Contraception in Yemen:Challenges and strategies for intervention [Archives:2004/726/Health]

April 5 2004
Photo from archived article: photos/726/health1_1
Photo from archived article: photos/726/health1_1
By Dr. Nabil al-Soufi

According to UNICEF, Yemen has the second highest fertility rate in the world. The population has doubled in the last 15 years to become 20.5 million and it is estimated that the current number will double again in 20 years. We get a better feeling of how serious this number is if we remember that the population of Sweden (8.5 million) is expected to double in a period of 4077 years. High child-bearing rates have adverse health effects on women's and children's health as it is well known that such rates lead to higher infant mortality and higher maternal mortality rates. Bigger families also reduce the chances for adequate nutrition, adequate education, and the overall parental and societal care for children. A woman with more children has diminished chances for education and employment. As Yemen has limited natural resources, the exploding population is a serious problem that challenges successive governments. This problem has aggravated the economic effects of the unreasonable misunderstanding of Yemen's position towards the Iraqi invasion of Kuwait, and the dishonorable divisive war in 1994.
At the 1991 population conference Yemen adopted a national strategy to reduce fertility rates to 6.5% and raise contraception use from 10% to 35%. While fertility rates had dropped from 7.5 to 6.5 (it is debatable whether or not this was the result of the government-adopted policy), rates of contraception use were still only at 20% according to the Health and Demographic Survey in 1997. Furthermore, only 50% of these women were using modern methods. The most popular contraception method is the pill (40%), followed by intrauterine device (30%), female sterilization (14%) and injections (12%).
In order to craft a good public health intervention, we should first look at the reasons that make Yemeni women reluctant to use contraception. Those reasons, reported in Yemen's Demographic and Health Survey (YDHS) of 1997, are shown in the table below:

Percentage distribution of currently married women who are non-users,* by reason for nonuse, according to age.
Yemen Demographic and Health Survey, 1997

* Refers to women who are not using contraceptives and who do not intend to use them in the future
The leading reported reason for Yemeni women not to use contraception is their desire to have more children. YDHS does not show the rural-urban differences as to why those women want many children. The reasons that compel rural women to have more children may different for urban women, and any intervention should be attuned to peoples' specific situations. It is well established that high infant mortality rates lead to high fertility rates, in part, because couples try to compensate for infant deaths they have witnessed or experienced. Large families, in turn, reduce the ability of poor parents to invest adequately in the health and education of each child. A reduction in infant mortality can create an environment in which couples feel less compelled to maintain high fertility levels to ensure the survival of at least some children. As a result, parents will be able to invest more in each child at any income level. On the other hand, women who practise family planning can avoid high-risk births and therefore reduce their chances of having a baby who will die in infancy. While it is true that infant mortality can be reduced through providing better health care, another important factor is the educational level of mothers. The Yemen Demographic Survey of 1997 showed that education level was negatively correlated with infant mortality rates. This is because educated women are more likely to provide good care for their children and are more likely to seek medical help for a sick child. According to the World Bank, educated parents have better nourished children who are less likely to die in infancy than the children of uneducated parents. On average, one additional year of schooling for a mother results in 9/1000 reduction in child or infant mortality. Whilst this may be accurate to some extent, we should be careful in generalizing in all situations. This is because some people can't afford adequate nourishment for their children regardless of the educational level of mothers. In addition, Yemeni men usually make decisions as to what food items to buy for the family or when a sick child should be taken to the clinic. Women may have the right knowledge about such matters, but they may be unable to implement their ideas without a man's permission.
There is considerable research showing that factors such as education, female empowerment, female employment, access to health services etc. are positively correlated to women's use of modern contraception methods regardless of the reason reported. There should be a broad campaign that involves local leaders promoting small families, religious referents explaining Islam's permissive law with regards to contraception and doctors informing the public about modern and safe methods. Family planning is not an issue that can or should not be dealt with by the Government alone, it is a matter of family affair that should get a great deal of public involvement.