Family Planning in Zambia

By Brenda Zulu

The focus on this article is on women who are sexually active because these women have the greatest risk of exposure to pregnancy and the need for regulating their fertility.

According to the Zambia Demographic Health Survey (ZDHS) 2007, contraceptive methods are grouped into types which are modern and traditional methods. Modern methods include female sterilization, male sterilization, the pill, intrauterine device (IUD), injectables, implants, male condoms, female condom, diaphragm, foam/jelly, lactational amenorrhoea (LAM) and emergency contraception. Traditional methods include the rhythm methods (periodic abstinence) and withdrawal. This also includes Folk methods.

Zambians widely know modern than traditional methods.  Among traditional methods, withdrawal is the most commonly known among women.

Similarly to women, the most common known method among men is the male condom. It is worth noting that among men is the likely as women to know of implants.

Younger women aged between 15 to 19 and women living to western province are least likely to know of a contraceptive method. For men, knowledge of any family planning method is almost uniform regardless of age, residence, province, educational level or wealth quintile.

The pill is the most common method of contraception followed by the condom and injectables. Implants, IUD and the emergency contraception are the least used methods with less than 1% of women having ever used any of these methods. Cycle beads are the least used. Among males less than 1% of men have used sterilization. For the traditional methods, withdrawal is more common than rthym method.

On the knowledge of family planning preference, a Elijah Kabwe a married with two children said he did not trust the norplant which his wife has inserted on her arm and as a result he has continued to use the withdrawal method as he did not want to have another child.

Asked if he would then choose to go for vasectomy Kabwe said he wouldn’t as he was already satisfied with his family planning method of choice.

For Zambia, the use of family planning method increases with age from 10% in the age group 15 to 19years to 40% in the age group 25 to 29 years and then starts to decline to 24% in the 45 to 49 age group. The female condom is the least used modern method for women (1%).

 The contraceptive prevalence rate for modern methods has increased from 7% in 1992 to 25% in 2007. Contraceptive use is higher among women in urban areas than among women in rural areas. Eastern province has the highest proportion of women currently using family planning methods, followed by Copperbelt. The lowest proportion of married women using a family planning method is in Luapula. In general, women do not beg to use contraception until they have had at least one child.

Contraceptive use among women increases with educational attainment compared to women who are uneducated. Condom use has more than doubled from 2 percent in 1992 to 6percent in 2007. The proportion of married women undergoing female sterlisation has remained relatively stable between 1992 and 2007 at 2%.

Among pill users the brand commonly used are safeplan and Microgynon and Oralcon. Among women using injectables, 56 % use DepoProvera and 42% use Noristerst.  The most common brand of male condom used is the Maximum classic.

“From one menstrual period to the next, are there certain days when a women is more likely to get pregnant if she has sexual relations?” A women is most likely to conceive halfway between two periods. Users of natural family planning methods users are more knowledgeable about their fertility period.

Couples use family planning methods to limit family size or delay the next birth. Couples using family planning as a means to control family size adopt contraception when they have already had the number of children they want. When contraception is used to space birth, couples may start to use family planning earlier with the intention to delay a pregnancy. This may be done before a couple has had their desired number of children. In a culture where smaller family size is becoming a norm, young women adopt family planning at an earlier age than their older counterparts.

Women start using contraception at a younger age while some use contraception before they had any children. Timing of sterilization for many women is at 34 years. The many women who use modern methods contraceptives obtain them from the public sector, mostly government health centres private medical institutions are the second most common course of contraception while non medial sources are the least common.

There has been a shift away from reliance on private medical sources for contraceptives methods. The proportion of current users relying on private medical sources has declined from 32% in 1992 to 17% in 2007.

The cost of contraception for people who use modern methods get them for free and or not so many people buy contraception. About 8 in 10 women who obtained their family planning methods from public sector facilities were informed about two thirds of women who obtained their methods related problems and how to address them should they occur.

There are some married women who have no intention of using any method in the future and 5% are unsure of their intentions.

Reasons for women not intending to use contraception in the future include fertility related reasons which include infrequent sex, no sex, menopausal, had hysterectomy, subfecund, infecund and wants as many children as possible.

