: 311 pages

Reviewer: Uche C. Isiugo-Abanihe

 

African Journal of Reproductive Health, December 2010; 14[4]: 155-157 [Special Edition]

The original draft of the book was ready for publication in 1993 after peer review, but for some reasons did not get published. The present book, Sociocultural Aspects of Family Planning and HIV/AIDS in Nigeria, is a revised and enlarged version of the original manuscript, which given a time lag of more than one decade and a half, tremendously benefitted from the exponential growth in knowledge on sexual and reproductive health, including HIV and AIDS. The book is presented in eleven chapters, which together make up its 311 pages, excluding 22 preliminary pages. That the book is well-researched is partly borne out by its 28 pages of references as well as its numerous tables, charts, and illustrations.

The book addresses two issues of potentially conflicting interest – rapid population growth and the epidemic of HIV and AIDS.  On the surface, the HIV/AIDS epidemic may be looked upon as solving the population control problem.  But it is now clear that for large populations such as Nigeria’s it will take more than the elevated mortality levels arising from the epidemic to make any significant impact on the pace of population growth, apart from the social and demographic unacceptability of allowing high death rates as a means of achieving population reduction.

Once that premise is accepted, the position of the book is that family planning and HIV/AIDS control programmes should be seen as two sides of the same coin.  The author points out that the childbearing and sexually transmitted infections share the same origin: they are products of human sexual activity.  Consequently, the separation of family planning from HIV/AIDS control places a social barrier, and by implication, a stigma on the infections whilst absolving excess childbearing of all blames.  Becoming pregnant is as accessible as becoming sexually infected in any active population. The challenge is to make family planning responsive to the needs of HIV prevention. Therefore, the integration of robust HIV prevention services into reorganized family planning and reproductive health services is seen as the way forward.

The implication of this central thesis of the book informed the content.  The book opens in Chapter 1 by drawing attention to the Nigeria population problem and its consequences, and in the next two chapters presents an exposition on reproductive system and early birth control efforts, making a clear distinction between facts and perceptions in these matters.  In the main, the nature of the dilemma between a rapid growth rate and a weak family planning programme is explained.  Because the focus of the author is on the social and cultural constrains against the propagation and acceptability of various methods, the book clarifies the links between the biomedical aspects of each method and the prevailing cultural conditions that make it difficult to achieve progress in the field of population control.

The position of the author is that the poor performance of family planning programmes has to be blamed on both the feeble efforts at changing people’s normative values attached to large families as well as to the weak programmes of propagating and promoting family planning in the most systematic way. The superficial increases in the knowledge of contraceptives are not matched by the slow pace of adoption of the modern methods.  Inadequate population education is seen as the fundamental flaw.  Chapter 4 goes into details of how the concept of family planning has been popularized in the UK and in the USA and suggests that technology of contraceptives, the legal framework as well as the mass media played their role.

In chapter 5, the emphasis is placed not merely on the science of contraceptive techniques but on the role of social and cultural values, and what the author refers to as “life style” on the suitability of any method to the circumstances of the woman or man.  In the discussion of natural family planning, the author tackles the question of the role of religion (especially the position of the Roman Catholic Church) in the propagation and adoption of family planning.  Some fascinating materials are presented on the role of religious hierarchy in the evolution of their respective positions.

In the second half of the book starting from Chapter 6, attention is turned to a comprehensive review of the development of Nigeria’s population policies and family planning programmes.  The disconnect between rhetoric and action in the policy arena is highlighted and illustrated from the series of Nigeria’s Development Plans. The author argues that the global attempt to put the MDGs at the heart of socio-economic transformation strategy has succeeded in showing up the “inconsistency between development aspirations and the demographic imperatives of a rapid population growth rate” in Nigeria (p.129).  With a rapid population growth rate, some of the gains of developmental efforts are continuously being eroded by the rising demand for services, and in some cases, the demand overwhelms the system.

The author draws attention to the positive impact of NGOs (local or foreign) in the promotion of family planning. He identifies the militating factors to include non-involvement of the medical profession in the family planning efforts since family planning was peripheral to their training; urban bias in the location of moribund services; poor funding; low morale of staff; the limitations on the provision of a wide range of methods.   The unfortunate result has been the stagnation of ever use of some modern methods for forty years.

On the positive side, the author discusses the “factors of limited success” (p.142), including the rising profile of political leaders in the population debate.  But progressive views of leaders are not always translated into aggressive family planning programmes because of what the author terms “the established and controversial link between population size and access to national resources especially access to the national oil wealth (p.143).” Attention is next turned to the primary stakeholder in family planning, the public. The author contends that economic hardship is producing converts to family planning when they can access the services. Service delivery strategies are not complementing the rising demand and unmet needs for family planning.  Other major drawbacks include: quality of care issues in choice of methods, technical competence of service providers, and what is the major thrust of the book, the lack of appropriate constellation of services when family planning services are isolated and away from other health  services.

