101503 Maternal and Child Nutrition and Health Results Project Technical Brief: The Gambia December 2015 Health, Nutrition, and Population Global Practice Impact Evaluation Baseline Report: Fertility and Family Planning Key Messages •• In The Gambia, the total fertility rate (TFR) was 5.6 births per woman in 2013 with Central River Region (CRR), Upper River Region (URR) and North Bank Region (NBR) having the highest TFRs (Gambia Bureau of Statistics 2014). •• In this survey, an average of 12 percent of women reported using modern contraceptives: 4 percent in URR, 10 percent in CRR, and 27 percent in NBR-West (NBR-W). •• With substantial regional variation, 40 percent of women did not approve of family planning. •• Use of modern family planning for birth spacing was much more acceptable to women than using it for limiting the number of children. •• Less than 13 percent of women reported being the main decision maker regarding contraceptive use and 40 percent reported that the decision was shared by herself and her partner as a couple. •• Across all three regions, community members voiced strong opinions that family planning services should only be used by married women. •• General availability of family planning supplies was extremely high across all regions and methods, but high stockout rates were also reported, suggesting interruptions in the supply chain. Introduction The MCNHRP baseline evaluation was The government of The Gambia is implement- conducted between November 2014 and ing the Maternal and Child Nutrition and February 2015. Quantitative and qualitative Health Results Project (MCNHRP) to increase data were collected on three regions: CRR, the use of community nutrition and primary NBR-W, and URR. Its purpose was to estab- maternal and child health services. In collab- lish a baseline against which project perfor- oration with the government, the World mance will be assessed in the future. This Bank is conducting an impact evaluation to technical brief summarizes the baseline assess the project’s impact on key aspects report findings related to fertility and the of maternal and child nutrition and health. use of family planning. This series of policy briefs was produced in direct This brief was prepared by a core team comprising Laura Ferguson (Principal Investigator, University of Southern California), response to a request from the government of The Rifat Hasan (co-Principal Investigator, Health Specialist, World Bank), and Alexandra Nicholson based on the Impact Gambia to share the findings of the Maternal and Evaluation Baseline Report produced by Laura Ferguson, Rifat Hasan, Guenther Fink, Yaya Jallow, and Chantelle Boudreaux. Child Nutrition and Health Results Project Impact Evaluation Baseline Survey. The Impact Evaluation Baseline Report benefited from substantial inputs from The Gambia Bureau of Statistics, Mariama Dibba, Halimatou Bah, Momodou Conteh, Sering Fye, Alexandra Nicholson, Hannah Thomas, and Steven Strozza. The team benefited from the general guidance of Vera Songwe (former Country Director), Louise Cord (Country Director), and Trina Haque (Health, Nutrition, and Population Practice Manager). Helpful comments were received from the Project Implementation Committee led by Modou Cheyassin Phall (Executive Director, The Gambia National Nutrition Agency) and comprised of Haddy Badjie, Abdou Aziz Ceesay, Ousman Ceesay, Modou Lamin Darboe, Malang Fofana, Catherine Gibba, Bakary Jallow, Musa Loum, Lamin Njie, and Matty Njie, and Menno Mulder-Sibanda (Senior Nutrition Specialist, World Bank). The work was made possible by support from the Health Results Innovation Trust Fund. 1 Figure 1. Use of Family Planning, by Region Figure 2. Cultural Acceptability of Family Planning, by Region 50 45 100 40 90 35 30 30 27 80 Percent 25 70 20 17 14 60 Percent 15 13 12 10 10 50 4 5 40 0 30 Central North Bank Upper Average 20 River Region-West River across three Region Region regions 10 0 Use of any family planning method Central North Bank Upper Average Use of a modern family planning method River Region-West River across three Region Region regions Woman approves of couples using Fertility family planning In The Gambia, the TFR was 5.6 births per Woman believes partner approves of woman in 2013: 4.7 in urban areas and 6.8 in family planning rural areas. CRR, URR, and NBR have the Woman approves of other women younger than age 18 years using family planning highest fertility rates in the country (Gambia Bureau of Statistics 2014). The same regions also have the highest levels of teenage childbearing, especially CRR and URR. approval of family planning by literacy: Childbearing begins early with 15 percent of while nearly 60 percent of literate women adolescent girls ages 15–19 years nationwide approved of using family planning methods, already mothers or pregnant with their first only 45 percent of nonliterate women child. approved of their use. Nearly half of women reported being in favor of family planning use to prevent a pregnancy, but only one-third of Family Planning Uptake women reported thinking that their partners Overall, the use of modern contraceptives was were in favor of using family planning low; across the three regions, approximately (figure 2). 12% 12 percent of women reported using modern contraceptives with large variations (figure 1). Across all three regions, but especially in CRR and URR, community members voiced of women use modern By far, the most common modern method strong opinions that family planning should ­ ontraceptives c was the injectable (Depo), used by 50 percent only be used by married women. Only 18 of women using family planning, followed by percent of women approved of women under the oral contraceptive pill used by 15 percent. the age of 18 using family planning, with URR had particularly low uptake, where variation by region and literacy. Unmarried only 4 percent of women reported using women said that it was difficult for them to modern contraceptives, but utilization rates seek contraceptives because of prevailing were higher in NBR-W (27 percent). Use of social attitudes in this area. modern contraception was higher among A suggested potential justification