With More Babies Surviving, West African Women Are Desperate for Birth Control

The woman in the orange dress with a cheery bluebird print was the first to arrive, at 6 a.m. She’d lied to her husband, telling him she was going out to grind millet, and now, two hours later, she is standing outside a cement box of a building in Tuire, Burkina Faso, a village about two hours outside the capital, holding a wobbly bicycle and with a baby slung over her back, a distraught look on her face. The only millet in sight is sprouting from the dusty red soil in grassy clumps. Nearby are a few stout farmhouses, cylindrical mud-brick towers 15 feet tall, with thatched roofs that look like they too might have sprouted from the ground. A crowd of women has since the joined the woman in orange, all waiting for the mud-splattered pickup truck that pulls up. A few nurses get out. They are local employees of the British NGO Marie Stopes International.

“It’s so late!” says the woman in orange. She and the others have come here, to this health clinic, to get birth control—IUDs, arm implants, and tubal ligations, the range of reproductive health care that is in short supply in rural Burkina. She tells the nurses she needs to get back quickly or her husband will become suspicious.

“You must tell him there was a long line at the grinding machine,” says Eloi Zoungana, a nurse in his 40s. From inside the truck emerge plastic tubs, boxes of syringes, heavy-duty red plastic gloves, and a rusty metal bathroom scale.

(Image and data from Unicef, illustrated by Lauren Wade)

“But he will ask why I did not come back!” she protests. Zoungana opens the truck and starts taking out supplies. “Ah, but when you came, the chain on your bicycle broke!” he offers, a grin spreading across his face.

Awa Kolompare, another nurse, goes inside, where a bench runs along all four aquamarine walls, and begins sweeping the cement floor. Her hair is arranged in a short Motown-esque swirl, and a faux-diamond bracelet peeks out from under the cuff of her baby-blue scrubs. “OK, OK,” she says, motioning the woman inside. “We will get it done quickly.”

Burkina Faso is probably the fastest-growing country you’ve never heard of. It’s among the nine nations that make up the Sahel region. The word means “shore” in Arabic and refers to the transition zone where the Sahara Desert meets the grasslands to the south. It’s a fragile ecosystem, prone to increasingly unpredictable weather patterns. Most people in Burkina Faso live in extreme poverty; more than 44 percent subsist on less than a dollar a day. Roughly the size of Colorado, it ranks in the bottom 10 on the 2014 Human Development Index, a measurement that combines life expectancy, education, and national income.

Burkina Faso is one of many poor African countries going through a demographic transition: As countries develop, better nutrition, broader distribution of medical care and technology, and other factors reduce mortality rates. Infant mortality in particular—one of the United Nations' Millennium Development Goals—has seen subsantial declines in sub-Saharan Africa. Meanwhile ancient and deeply held traditions such as polygamy, low contraceptive use, and the social status of having a large family persist. In less developed societies anywhere in the world, people on the whole have many children because relatively few survive to adulthood, and without a social safety net parents feel they need to be sure someone will be around to take care of them in their old age. In agricultural communities (like Tuire), there are other reasons to have lots of kids: Children are a critical part of the workforce.

(Image and data from Unicef, illustrated by Lauren Wade)

With high birth and death rates, a population remains stable. But in Burkina Faso and elsewhere, dramatically lower mortality without a corresponding reduction in family size has led to a population explosion in places that have had a tough time providing for far fewer people. The current population of Burkina Faso is expected to double in the next 25 years. A UNICEF report released in August states, “Africa…is experiencing a demographic shift unprecedented in its scale and swiftness.” Citing concerns about potential increases in both poverty and inequality, along with resource scarcity resulting from climate change, the report calls for extending reproductive health education and services to African women. “Investing in girls and women, especially in reproductive health, education, and preventing child marriage is key to Africa’s demographic transition.”

