Ethiopia: Family planning as decision

Solomon Betre sums up his experience like this: "Contraception is a matter of income and education!" The man with the winning smile is in his mid-fifties and has been a pharmacist for 20 years. One of his shops is in a poor neighborhood of Addis Ababa, the second in an affluent area of the Ethiopian capital, so he serves customers from all strata of society – from the illiterate to the intelligentsia – among the three and a half million inhabitants. He knows their levels of knowledge, their needs, their decision-making processes and their purchasing patterns.
"The richer customers – those who are educated, well informed and use the internet – they come into my pharmacy and already know about contraceptives. They don't need any general counseling on family planning; they just want to know which option is the best one for them."
That almost sounds like Europe, but in poverty-stricken Ethiopia it is a big exception. Hardly anyone here is rich and educated. More than a third of the population live on less than a dollar a day. Half of them are malnourished. Two thirds can neither read nor write. Even in downtown Addis Ababa there are mud tracks lined with shanties. Ragged beggars and street children, emaciated donkeys, cows and goats are an integral part of the scene on the few grand boulevards with their rich, commercial buildings. As recently as 2011 the country again fell victim to a catastrophic drought. In December, the inflation rate was 33 percent. Every year more than 2 million new children are born into this misery.

Solomon Betre, 56, pharmacist

"Many parents have no way to feed their children or send them to school," says Solomon, describing the effects. He emphasizes his point by tapping his index finger on his desk, which is a reassuringly untidy counterpoint to the pristine perfection of his pharmacy. "We often first have to explain what birth control is – and that it's OK to talk openly about it," he fumes. He comes from a poor, uneducated family himself. He knows that hardly anyone knows much about the subject in this area. "People are afraid to talk to us about their questions and problems, because the topic is taboo – for cultural and religious reasons."
However, the latest figures have given rise to hopes that the situation might be improving a little. For 15 years the government has been making huge efforts to reform the totally inadequate, chronically underfunded health system. It is supported in this by international governmental and non-governmental organizations, as well as public-private partnerships. This has led to a significant increase in the number – and improvements in the staffing – of the day clinics and hospitals that are distributed all over the country. Primary healthcare and many drugs are now available free of charge – without distinctions according to person and income.

Shanty town in downtown Addis Ababa

"We also give advice on family planning and provide all contraceptives for free," confirms Bertukan Michael, 50, from the public health center in Adama. The city has about 220,000 inhabitants and is located 90 kilometers southeast of Addis Ababa. Because of its large rural catchment area, Bertukan sees people of all origins and education levels every day. "I have had 35 years of experience in the field of healthcare for mothers and their children," she says proudly. "Contraception was hardly practiced at all in the nineteen-nineties. But during the past decade, the government's educational programs and the way the topic is treated in the mass media have led to a change."
Her personal experience is backed up by the latest surveys conducted by the Ethiopian Central Statistical Agency (from 2011). Half of all city dwellers and a quarter of the country's population now practice birth control. This means that the number of women using contraceptives has quadrupled over the last decade.

Bertukan Michael, 50, mother-and-child nurse

Some of them prefer not to take the free advice and contraceptives offered by public health facilities. "Women from the city who have a higher income prefer to go to the pharmacy because we serve them straight away; they don't have to wait," says Solomon Betre's colleague Nemayehu Dhabu. He runs the Time Pharmacy in Adama. "Most of our women customers can't come until after work, i.e. after 5 p.m., when public hospitals are already closed. Apart from which, our prices really are affordable: a month's supply of birth-control pills costs 10 birr, the price of a cappuccino in a modern cafe. That's no problem for a middle-class woman."

Time Pharmacy in Adama

Social class also plays a major role when it comes to the weapons that women choose to use against unwanted pregnancy. "Wealthy, educated customers usually buy the Pill. They are intellectually able to follow the instructions and disciplined enough to take the pills every day. Poorer, less well-educated customers quite often forget," analyzes Solomon, but immediately adds, full of understanding: "That's due to their living circumstances: they have many worries, they work hard, they are often tired and simply don't remember. That's why they tend to opt more often for three-month injections."

Solomon Betre, 56, pharmacist

Nemayehu adds another insight from his everyday life as a pharmacist: "Women today really look into the problem. Men still don't. They don't even ask about methods for themselves," says an irritated Nemayehu. He is in his late twenties and worked in a hospital for five years before opening his business. “If they come along at all, they wait outside. Sometimes I have the feeling they don't even know what their wives are doing in the pharmacy."

Nemayehu Dhabu, 28, pharmacist

But this front seems to be slowly changing. At least among the younger generation. Fikirte Disasa, now 22, got married as a teenager, as is common practice in Ethiopia. "I was still at school and didn't know anything at all about family planning," she recalls, "until my husband told me about it. He suggested we should use contraceptives until I finished my education and not have children until afterwards."
Fikirte has a six-month-old son in the meantime. "I don't want another child," she explains, happily balancing the little one on her knees, "because I only earn very little. I want my son to have enough to eat, to grow up healthy, go to school and get an education. I'm responsible for that."

Fikirte Disasa, 22, cleaning lady

Fatuma Aman has an equally well-thought-out view on this question. Like Fikirte, this selfconfident young woman has decided to use an injected contraceptive – against the wishes of her husband. An incredible thing to do in an extremely conservative country like Ethiopia, especially in rural areas where women are still regarded as their husbands' property and handed-down traditions nip all progress in the bud.
Fatuma stands proudly outside her house in a village about 100 kilometers from Addis. Without hesitation she is quite happy to say that she uses contraceptives and to tell us what methods she uses. She also talks quite openly about the difficult situation she finds herself in as a result: "I work as a maid for a wealthy family in Riyadh. My employer sent me home because I was sick, saying I should get treatment here and then go back. I'm healthy again in the meantime, but now my husband would like me to stay here, stop the injections, and have a child with him."
Fatuma leans against the rough plaster wall of her tiny living room and lays her hands in her lap. With an expression of peaceful self-assurance, she continues: "When I look at our economic situation, it's obvious that I can't have a baby at this moment in time. It would be irresponsible. I first have to return to Riyadh and make some more money – no matter what my husband says." After a short pause she adds emphatically: "I'm extremely grateful that there are contraceptives. They're part of my personal freedom!"
Fatuma is probably unaware that she represents an almost unbelievable exception. In a country like Ethiopia, these words point far beyond her own personal fate. Here is someone who is breaking through the eternal cycle of poverty, lack of education and inhumane tradition, pointing the spotlight at the future of an entire nation. It's not surprising that Solomon Betre is convinced: "We need more information programs, more health counselors to go from door to door and advise people. Many of our country's problems could be solved by increased knowledge about birth control."

Fatuma Aman, housemaid in Riyadh

(Report, Photos and Podcast by matias boem, 2012)