for women in higher wealth quintiles compared contraceptive use was shame associated to poorer women. with pregnancy and childbearing out of Many women, particularly in URR, wedlock, or with becoming pregnant again “With the injection, when I reported using traditional methods to delay while still breastfeeding a previous child. started menstruating, the pregnancy. Reliance on breastfeeding to blood did not stop coming and prevent or delay pregnancy was particularly Method Preference and Side Effects that is not good for a Muslim.” common in URR, where it was the dominant A strong perceived association between – Female community family planning method for this reason. modern contraceptives and severe side member, URR effects may constitute a barrier to uptake. Reasons for Not Using Family Planning Although Depo was a preferred method of Cultural Acceptability of Family Planning modern family planning, a striking number 40% Approval of family planning was generally low with 40 percent of women not approving. of women reported side effects from this injectable contraceptive, which led to discon- of women did not approve of Approval was highest in NBR-W and lowest tinuation. Women also reported high levels family planning in URR. There was a large difference in the of side effects from oral contraceptive pills. 2 Accessibility Figure 3. Stockouts of Family Planning Supplies Lack of knowledge on how to access services for at Least 1 Day in the Past 30 Days, by Region can present a fundamental barrier to health 100 care utilization, including family planning 90 services. While knowledge of where to access 80 contraceptives was high in NBR-W and URR, 70 nearly 20 percent of women in CRR reported 60 Percent not knowing where to get contraceptives. 50 Lower proportions of women in the lowest 40 socioeconomic quintile and women living 30 20 further from health facilities reported 10 knowing where to access family planning 0 commodities. Central North Bank Upper River contraceptive ­ “The ­ River Region Region-West Region prevalence rate is very low Availability Oral contraception Injectable (Depo) because the service providers Implant (Jadelle) Intrauterine are not trained on this and Availability of family planning supplies was contraceptive device extremely high with the exception of the they need equipment to be Female condom Male condom intrauterine contraceptive device, which was able to do this.” not widely available. Despite the generally – Regional Health Directorate high availability of supplies, there was also a Among pregnant women, it was more member, CRR high prevalence of stockouts of family common in URR for the woman to have planning commodities for at least one day in wanted the pregnancy at that time. the 30 days before the survey. This gap Mistimed pregnancies were more common suggests that regular interruptions in in CRR and NBR-W, with 30 percent and the supply chain occur. Stockouts were 34 percent of women in these regions, particularly frequently reported for Depo respectively, reporting that the pregnancy (96 percent of health facilities), oral contra- was mistimed. “The man decides as he is the ception (92 percent), and the contraceptive Overall, less than 13 percent of women one who married the woman. implant (Jadelle) (92 percent) (figure 3). In reported being the main decision maker It is his decision to make—the focus group discussions, women suggested regarding family planning use, and that making contraceptive supplies available number of children the woman 40 ­percent reported that the decision was in the community in addition to health should have.” shared by herself and her partner as a facilities would improve accessibility. – Male community member, couple. Nearly one in four women reported Lack of available financing to train health that their partner had primary control over CRR workers was cited as a limitation to the whether they used contraceptives to provision of family planning. prevent or delay pregnancy. In one instance, a group of men in a Fertility Desires, Intentions, and community of “Jahankas” (a branch of the Decision Making Mandinka ethnic group) in CRR joked about Across all three regions, expressed desired the very high fertility rate among their ethnic fertility was high with both male and female group. This high fertility was a source of pride respondents stating that women should have with men stating that they benefit from their at least six children and some suggesting that wives having many children as some of them more than six children was ideal. This reflects will likely prosper. the particularly high TFR in these three Many people reported that the number of regions. A stated preference for sons was children they would have was in God’s hands, given as a reason for women to keep having which meant that for them family planning children if they only had female children. was irrelevant because they felt that it was © 2015 International Bank for Reconstruction and Development / The World Bank. Some In the survey, 71 percent of pregnant not for them to decide the number of children rights reserved. The findings, interpretations, women reported that their current pregnancy they should have. and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its was desired at that time, while 28 percent of Board of Executive Directors, or the governments respondents would have preferred their they represent. The World Bank does not guarantee pregnancy to have happened later. Only 1 Reference the accuracy of the data included in this work. This work is subject to a CC BY 3.0 IGO license Gambia Bureau of Statistics (GBOS) and ICF percent of women who were pregnant at the International. 2014. The Gambia Demographic and (https://creativecommons.org/licenses/by/3.0/igo). The World Bank does not necessarily own each time of the survey did not want to ever be Health Survey 2013. Banjul, The Gambia, and component of the content. It is your responsibility pregnant again. Rockville, MD: GBOS and ICF International. to determine whether permission is needed for reuse and to obtain permission from the copyright owner. If you have questions, email pubrights@ worldbank.org. SKU K8563 3