Jane Wanjiru, a 25-year-old mother of two, was one of the thousands of women who gave birth two weeks ago as the world welcomed its 7th billion baby.

Wanjiru was back to Nairobi’s Pumwani  Maternity Hospital a year after  giving birth to her second baby.

“It is my third baby. I wasn’t planning for it, but now I have no choice but to take care of it. I only hope for the best,” said Wanjiru, holding the newest member of the family outside her one-roomed house in the Mathare slums.

Like Wanjiru, thousands of women in East Africa are having unplanned births every year as the region battles rising birth rates, among the highest in the world. (READ: EYAKUZE: Seven billion hungers, seven billion thirsts)

According to the latest State of Kenya Population report, 1.8 million married women have unplanned births every year and another 1.1 million have unmet contraception needs due to difficulties in accessing the necessary family planning facilities.

The case is similar in all the East African Community member states. In Uganda, four in every 10 married women would like to use family planning services but  neither have access to services nor supplies.

In Tanzania, slightly more than six per cent of those on family planning use the injection method. Even though the majority of them would prefer pills, they lack access to the services.

Rwanda has registered progress, with the use of family family services increasing two-fold to 24 per cent between 2007 and 2008, but these are still inadequate. Contraceptive use in Burundi is the lowest in the region at only 5.4 per cent of women.

According to the Population Reference Bureau, a  global research organisation specialising in population issues, both Uganda and Burundi have the highest fertility rates of 6.4, followed by Tanzania at 5.4, Kenya 4.7 and Rwanda at 4.6.

“The  population growth in the region is currently unsustainable. It is the reason we need to support government initiatives to bring it down to levels the countries can manage,” said Dr Boniface K’Oyugi, chief executive officer of the Kenya Co-ordinating Agency for Population and Development.

Though some economists argue that a big  population is good for a fledgling economy as it provides labour and stimulates demand for goods and services, it is also true that it can be a burden when economic growth cannot keep pace with the rapid  increase.

“Population can be  an asset but can also a liability. To make it an asset, we must invest in the extra numbers by  ensuring they are well fed, educated and also create employment opportunities for them. If not, then the additional population becomes a liability,” said Dr K’Oyugi.

As a result, population experts stress the importance of family planning initiatives, if the East African Community is to transform itself from a low income to a middle income region.

One of the contraceptive devices East African countries have been relying on to check population increase is the hormonal contraceptive, most popular among educated and urbanised women.

Hormonal injectable or depot medroxyprogesterone acetate, as it is scientifically known, is available in East Africa under the name Depo Provera. It is manufactured by the American pharmaceutical company Pfizer and contains the hormone known as progestin.

“The hormonal contraceptive is popular among women because it is easy to use and has been effective in family planning,” said Dr Marsden Solomon, reproductive health advisor at FHI 360, a global health and development organisation.

Women only need an injection once every three months to protect them against unwanted pregnancies.
According to the Kenya Demographic Health Survey (2008-2009), modern methods are still the most popular at 39 per cent, while the traditional ones are at a lowly six per cent.

Of the former, injectables are the most widely used, a trend that is also common in other East African countries.

But East Africa has suffered a double blow. Apart from the worrying figures released by the United Nations Population Fund, which showed that the region’s population was still increasing at a very fast rate, governments are faced with another headache of managing damaging information on injectables.

A recent study published in the respected science magazine, The Lancet, argues that hormonal injectables double the risk of users contracting the HIV virus.

The core finding of the research, done by American and local scientists,  is that the injectable contraceptive, when used by discordant couples, makes a partner twice as likely to get infected with the virus.

The study, led by researchers at the University of Washington, involved 3,800 couples in Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia. In each couple, either the man or the woman was already infected with HIV.

“The outcome of the research poses a real threat to the gains made in reducing our high population to manageable levels. We will have to strategise on how to counter  misinformation that might be peddled following the release of this study,” says a reproductive health official at Kenya’s Ministry of Public Health, who did not want to be named.

Researchers followed the couples for two years, had them report their contraception methods, and tracked whether the uninfected partner contracted HIV from the infected partner, said Dr Jared Baeten, an infectious disease specialist.