In Chapter 7 the socio-cultural influences on family planning adoption are discussed in terms of the cultural traits surrounding reproductive behaviour in the country.  Love of large families, fatalism in matters relating to reproduction, belief in evil spirits, and ignorance of the scientific explanation of phenomena are some of the influences.  The demographic factors associated with this cultural attitude are discussed in terms of response to high infant and childhood mortality, polygamy and reproductive rivalries and anxiety about old age support. The socio-economic characteristics affecting access are discussed in terms of settlement patterns, impact of extended family support systems on reproduction and the pressure on people to conform to traditional values. Some personal characteristics influencing reproduction include age, education, occupation and religious beliefs.

Having prepared the ground in the preceding seven chapters, Chapter 8 discusses the prospects for achieving a substantial reduction in fertility through family planning.  The social changes in the family system, the erosion of gerontocracy, the reduction of family cohesion through migration and the associated urbanization and rising individualism as well as the commercialization of basic needs are producing a rethink in the value attached to children and an evaluation of their costs and benefits. The logic of these modernizing influences should be the adoption of family planning.  That such a demand exists and is unmet is no news.

What are the prescriptions for getting the country out of the family planning lethargy?  It is here that the author brings his creative genius to bear on the natural link between the current HIV/AIDS epidemic and the role of population education in addressing both the population control issue as well as the HIV prevention and control issues. In Chapter 9, the author demonstrates that public enlightenment has been put to good use in Nigeria’s economic development, and that education can act as an agent of change.  Although the HIV/AIDS prevention efforts draws attention to deaths at the expense of the consequences of rapid population growth, the author argues that “Resolving the conflict will rely on the contribution which a systematic population education can make to promoting behavioural change across sexual and reproductive health spectrum.” Illustrative examples of successful government-led behavioural change, from eradication of cocoa black pod disease to social mobilization programmes, are presented.  The extent to which the ownership of programmes plays a role in programme acceptance is also discussed as well as the scope and evolution of population education in the last four decades. In elaborating the potential channels of change communication the author discusses the effectiveness of different media and the platforms that can be employed in personal communications such as learning institutions, health and social institutions and within communities.

Making a case for population education and behavioural change communication, the author tackles the issue of the transformation that has taken place in the knowledge and perception of sexually transmitted infections in the context of the HIV/AIDS epidemic in Chapter 10.  Here again the author managed to combine basic scientific information with a profound knowledge of the social and cultural context in which the public operates.  The cultural constraints of unorthodox explanation of health phenomena as well as ignorance of the germ theory of diseases combine to complicate the HIV prevention initiatives.  The culprit in the fueling of the epidemic is the nature of sexual practices as well as some traditional practices.

In the process of correcting some of the sexual practices predisposing to HIV infection some tragic errors are made. The identification of most-at-risk-population may serve some epidemiologic purposes, but the identification of least-at-risk-populations makes such populations the victims of sexual predators. The rape of virgins and small children which took place in some countries in the earlier phases of the epidemic is a case in point.

The prospects for sexual behaviour change are discussed in terms of the rising profile of the epidemic which triggers the intention to do something about its prevention in individuals. The past attempt at controlling STDs and the effort that has gone into AIDS control programmes are yielding results.  Some early missteps have been corrected and the role of IEC and BCC now well established.  The author, however, argues that there are new requirements for fully exploiting the contribution of the communication efforts.  “Devising new concepts and their meanings which can be communicated in the local languages and idioms but which have precise modern scientific validity’’ (p. 255). The author also presents some evidence of work done in this connection on HIV/AIDS prevention projects in parts of Oyo State.

In the final Chapter 11, the author ties the family planning and HIV/AIDS concerns together in reflections on the Nigerian population situation. The most germane in this regard is the section on Integration of HIV prevention and family planning programmes in maternal and child health.  It is in these closing pages that the depth and range of the author’s knowledge of Nigeria’s family planning and HIV/AIDS terrain come to the fore.  In reforming the family planning strategy to serve the dual purpose of population control and HIV prevention, he suggests that the focus on married women is a mistake.  The isolation of clinics is the next point of reform needed. In his words “approaching people of both sexes in market places with the joint message of HIV prevention and incidental birth control is feasible and likely to be more productive of uptakes of dual protection than is possible with the focus on clinic services’’ (p. 269). The issues of method mix, and cost recovery and the provision of infrastructure for service delivery are also discussed.

The challenges of creating demand are addressed in terms of making people conscious of the public and private health importance of family regulation. The contribution of individual family decisions to national welfare also needs to be in plain view.  In addition, the quality of services is considered as central to the creation of demand. Moreover, the evaluation of the programs and the feedback to the public is a way of justifying the utility of family planning.  The provision of incentives for small to medium family size and an increased role for the use of emergency contraceptive pills in the management of adolescent reproductive health needs are also advocated.

Overall, this is a very detailed and authoritative discourse of the family planning and HIV prevention situation within the context of the social and cultural backgrounds of Nigeria. The author is commended for this lucidly presented work, the crowning of his many years of research on this very important topic.

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