Cultural and Human Rights Dimensions of Family Planning in Mozambique

September 20, 2011 marks the one-year anniversary of Every Woman, Every Child, a global effort to achieve country-led commitments to bring life-saving health care to millions of women and children in the developing world by 2015. This series looks at maternal health in several countries with the highest number of maternal deaths every year. UNFPA, UNICEF, WHO, the World Bank and UNAIDS – known as the Health 4+ -- are supporting these countries to achieve their Global Strategy commitments.

MAPUTO, Mozambique – “We have ten children,” says Silvestre Celestino, 59, proudly, as he works his garden on the outskirts of Maputo, Mozambique, with his wife, Felizmina.

In a country with a stronger health system, it might be less remarkable that Felizmina, 57, and her ten children are all alive and in relatively good health. Felizmina had survived pregnancies totalling some 90 months – the equivalent of seven and a half years – in a country where the risk of maternal death is 130 times higher than in the United Kingdom.

Women in Mozambique face a one-in-36 lifetime risk of dying in pregnancy or childbirth – and the more pregnancies, the greater the risk. For every woman who dies, about twenty more suffer long-lasting and devastating childbirth injuries such as obstetric fistula. The risks increase for women who give birth too young, too often or with too little time between pregnancies.

The big payoffs of thinking smaller

Women who are unable to plan and space their births are at much higher risk of the leading causes of death during pregnancy and childbirth – haemorrhage, infections, unsafe abortions, high blood pressure leading to seizures and obstructed labour. Treatment of these complications is difficult given other challenges within Mozambique’s health system.

A severe shortage of health workers and lack of basic medical supplies put even rudimentary medical care out of reach for many in the country. More comprehensive treatment – as might be needed during a complicated pregnancy or childbirth – is especially hard to access. The number of health facilities equipped to provide emergency obstetric care, like blood transfusions or Caesarean sections, comprise just 40 per cent of the total needed to serve Mozambique’s population.

Despite the risks, many couples in Mozambique have large families -- six children, on average. For those who live in some rural areas, the average is closer to seven.

One explanation for large family size is the high rate of mortality among young children. Large families are a sign of wealth in many communities, and parents may fear ageing without the support of adult children.

Large families are a form of social protection

“Having too many children was for a long time, and still is today, the main form of social protection in Mozambique,” António Francisco, Rosimina Ali and Yasfir Ibraimo of the Institute for Social and Economic Studies in Maputo explain in a recent analysis, titled “Financial versus Demographic Social Protection in Mozambique.”

Some women, however, report that they would prefer to have much smaller families.

“I want three children,” Ana Maria says, pointing to her belly as she waits for prenatal care at the Boane Health Centre about an hour outside the Mozambican capital of Maputo.

“I already have two—a boy and a girl—and I want this to be my last,” she adds, explaining that raising children is expensive and that she would rather use the money to build a new house, one that has four rooms.

At an impromptu market on the outskirts of Maputo, Asucena, a 22-year-old tomato vendor, says she wants only three children. The women working the adjacent stalls all say they want only two or three children. Worldwide, smaller families are closely correlated with life in urban areas.

Yet in Mozambique, only 11.8 per cent of women rely on a modern method of contraception, such as pills, injections or condoms, according to the United Nations Population Division. In one province, just 3 per cent of women use modern contraceptives. Another 4.7 per cent of women in the country use a traditional method or the ‘rhythm method’.

Worldwide, 56 per cent of women between the ages of 15 and 49 use a modern method of family planning. The much lower contraceptive prevalence rate in Mozambique may in part reflect a lack of supply. In some parts of the country, contraceptive availability is limited, mainly because of difficulties transporting them to distribution centres in remote areas.

But another reason behind the low contraceptive prevalence is a lack of demand. The ‘unmet need’ for family planning in Mozambique is about 18 per cent, compared with an average of 25 per cent in all of sub-Saharan Africa. Unmet need is the share of women of reproductive age who are married or partnered who want to avoid or delay a pregnancy but are not using a contraceptive.

The unmet need for family planning actually has risen in recent years, according to Mozambique’s Ministry of Planning and Development. Women or couples may be increasingly aware of contraceptives, but the health system is not able to satisfy the demand for these items.

Planning for health and opportunity

Dr. Carlos Arnaldo, a demographer at Eduardo Mondlane University in Maputo, points to another challenge. “Family planning is [becoming more available in places], but women are not the decision-makers,” he says. “Men are against family planning because they want more children, and if a woman uses contraception, the man thinks that the woman is trying to hide an affair.”

Patricia Guzman, UNFPA Representative in Mozambique, explains that increasing voluntary use of modern family planning is fundamentally linked to women’s status in the household and their ability to exercise their reproductive rights.

“Ensuring every pregnancy is wanted and every childbirth is safe leads to smaller and stronger families,” Guzman says. “But beyond the lives saved, we need to remember that the power to decide when and how many children to have is a fundamental human right.”

It is a right that is often compromised by gender inequalities, and Mozambique ranks near the bottom of the Gender Inequality Index, which is compiled by the UN Development Programme. It is also one of the world’s least developed countries.

Guzman explains that inequities of gender, wealth and education must also be addressed if voluntary family planning use is to be increased. In turn, she says, planning and spacing pregnancies will give women more influence in their homes and communities, as their options to work, to earn money, and to spend and save increase.

On his vegetable plot outside Maputo, Silvestre considers how his children have fared in such a large household. “They’re all alive,” he says. After a pause, he adds, “And healthy.”

— Richard Kollodge and Kathleen White