Family planning

Region focus: Africa

Country focus: Kenya. Gray map of Africa with Kenya highlighted in pink.
There’s an elephant in the room. Population issues are so difficult to talk about that the development community has been ignoring them for years.

Alex Ezeh

The data
Human Capital and Population Growth
chair people

Alex Ezeh

Visiting Fellow, Center for Global Development

I think about the future of my continent in terms of three questions: Are Africans healthy? Do they have access to a good education? And do they have opportunities to apply their skills?

Chart showing the projected population growth of sub-Saharan Africa (from 2018 to 2100) if it continues unimpeded, if there’s a shift from early births, and if all unwanted fertility is addressed.

Millions more Africans have been able to answer yes to these questions in recent years. But there’s an elephant in the room. One of the keys to keeping this progress going is slowing down the rapid rates of population growth in parts of the continent. But population issues are so difficult to talk about that the development community has been ignoring them for years.

Population growth is a controversial topic because, in the not-too-distant past, some countries tried to control population growth with abusive, coercive policies, including forced sterilization. Now, human rights are again at the center of the discussion about family planning, where they belong. But as part of repairing the wounds created by this history, population was removed from the development vocabulary altogether.

For the sake of Africa’s future, we should bring it back. Based on current trends, Africa as a whole is projected to double in size by 2050. Between 2050 and 2100, according to the United Nations, it could almost double again. In that case, the continent would have to quadruple its efforts just to maintain the current level of investment in health and education, which is too low already. If the rate of population growth slows down, however, there will be more resources to invest in each African’s health, education, and opportunity—in other words, in a good life.

To be very clear: The goal of family planning programs is not to hit population targets; on the contrary, it is to empower women so that they can exercise their fundamental right to choose the number of children they will have, when, and with whom. Fortunately, empowering couples to make decisions about their lives also improves Africa’s future by changing the population growth scenario across the continent.

The Track20 Project modeled some relatively simple future scenarios for sub-Saharan Africa to consider how various family planning-related investments might affect population growth. Let’s examine the data.

Wanted fertility: The black line represents sub-Saharan Africa’s population to 2100 based on estimates by the United Nations Population Division. The red line represents its population to 2100 if every woman had only the number of children she wanted. Currently, women in the region have an average of 0.7 more children than they want. If that number went down to zero over the next five years, the population in 2100 could change by 30 percent.

Education: Another link between empowerment and population growth is the transformative impact of secondary education for girls. Educated girls tend to work more, earn more, expand their horizons, marry and start having children later, have fewer children, and invest more in each child. Their children, in turn, tend to follow similar patterns, so the effect of graduating one girl sustains itself for generations.

Though the impact of education is sweeping, our model looks at just one narrow aspect of it: a shift in the age at which women give birth to their first child.

The pink line represents sub-Saharan Africa’s population if every woman’s first birth were delayed by an average of approximately two years. The average age at first birth for women in Africa is significantly lower than in any other region. Currently, it is 20 or younger in half of African countries. This scenario doesn’t have anything to do with women having fewer children. It just has to do with when they start having them.

Consider this thought experiment. If every woman started having children at age 15, then in 60 years you’d have four generations (60/15=4). But if every woman started having children at age 20, then in 60 years you’d have three generations (60/20=3). Even if those women had the same number of children in each generation, the total population would be one-quarter smaller in the latter scenario. To be conservative, we assumed a less substantial delay in our model. Still, it changes the projected population by nearly 10 percent.

Everyone I know supports sending girls to school and giving them access to information about family planning and contraceptives when they ask for them. I hope we will stop shying away from also pointing out that empowered women make millions of individual decisions that add up to a better demographic situation for themselves, for their children, and for Africa.

The story
Putting her in charge
chair people

Abigail Arunga

Kenyan writer and blogger

I look up at the office building where my interview is about to take place. It is a tall gray tower that’s a bit foreboding if a welcome is what you’re looking for. Inside, everything is swathed in more gray, with just a few lonely plants that don’t quite spruce things up.

What I see once I get to the office where I’m headed, though, is a complete contrast to what I’ve left behind. The walls are done up in bright colors. The receptionist doesn’t stop smiling. There’s a couch and a yellow armchair across from her desk, as cheery as you can get, and a television mounted in the corner tuned to the BBC.