Opposition to using contraceptives is also prevalent because of many other reasons which include the religion and the fact that some people are no longer sexually active.

Living postively and having babies

By Brenda Zulu

“I was raped when I was 18 years old in 1993. Due to the history of rape, I did an HIV test in 2004 as I had not encountered any sexual relationship with any man. I did not disclose anything to anyone because back then it was very hard. When I was tested I started medication and lived positively. That is when I started sharing information about my status.

In 2006, I got married to an HIV negative man and through counseling and consulting doctors I was able to conceive without infecting him. Throughout the pregnancy I was monitored until I delivered and chose not to breastfeed and that was a personal choice. I gave birth to an HIV negative baby and my partner is still negative because we follow precautions,” said Sophie Bwalya.

Sophie is one woman among many women who has managed her HIV status and the fact that she wanted to taste the joy of motherhood, being HIV positive did not stop her having a baby.

 According to the 2010 National Protocol Guidelines, under the integrated prevention of mother to child transmission (PMTCT) of HIV, the 2010 guidelines emphasize the introduction of more efficacious regimes and extended Nevirapine administration for the infant during the breastfeeding period as recommended by the World Health Organisation (WHO).

In Zambia, PMTCT services are available to address the burden of vertical transmission of HIV. With a high antenatal HIV prevalence estimated at 16.4 percent in 2008, approximately 80 000 infants born annually are at risk of acquiring HIV from their mothers. Integration of PMTCT into all maternal, newborn and child health services throughout the country will contribute to a significant reduction of transmission of HIV and subsequent child morbidity and mortality.

The entry point into the PMTCT programme for every pregnant woman and her partner is knowledge of their HIV status. The programme encourages a family centered approach. HIV testing is part of the routine Antenatal Care (ANC) services and results and post test counseling are provided for on the same day.

HIV infection transmitted from an HIV-infected mother to her child during pregnancy, labour delivery or breastfeeding is known as Mother-To-Child Transmission (MTCT). The prevention of mother-to-child transmission (PMTCT) is a highly effective intervention and has huge potential to improve both maternal and child health.

Mwelwa Nsabika a Nurse and Tuberculosis (TB) focal point at Kara Counseling and Research Center observed that health centers still face challenges in administering PMTCT programmes as some HIV positive women who are on medication will not say beforehand when they want to conceive.

  “It was important for an HIV positive woman to ask the health care provider beforehand if they wanted to conceive. This is very important for women who are already on medication because they will be taught the right time to conceive and monitored if there is need to change medication,” said Nsabika.

She added that the other challenge was that not all women were able to attend the clinic with partners as some were not willing. “This is important because they need to have protected sex during pregnancy and not expose the partner to HIV,” said Nsabika.

Speaking about family planning, Nsabika pointed out that all family planning was safe for HIV infected mothers except for the intrauterine device (IUD) of which health personnel have taken precautions in case the woman has another infection which could be a sexually transmitted disease (STD) or an inflammatory disease.

“In many cases we advise mothers to use dual family planning method for people on Lopinavir and Nevirapine as all family planning has a failure rate,” said Nsabika.

She explained that among HIV-infected women, the prevention of unintended pregnancies was essential for preventing mother-to-child transmission of HIV. She said HIV positive women are given all the information on family planning but those who intend to conceive were also asked to visit the clinic with their male partners.

She said male partners’ role in the PMTCT services was important in Zambia as couples were taught the right time when the woman could conceive which was between the 11^th  day from the first day she had her monthly period to the 14^th day although it is not guaranteed that the woman will be pregnant.

“That is the right time when HIV positive couples can meet without a condom and it should not be everyday because there is need to let the sperms mature so that they are not weak,” said Nsabika.

“Being HIV positive does not mean that you cannot have a child who is healthy. It is also important to go for cervical cancer screening which is also raised when one has HIV,” she said.  

What to know about cervical cancer

Cervical Cancer Questions and Answers as obtained from the Cancer Diseases Hospital and the Centre for Infectious Diseases and Research (CIDRZ).

