Academic journal article International Perspectives on Sexual and Reproductive Health

Fertility Decisions and Contraceptive Use at Different Stages of Relationships: Windows of Risk among Men and Women in Accra

Academic journal article International Perspectives on Sexual and Reproductive Health

Fertility Decisions and Contraceptive Use at Different Stages of Relationships: Windows of Risk among Men and Women in Accra

Article excerpt

In Ghana, fertility has declined steadily over several decades, from 6.5 children per woman in 1979 to 4.0 in 2008.1 Current modern contraceptive use among married women, however, has risen slowly, from 13% in 1998 to 17% in 2008. (1,2) Ever-use of a modern method among all women has increased more quickly, from 21% in 1988 to 42% in 2008; the 2008 rate among all men was similar (46%). Overall contraceptive prevalence in Ghana has been characterized by a persistence of traditional method use: (2-4) Twenty-five percent of all women report ever-use of a traditional method. (2)

The picture in Ghana is very different from that seen in eastern and southern African countries with similar rates of fertility decline, where the driving force has been increased modern contraceptive use. (2-4) Explanations other than contraceptive use have been proposed for Ghana's fertility decline, including underreporting of contraceptive use by women and the control of fertility through reduced coital frequency. (3,5) Widespread use of induced abortion may also be a major contributing factor in fertility decline in Ghana.1 Although abortion is legal in Ghana within broadly defined limits, (*) health care providers and clients commonly believe it to be illegal,6 and access to safe abortion services is poor. (7)

Ghana has good socioeconomic indicators, including women's primary education, and the country attained lower middle income status in 2011. (2) Ghana was one of the first countries in Sub-Saharan Africa to engage in family planning activities, although political commitment has varied over time. (8) A wide range of contraceptive methods is available in both the public and private sectors, including pharmacies. Ninety-eight percent of all women and men in Ghana know at least one method of contraception. (1)

Studies on the perceptions and use of contraceptives in Ghana are predominantly from the Navrongo-based demographic surveillance site and rural contraception project in the country's north. (9-12) Far fewer such studies focus on urban Ghana, (13) where family planning use is lower than expected. For example, in 2008, the total fertility rates for urban and rural areas were 3.1 and 4.9, respectively, yet current contraceptive use among married women differed little by location (19% and 15%). (1) With a steadily increasing rate of urbanization (currently at 44%), (2) understanding contraceptive dynamics in urban Ghana is particularly important.

Previous research has demonstrated shifting social norms around sexuality in contemporary urban Ghana, where it is now more common for single women to engage in sexual relationships; (14,15) however, to our knowledge, no studies have explored how individuals in Ghana make decisions about fertility and contraceptive use in the context of changing sexual norms and within relationships. In this study, we aim to understand the social and relational contexts in which reproductive decisions are made; we do not consider health facility-or provider-related influences (reported elsewhere (16)), except when specifically identified by respondents as a pertinent influence.

We examine three levels of variables found to be associated with contraceptive decision making in Ghana. The individual level includes personal, biological and psychosocial variables such as attitude to contraception, (17) knowledge and skill (behavioral capacity), (18) self-efficacy (19) and outcome expectancy. (20) Interpersonal factors focus on influence of the sexual partner (21) and power dynamics within the relationship. (22) And social factors focus on the social norms and pressures governing sexuality and gender roles, such as expectations for women to be sexually passive to safeguard their dignity and honor. (23) We draw these variables together to understand the contexts in which men and women make contraceptive decisions through their reproductive lives and at different stages of a sexual relationship. …

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