One year on from the launch of the Ivory Coast’s national plan to provide family planning services to all women in the country there is much progress, but more than 50% of women still lack access to vital services.
In the Ivory Coast, the fertility rate is estimated to be four births per woman and in 2010 only 12% of women of childbearing age used family planning services.*
Preventing unplanned pregnancy among HIV-positive women through family planning services is one of the four pillars of a comprehensive program for preventing mother-to-child transmission of HIV (the others being prevention of HIV in women, prevention of HIV parental transmission, and provision of care and support for HIV-positive women, their infants and families).
Limited choices for women living with HIV
Family planning counselling involves informing people about their contraception options and helping them make informed decisions regarding their reproductive wants and needs. But there are many barriers for women living with HIV who want to access family planning services in the Ivory Coast. And they often feel that their right to make decisions about their own bodies is not respected.
Abouo Séraphine , a woman living with HIV in Abengourou in the eastern region of the Ivory Coast, explained: “During my antenatal visit, the midwife told us about family planning options. I then decided to use contraceptive pills, and when I told this to the midwife, she said, ‘No, considering your condition you have to use condoms.’ I was very frustrated.”
Another woman, Amichia Ahou, a community counsellor, remembers one day being told by a midwife to stop sending women living with HIV for family planning counselling. She recalls the midwife saying: “Why do you keep sending us your women? You should tell them to stop getting pregnant or simply tell them to use condoms!”
Unmet family planning needs
Family planning is a key strategy in the Ivory Coast’s national plan to eliminate mother-to-child transmission of HIV. When the plan was launched in November 2012 by the first lady, one of the objectives was to provide services to 100% of women of childbearing age by 2015. The plan recognises that providing women living with HIV with adequate contraceptive methods helps prevent unwanted pregnancies.
The annual review of the national plan in July 2013 revealed an estimated 43% of women living with HIV now have access to services, while 13% of women in general used modern contraceptives in 2012. That means there has been a big increase in the number of women using family planning services, but the objective is still far from being achieved.
So far, activity has focused on providing contraceptives. But other key interventions, such as the training of health service providers, rebuilding facilities hit during the post-election crisis, and investigating socio-cultural barriers to accessing family planning have not started.
Service integration: the solution
One of the struggles women face is that HIV testing, services to prevent mother-to-child transmission and family planning are scattered, and patients have to seek services separately. Ama Bosso, a young woman living with HIV, said: “It is very tiring. You have to walk or sometimes use taxis to move from one service to another, while it could be so much easier if we had all of them in the same place.”
Due to this situation the number of women living with HIV who receive follow-up care decreases at every step. Of the women who are tested positive, fewer go to the care services to receive their prophylaxis, and of those who receive their prophylaxis, fewer attend the family planning center to receive counselling after giving birth. This affects patients’ long-term care. Akoussi Martine who is a community counsellor said: “This situation means that we have many patients who are lost to follow-up.”
Dr Aka, from the National Care Program, also has a view on the challenges involved, he said: “The main reason for this situation is that national programs—both national care and sexual and reproductive programs—are not collaborating. PMTCT [prevention of mother-to-child transmission] sites are built without consulting with national sexual and reproductive programs, and vice versa.”
If prevention of mother-to-child transmission and family planning services were provided in the same facilities, it would allow better follow-up for patients while ensuring easier delivery of services. And this solution will also help decrease the stigma associated with specific HIV care facilities. Unfortunately, this is not yet the case in the Ivory Coast.
*This is according to the World Health Organization in their 2011 World Health Statistics report (pdf).
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