By Brenda Zulu

Q. What is cervical cancer?

A. This is an abnormal growth of cells on a woman’s cervix.

Q. What are the symptoms of cervical cancer?

A. In it’s the early stage the disease is asymptomatic. It will start symptoms in the late stages as listed below:

Bleeding after intercourse (sexual intercourse)

Post Menopause bleeding

Intermenstrual bleeding

An increase in the length or amount of bleeding

Waterly or blood or odoriferous vaginal discharge

Pain during sexual intercourse

Lower back pain

Weight loss

Yellowish vaginal discharge

Blood in urine

Q. Are there different type of cervical cancer?

A. No, but we have different types of Human Papilloma Viruses (HPVs). Not all HPVs cause cancer of the cervix but some cause genital warts.

Q. Who is at risk of cervical cancer?

Every woman who is sexually active.

Risk factors include

Early onset of sexual intercourse before 18 years of age

Multiple sex partners

Tobacco use

Alcohol abuse

History of sexually transmitted disease eg HPV

Multiple Pregnancies

Infection with HPV Virus

Decreased level of Vitamin A, Vitamin C and Folic Acid in the diet

Q.  What is cervical cancer screening? What methods are available in Zambia?

Screening is the test done to determine wherether abnormal cells are present at the cervic, or not.

There are two methods available in Zambia, the Visual Inspection with Ascetic Acid (VIA), which uses common household vinegar applied to the cervix for a few minutes and visualized through special camera lens that magnify the picture of the cervix to see whether there are changes in the cells.

The other method is the Pap smear test which is when cells are taken frfom tehsurface and senr to the laboratory to be checked for abnormality. With the VIA, results are seen almost immediately whereas the pap smear test usually takes about two weeks for the results to be known. However, both these tests should be done by qualified personnel, with special instruments that open up the vaginal canal.

Q. How important is cervical screening and how many times should it be done?

This is very important and should ideally be done annually if the first result was negative for cancer. However, it is vitally important that individuals with compromised immunity be checked often or as per health practitioners’ advice. If the test was positive, the health care provider will advise on how often one should go back for another test.

Q. What age group of women should undergo cervical cancer screening?

All sexually active women or women who are 18 years of age and above (Child bearing age)

Q. How effective is the treatment?

The earlier the stage of cancer, the better the treatment and cure rate. In its earliest stage, cancer of the cervix is totally curable. The treatment in the later stage is determined by how far the cancer has spread.

Q. Why is cervical cancer the second cause of death for women in Zambia?

Women in Zambia rarely get check ups/screened.

Nature of the disease, the early stage has no signs or symptoms

Women don’t see their cervix, so have no way of detecting changes in the cervix.

Lack of screening/ treatment services especially in rural areas

Women are vulnerable.

Q. How should women react to positive cervical cancer results after screening/

They should take this as an eye opener and make sure that they follow exactly what the health care practioner tells them and keep their follow up appointments.

Q.  How safe is a baby born from a mother with cervical cancer?

Cancer of the cervix affects the woman’s cervix. It has no effect on the baby.

Q. How safe is pregnant mother with cervical cancer?

This depends on what stage the cancer is in. Cancer is usually a slow progressing disease and usually given after delivery, so a pregnant woman should remember to go back for treatment six weeks after delivery.

Q. Where can women get treatment for cervical cancer?

Cervical cancer screening and treatment for is available at most DHMT clinic including Kanyama, Chawama, George, Matero reference, Ngombe. Mtendere, Kalingalinga, Chelstone, UTH-AIDC building, Chongwe, Monze mission hospital, Chilenje, Bauleni and the Cancer diseases hospital at UTH.

Q. Is there a relationship between cervical cancer and HIV?

YES, just as there is a relationship between HIV and any other disease. Women who have HIV are more predisposed to having cervical cancer because of their compromised immune system, and also cancer progresses at a faster rate in women with HIV than in those who are negative, therefore it is important for HIV positive women to get screened regularly.

Family Planning in Zambia

By Brenda Zulu 

The focus on this article is on women who are sexually active because these women have the greatest risk of exposure to pregnancy and the need for regulating their fertility. 