(Image and data from Unicef, illustrated by Lauren Wade)

“You women who are outside, come in, we are going to start the talk,” Kolompare says. “Come, come. Come sit down.” Within a few minutes the cool cement floor is filled with several dozen women in bright patterned dresses or secondhand T-shirts and the blue, yellow, and red jerseys of the national football teams of Belgium, Burkina Faso, and Ivory Coast. A dozen spill outside. Many bear shallow cuts on their cheeks and temples, decorative scarification that’s traditional in this part of Africa. “You sit here,” Kolompare says to the woman who came early. “People will come take care of you right now,” she tells her. “Good morning, everyone. How are you? How are your children?” Kolompare asks the crowd in Mooré, the language of the region’s Mossi people.

“Many of you are hiding to come here,” Kolompare says. “You have suffered while giving birth, and you have given birth many times. You are tired. Now, what is family planning?” she asks. “Don’t be afraid. It’s why you are here.”

“Family planning is to protect us and our children,” one woman offers.

“Family planning means helping reduce women’s suffering and increase their incomes,” says another.

“You are right,” Kolompare says, making eye contact with many of the women. “If you use family planning, you won’t be walking with one child and have another in your arms and be pregnant at the same time. You will be working healthily. And if you are healthy and you work, you will have more money for the owner of the house.”

She takes a binder from the table and walks around the room, holding it up for everyone to see. On the laminated pages are images of condoms, injectable arm implants, and IUDs. Embarrassed, an old woman laughs and turns away as the binder comes by.

“Why didn’t you start these methods earlier?” she jokes. “I have finished having my children, and these are too late for me now.”

Investing in girls and women, especially in reproductive health, education, and preventing child marriage is key to Africa’s demographic transition.

-UNICEF

Despite the warm welcome they get in clinics like the one in Tuire, Zoungana and Kolompare must tread carefully between modern medicine and traditional cultures. In rural Burkina, men usually have several wives, and girls are often married by 16. Husbands mostly make decisions about family size; men carrying sticks and guns, resentful of what Kolompare is providing their wives, have threatened her and her fellow nurses. In urban areas, prostitution is common and access to birth control is sometimes seen as a way into this trade. Others view family planning simply as an insult to patriarchal authority.

Kolompare and Zoungana have returned to clinics to find women waiting for them with suitcases, having been kicked out of their homes until their implants are removed. Once a husband came to complain to the nurses about the tubal ligation—an irreversible surgery—his wife received without telling him. The husband said he’d had a divine consultation and that the marriage would be terminated unless the surgery was reversed (despite his wife having already borne him 10 children). The nurses agreed to his demand and took the woman inside, where they splashed some of the antiseptic Betadine, which leaves a red stain, on the since-healed incision in the woman’s abdomen. They waited a few minutes, then came out and told him they’d reversed the surgery. Satisfied, her husband thanked them. If the women never had more children, they hoped that too would be God’s will.

The MSI nurses are trying to cultivate in communities like Tuire a belief among residents that they can safely have smaller families. While their first priority is giving women the choice of how many children to have, helping to slow demographic momentum is a side benefit. “We don’t have the means in Burkina to support this population,” says Kolompare, who, before she worked with Marie Stopes International, was employed by the government as a midwife.

These days, the mobile nursing unit she operates can be found pushing its way from Ouagadougou, the capital, through the knot of bicycles, motor scooters, and donkey carts clogging the city, and out into villages. The team is well known around Tuire. Crowds of women eager to get condoms or IUDs, or hoping for advice about how many children to have, await them at every clinic; nearly a quarter of women in Burkina Faso report having an unmet need for contraceptives. As Burkina Faso’s population makes its slow transformation, Kolompare and her fellow nurses will keep traveling the countryside with a truck full of medical supplies, helping one woman at a time.

At the end of the day in Tuire, two women on their way out, both with babies on their backs, thank Kolompare for the services they’ve received. She stands, looking exhausted, eating a bowl of beans. Today her team has assisted 52 women, providing 36 arm implants, 12 IUDs, and four tubal ligations.

Recalling her background, first as a midwife and now as a nurse, she says, “What I liked was being with women and helping them. The woman comes from suffering to joy – she will hold your hand and say, ‘Thank you!’ She’s happy. She’s smiling. I like this!”