Sexuality, Contraception, Unplanned Pregnancies and Abortion in West Africa and Morocco: The ECAF Survey

Context and Goals

Despite national and international political commitments to improving contraceptive access in Africa (Lesthaeghe and Jolly, 1995; Ross and Stover, 2001), use of modern methods remains limited in West Africa. Contraceptive prevalence is low among married women not wishing to get pregnant, and even lower among unmarried women (Cleland et al., 2006). Since the number of children born is higher than the number desired, low prevalence is usually analysed in terms of an unmet need for contraception (Cleland et al., 2006), defined as non-use of either modern or traditional methods by sexually active women who do not want to have a child over the following two years (Sedgh et al., 2007). West African societies are in a process of change, and one aspect of this change is a growing need for contraception in a context of increasing, and often socially condemned premarital sexuality linked to the growing dissociation between sexuality and procreation (Onuoha, 1992). A shortening of the period of post-partum abstinence among married women is a second factor of increased demand (Bledsoe and Cohen, 1993). Illegal abortion is frequent in this context; the estimated abortion rate is 23 abortions per 1,000 women aged 15-44 in North Africa, and 28 in West Africa (WHO, 2007). Studies suggest that the incidence of abortion is rising among educated young women and in the most urbanized areas (Desgrées du Loû et al., 2000; Guillaume and Desgrées du Loû, 2002).

Despite the rapid pace of societal change in West Africa and Morocco, social organization in these countries is still based on the extended family and on highly codified relations between parents and children, and between men and women. In West Africa especially, the status of both men and women is enhanced by having many children: high fertility is socially valued (Kaida et al., 2005; Randrianasolo et al., 2008). Sex, age and, to a lesser extent, ethnic group and social class, are all intertwined in a complex arrangement where female subordination is just one element in the mosaic of social relations. Demand for contraception is a question which – probably even more so than in other social contexts – cannot be understood solely from the woman’s standpoint. Marriage and control of sexuality are central to the reproduction of power relations designed to maintain the social hierarchy between old and young, and between men and women. Thus, condemnation of sexual relations before marriage, especially for young women, and of extramarital sexuality, is the dominant norm, applied with varying degrees of rigour across different countries. At the same time, new representations of sexual models incorporating notions of personal fulfilment through romantic love are spreading, notably via the media. These models compete with older ones, often referred to, rather simplistically, as “traditional” (Cole and Thomas, 2009).

In such social configurations, where contraceptive use is still rare but where non-procreative sexuality is becoming increasingly common, emergency contraception could reduce the number of unplanned pregnancies and consequently reduce mortality and morbidity linked to illegal abortions, a major public health problem in Africa. By examining the role of emergency contraception in relation to contraception as a whole in three West African countries and Morocco, the ECAF (Emergency Contraception in Africa) project aims to explore contraceptive issues in a broader perspective, analysing contraceptive practices in their relational, sexual and reproductive contexts. This research looks at contraceptive practices (emergency contraception and other methods) in relation to individuals’ sexual, relationship and reproductive histories in order to better understand the meaning of contraceptive failures and of pregnancies that are labelled as “unplanned.”

Methodology

The ECAF survey was carried out in 2006-2007 by a multidisciplinary team of sociologists, demographers and public health physicians in three countries of West Africa – two French speaking (Senegal and Burkina Faso), and one English speaking (Ghana) – and in one French-speaking country of North Africa (Morocco). The research focuses on the capital cities of the four countries, where new models of contraception are most likely to have become widespread. The countries were chosen because they have different public family planning policies and because their...