The study found that women using hormonal contraception became infected at a rate of 6.61 per 100 person-years, compared with 3.78 for those not using that method. Transmission of HIV to men occurred at a rate of 2.61 per 100 person-years for women using hormonal contraception compared with 1.51 for those who did not. Though the research was not conclusive on the effects on reproductive organs of males and females, some scientists have speculated that hormonal contraception might cause immunological changes or could increase HIV’s ability to replicate.

The aggressive campaigns in the region are not only aimed at checking the burdgeoning population, but also improving the health status of women and children  in the region.

Health problems

This is because thousands of women still experience reproductive health related problems, namely bleeding, infections and even death from pregnancies due to poor health standards. Getting affordable and convenient contraceptives is a major goal for health authorities in all the five member states of the East African Community. Besides common reproductive health problems and high birth rates in the region, member countries are still ravaged by Aids.

It is one reason why the evidence suggesting that the injectable contraceptive’s biological properties may make women and men more vulnerable to HIV infection is so troubling.

Doctors in Kenya and Uganda have already asked their governments to offer clear guidance on the issue.

Rosemary Nyambura, who has been using hormonal contraceptive for the past decade, said: “The study has left me more confused than before. It has left me with more questions than answers.”

According to 35-year-old mother of two, she chose hormonal contraceptive ahead of others because of its effectiveness and ease of use.

“You only need to use it once and for the next three months you do not need to think about contraceptives because you are protected against unwanted pregnancies,” she added.

Nyambura said she would continue using the method but urged the government to ensure women get correct information on its use.

Kenya has already questioned the validity of the research, urging members of the public to continue using the contraceptive. 

However, the government, through the Ministry of Public Health and Sanitation, has conceded that the publishing of the article had caused alarm, panic and confusion among the general public.

Dr Shanaaz Sharif, the Director of Public Health and Sanitation, says to date, 13 studies have been published and five have suggested some association while the rest have not.

“Similar to previously published studies addressing this potential association, observational data was used and this could contain selection bias,” said Dr Sharif.

According Dr Sharif, women who use hormonal contraception may differ from non-users with regard to risk of HIV infection.
“For example, they may be less likely to use condoms. The 13 new HIV infections that were recorded were a small number, thus it is difficult to make definite conclusions,” said the director.

Dr Sharif added that limitations to the study emphasise a need for a thorough review of the available body of evidence on the topic, so as to weigh the risks and benefits of hormonal contraceptive use for women.

The limitation of the study was that contraceptive use was determined by self-report as the researchers did not gather data on adherence to contraception, and also failed to record the specific brand of contraception “and thus cannot comment on HIV-1 risks from specific exogenous hormones.”

During the study period, low-dose combination hormonal oral contraceptives and long-acting injectable Depo Provera were the most commonly used methods in national family planning programmes. Few studies have assessed HIV-1 risk from other injectable methods, for example norethisterone enanthate.

However, Dr Nelly Mugo, one of the researchers, has defended the study.

Potential risk

Speaking recently at Kenyatta National Hospital, Dr Mugo said the team identified a potential risk of the transmission of the HIV virus through hormonal contraception, especially injectables.

Like Dr Sharif, Dr Solomon argues that such studies are basically observational in research design.

“They bring in set of selection bias and it is always difficult to make general conclusions,” said Dr Solomon.

He says it is difficult to make general conclusion for the whole population because the study only dealt with the sero-discordant population.

Randomised clinical trials are one method that scientists use for rock solid results on which general conclusions can be drawn and that is the reason why some scientists are questioning the authenticity of the contraceptives study.

The World Health Organisation plans to convene a meeting in January, next year, to review the study and consider if the evidence is strong enough to advise women against using the method.

“We are going to be re-evaluating World Health Organisation’s clinical recommendations on contraceptive use,” Mary Lyn Gaffield, an epidemiologist at the WHO’s department of reproductive health and research, said after the release of the study.

Gaffield emphasised that the  organisation would not make any rash judgement, adding that a decision would be made after a thorough review of the studies.

“We want to make sure that we warn when there is a real need to warn, but at the same time we don’t want to come up with a hasty judgement that would have far-reaching consequences for the sexual and reproductive health of women,” she said.