A group of women in Nairobi, Kenya gather to take a selfie with a smartphone.

Future Fab’s teen connectors chat with clients about health. (Nairobi, Kenya)

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I’m here to talk about Future Fab, a three-year pilot program designed by Marie Stopes Kenya (MSK) to help teenagers—especially teenage girls—access contraceptives and other reproductive health care.

I wonder if this is the same aura that envelops Marie Stopes centers all over Nairobi, and I hope so, because if I were a nervous teenager asking about contraception for the first time, this is exactly the kind of aura—and armchair—that I would want to sink into.

I meet youth lead Elizabeth Ogott first: a slender woman, taller than my 5’8” even without the boots she’s wearing to ward off Nairobi’s winter. She’s purposeful in her movements—she definitely does not look like she is running on the three hours of sleep she claims to have gotten—and her handshake is firm. A few minutes later, marketing lead Roselyn Ouso joins us in the boardroom, and the quorum is complete.

Our conversation takes me back to my own teenage years, when my friends and I thought you could get pregnant from just being around genitalia, and a period was something that we needed to hide from the world like a shameful secret.

Adolescents in Nairobi have little to no information about sex, because everyone pretends they’re not having it.

Abigail Arunga

Kenyan writer and blogger

Not much has changed in that regard since I was a teenager, according to Step Up, the 2014 African Population and Health Research Centre report that Roselyn shows me. Adolescents in Nairobi have little to no information about sex, because no one is giving it to them. Their parents and teachers tell them not to get pregnant, but no one tells them how: for example, according to the report, only about 25 percent of unmarried young women know when in the month they are most likely to get pregnant. Not helping matters is the stark contrast between many adolescents’ beliefs and their reality. A large number of teenagers believe that they should stay virgins until they marry, the report says, but many are having sex anyway.

It was against this background, and reports such as this one, that MSK began offering free contraception to adolescent girls in 2016. It didn’t work. Very few girls showed up.

“We needed a new strategy,” says Elizabeth, “because the services we had were not responsive to adolescents. We needed a human-centered design process that would fit into the life of a young girl.”

So they started talking to teenagers and realized that adolescent girls weren’t interested in talking about contraception. They were interested in talking about their aspirations and what they wanted their futures to look like. So MSK began working with a design firm, and instead of ads and announcements about family planning, they came up with Future Fab, which they call an “adolescent lifestyle brand.” Their 22 privately owned clinics across Kenya began hosting events—dance contests, fashion shows—and publishing a magazine, all focusing on young people and their dreams. Along with all this comes discussions of how unplanned pregnancy can get in the way of achieving those dreams—and how to avoid it. Future Fab helps young women explore their goals while also helping them understand exactly how sex fits into a future that they’re in charge of. “I own my future,” reads one of the slogans splashed across the pages of the magazine.

Future Fab started offering popup services, and they took care to be as youthful, colorful, and cool (without using the word “cool”) as possible. They hired “diva connectors,” taking the job title from the popular catchword describing a fabulous, put-together girl. Diva connectors have direct contact with girls on the ground who are searching for what Future Fab has to offer; they get the community excited about Future Fab events, build relationships with girls, and take them to the center and follow up after the visit. They are an essential part of what makes the girls who come to the center comfortable.

Although Future Fab focuses on teenage girls, it’s really aimed at the community as a whole. So MSK also works with healthcare providers so they understand better what girls need, with parents so their own misconceptions about pregnancy are replaced with good information, and even with security guards so they understand how not to make teenage girls uncomfortable.

Close-up of hands holding Future Fab event promotional cards. Nairobi, Kenya.

Future Fab leads with lifestyle messages. (Nairobi, Kenya)

To say that the new approach succeeded where its old one had not would be an understatement: Since the three-year pilot started, visits to MSK clinics by adolescent girls have shot up sevenfold.

After talking to Elizabeth and Roselyn, I want to see for myself how Future Fab works on the ground. I go to one of their health centers in Kangemi, a peri-urban slum about 15 minutes from the headquarters. I’m not sure what to expect, but I know it’ll be like nowhere in Nairobi I’ve ever seen.

I’m wrong. It’s exactly like everywhere in Nairobi I’ve seen, because there’s no parking.

As soon as you turn into Kangemi, the ratio of people to cars on the road is 20 to 1. When we pull into the lot in front of the building that houses the clinic, there is no space. I have to double-park behind another car and ask one of the men directing the traffic to watch the car for me.