According to the Zambia Demographic Health Survey (ZDHS) 2007, contraceptive methods are grouped into two types: modern and traditional methods. Modern methods include female sterilisation, male sterilisation, the pill, intrauterine device (IUD), injectables, implants, male condoms, female condoms, diaphragm, foam/jelly, lactational amenorrhoea (LAM) and emergency contraception. Traditional methods include the rhythm methods (periodic abstinence) and withdrawal. 

This also includes folk methods. Zambians widely know modern than traditional methods. Among traditional methods, withdrawal is the most commonly known among women. Similarly to women, the most common known method among men is the male condom. It is worth noting that among the men they are as likely as the women to know of implants. 

Younger women aged between 15 and 19 and women living in western province are least likely to know of a contraceptive method. For men, knowledge of any family planning method is almost uniform regardless of age, residence, province, educational level or wealth quintile. The pill is the most common method of contraception followed by the condom and injectables. Implants, IUD and the emergency contraception are the least used methods with less than 1% of women having ever used any of these methods. Cycle beads are the least used. 

Among males less than 1% have used sterilisation. For the traditional methods, withdrawal is more common than rthym method. On the knowledge of family planning preference, Elijah Kabwe, a married man with two children said he did not trust the Norplant which his wife has inserted on her arm and as a result he has continued to use the withdrawal method as he did not want to have another child. Asked if he would then choose to go for vasectomy, Mr Kabwe said he wouldn’t as he was already satisfied with his family planning method of choice. 

 For Zambia, the use of family planning method increases with age from 10% in the age group 15 to 19 years to 40% in the age group 25 to 29 years and then starts to decline to 24% in the 45 to 49 age group. The female condom is the least used modern method for women (1%). The contraceptive prevalence rate for modern methods has increased from 7% in 1992 to 25% in 2007. Contraceptive use is higher among women in urban areas than among women in rural areas. Eastern province has the highest proportion of women currently using family planning methods, followed by Copperbelt. The lowest proportion of married women using a family planning method is in Luapula. In general, women do not beg to use contraception until they have had at least one child. Contraceptive use among women increases with educational attainment compared to women who are uneducated. Condom use has more than doubled from 2% in 1992 to six percent in 2007. 

The proportion of married women undergoing female sterlisation has remained relatively stable between 1992 and 2007 at 2%. Among pill users the brand commonly used are safe plan and Microgynon and Oralcon. Among women using injectables, 56 % use DepoProvera and 42% use Noristerst. The most common brand of male condom used is the Maximum classic. 

 “From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?” 

A woman is most likely to conceive halfway between two periods. Users of natural family planning methods are more knowledgeable about their fertility period. Couples use family planning methods to limit family size or delay the next birth. Couples using family planning as a means to control family size adopt contraception when they have already had the number of children they want. When contraception is used to space birth, couples may start to use family planning earlier with the intention to delay a pregnancy. This may be done before a couple has had their desired number of children. In a culture where smaller family size is becoming a norm, young women adopt family planning at an earlier age than their older counterparts. 

 Women start using contraception at a younger age while some use contraception before they have any children. Timing of sterilisation for many women is at 34 years. The many women who use modern methods contraceptives obtain them from the public sector, mostly government health centres while private medical institutions are the second most common source of contraception with non medial sources being the least common. There has been a shift away from reliance on private medical sources for contraceptive methods. 

The proportion of current users relying on private medical sources has declined from 32% in 1992 to 17% in 2007. Contraceptions for people who use modern methods get them for free and or not so many people buy contraceptions. About 8 in 10 women who obtained their family planning methods from public sector facilities were informed people while about two thirds of women who used methods with related problems were taught on how to address the problems should they occur. 

There are some married women who have no intention of using any method in the future and 5% are unsure of their intentions. Reasons for women not intending to use contraception in the future include fertility related reasons which include infrequent sex, no sex, menopausal, had hysterectomy, sub fecund, in fecund and wants as many children as possible. Opposition to using contraceptives is also prevalent due to many other reasons which include religion and the fact that some people are no longer sexually active.