We climb one flight of stairs before we see the prominent Future Fab sign at the door. Next to it is another poster: “Children By Choice, Not Chance.” And in case you come here past business hours and need urgent help, there’s a piece of paper stuck to the front door with an emergency-contact telephone number on it.

Once we walk in, I see that here, too, the receptionist is smiling. The floor is sparkling clean, and a few posters about healthy living cover the walls, much like your regular local small health center. Lydia, the clinic manager and head clinician here, is busy, which seems to be the usual for her. She bustles past me in her pristine white shirt, then past me again in the other direction. She focuses on me every so often, reassuring me with a kind smile that she will be with me shortly.

The small waiting area has about seven people in it; most are girls, but since MSK serves anyone who needs their care, not just girls: I also see a man who looks slightly uncomfortable and a couple here for postnatal care.

Lydia introduces me to one of the patients in the waiting room, a shy young woman in a headscarf. She doesn’t seem comfortable in these surroundings: she has been watching me, though furtively, as much as I have been watching her. Her clothes—a knitted sweater and a long skirt—are draped over her slight frame, and she holds her possessions closely to herself. When we meet, I don’t want to ask her name, lest she grow even more uncomfortable, but she is willing to talk to me a little bit about what brought her here today.

She is 23, she says, a bit older than the girls Future Fab usually caters to. She tells me she has never been here before, and she adds that she’s never been welcomed like this before at a health center. Her stomach has been hurting for almost a year, and eventually she decided that since she passes by the center every day anyway, she might as well go see what they had to tell her. She has no children; she feels like she’s too young for them. She’s been looking for a job but can’t find one, and is at the point where she will take anything that comes her way.

Lydia has just finished seeing a mother and her baby when she finally has time for me. There is rarely a dull moment at the clinic, she says with a laugh; new clients come in every half hour. Adolescents get first priority at the desk so that they don’t have to deal with questioning stares or comments from irate adults. When they are ushered in to Lydia’s office, she asks them about what’s going on with them and helps them figure out what they want to do, whether it is talking, medication, or counselling. Whatever they need.

“Our society is hypocritical,” says Lydia, discussing the challenges the center faces. “We’re not ready to face reality, and we’ve buried our heads in the sand about adolescent pregnancies.” Another problem, she adds, is that a lot of Kenyan health service providers are overworked and underpaid. “Future Fab is wonderful because it is so easy,” she says. “The health services are free if you’re under 20”—free for the clients, that is; they cost MSK and its funders $25-30 per girl—“the provider and the products are available, and they are in close proximity to the girls, within the neighborhoods.” In a society where no one else seems to be doing much, accessibility is a key advantage.

A patient checks in at the Kangemi clinic. Nairobi, Kenya

A patient checks in at the Kangemi clinic. (Nairobi, Kenya)

I recall my conversation earlier in the day with Elizabeth. It can be hard to make change happen, especially in a country like Kenya with so many complications—religious dogma, parental supervision, legal loopholes—to navigate. Elizabeth said that they have had some champions, from, remarkably, the religious field, who understand the value of what a project like Future Fab can do. “The poverty is so entrenched,” Elizabeth said, “and they see what goes on and want a solution.”

By all measures, the Future Fab pilot has been a great success. According to Anne Parker, the global adolescents lead at Marie Stopes International, the program increased contraceptive use among girls who participated by 50 percent while at the same time steadily reducing costs. More important, as far as she’s concerned, is what MSK has learned about working with this population. The organization has only begun to examine its data, and already its programs in Zambia, Uganda, Ghana, Mali, and Tanzania have made changes based on the lessons Future Fab has to offer.

In the meantime, Future Fab has made a real difference in the lives of adolescent girls here. Lydia tells us about a girl whose parents found out she had received care at MSK. They came down to the center to convey their displeasure; Lydia refused to give them any information, because it is against Future Fab’s policy. They came back again with their daughter, who admitted that she had had a procedure done. Though they were unhappy with her choice, they were also relieved because it meant that her life could continue as she had imagined. She’s in her second year of university now.

Not all stories end this way. But for every one that does, Lydia is reassured that something is going right. “We’re putting the power in their hands,” she finishes, almost absent-mindedly, as another client walks in to her office.