Cost, myths, stigma still deny Nigerians contraception choice — Okunlola

Professor Abiola Okunlola, a consultant obstetrician and gynecologist, is head of the Fertility Research and Endocrinology Unit, at the University College Hospital, Ibadan. In this interview with Sade Oguntola, he says Nigeria should ensure contraceptive choice for all by ensuring available, youth-friendly services, stronger counselling, and reliable supplies even as women’s autonomy is respected.

The theme of this year’s world contraception day is “A Choice for All.” What does meaningful contraceptive choice look like for women and couples in Nigeria, beyond simply having contraceptive methods available?

Meaningful choice is more than simply having methods available. It is the ability of every individual and couple to make a voluntary, informed decision that fits their health, life stage, and values, and to change that decision over time without penalty. People should be free to choose and free to change.

In Nigeria, that requires access to a range of methods, including pills, injectables, IUDs, and implants, as well as person-centred counselling. Counselling should address myths, possible side effects, non-contraceptive benefits, and protection against HIV and other sexually transmitted infections.

Affordability is also important, as is continuity of supply. There should be no stockouts, and people should be able to switch or stop a method easily.

Without these elements, “choice” remains theoretical rather than meaningful, even when contraceptive commodities are physically present.

But how much freedom do Nigerian women actually have to decide whether to use contraception, which method to use, and when to stop?

That is about agency—the power to decide whether to use contraception, which method to use, and when to stop, free from coercion, partner veto, or provider bias. Internationally, agency is measured partly by who makes decisions about contraception and whether women can refuse sex or insist on protection.

In Nigeria, decision-making may be shared, but it can also be male-dominated. Many women report needing partner approval before adopting a method. Socioeconomic status and education also influence agency. Women who are poorer or less educated may have less control over reproductive decisions. Provider practices, such as requiring unnecessary consent, can further undermine agency.

Strengthening agency means protecting the right to choose without coercion and ensuring that healthcare providers uphold client autonomy.

So, in a way, are you saying that freedom to decide whether to use contraception, which method to use, and when to stop is relative in Nigeria?

In some cases, yes. Not everybody has the same level of freedom. Nigeria is still, in many respects, a male-dominated society. When selecting a contraceptive method, women may not always have complete autonomy, as their partners can influence or limit their options.

The more educated and socially empowered women are, the more likely they are to be able to choose methods that are right for them without being coerced by partners, institutions, or other bodies.

How important is it for people to be able to plan if and when they want children? And what are the health consequences when pregnancies occur without that intention?

Intentionality, being able to plan if and when to have children, is central to maternal and child health. Unintended pregnancies can be associated with delayed antenatal care, unsafe abortion, maternal morbidity and mortality, and adverse birth outcomes.

In Nigeria, the unmet need for contraception remains an important concern. “Unmet need” refers to people who want to avoid pregnancy but are not using contraception. Such persons may be either unable to or unwilling to use a method, even where such methods are available.

Spacing and limiting childbirth are important for maternal health, child survival, and the ability of families to prepare for children financially and otherwise. So intentionality is not only a personal preference; it is also a public health imperative.

What are the biggest barriers Nigerians face when they want to access contraception?

The barriers are multifactorial. They intersect and often overlap. Cost and affordability are important. Even when contraceptive methods are nominally free, there can be additional costs—transportation, tests, time away from work, registration cards, and other expenses. These hidden costs can deter people from using contraception.

Availability and stockouts are another major barrier. Public and private facilities can experience contraceptive stockouts, particularly in rural settings, limiting method choice and continuity.

Distance and travel time also matter. Long distances to health facilities can reduce uptake, particularly among adolescents and working women. Then there is misinformation and fear of side effects. Myths about infertility, cancer, and a “damaged womb” are widespread and can reduce demand.

Social norms and stigma are also significant. Clients, particularly adolescents, may face judgment when seeking contraception. Lack of private consultation spaces and cultural disapproval can make people reluctant to seek services.

For example, an 18-year-old who needs contraception may hesitate to go to a facility because she fears being judged for seeking it at her young age.

Addressing these barriers requires strengthening the supply chain, reducing costs, expanding service points, including pharmacies where appropriate, and improving counselling services. Thankfully, many contraceptive commodities are now supposed to be free according to current government policy.

What specifically needs to change for adolescents and young people?

Adolescents and young people face distinct barriers: stigma, judgment from the wider community, fear of being seen seeking contraception, cost, lack of youth-friendly hours or private spaces in pharmacies and clinics, and misinformation from peers.

There are also myths that contraceptives can cause permanent infertility or that using contraception promotes promiscuity.

Health and educational facilities should provide adolescent- and youth-friendly sexual and reproductive health services with confidentiality, non-judgmental counselling, and flexible hours. They should ensure availability of methods, including pills, condoms, and injectables.

There should also be clear guidance on dual protection—preventing pregnancy while also protecting against HIV and other sexually transmitted infections. Community and digital outreach can help correct myths and normalize contraception as part of healthy life planning.

We have been talking about youth-friendly services for years. Looking at the past 10 years and now, are the challenges still the same, or have they changed? Have we had any impact?

Those issues are very much still with us.

There have been attempts over time to address them, but many of those efforts have not been sustained. Sustainability and implementation remain problems. We may have the ideas, but implementing them effectively and sustaining them is another matter.

For example, there may be such a youth-friendly facility within a university environment, but young people may not even know that it exists. We recently heard at a symposium where students said such services never existed in the said University. That shows there are gaps between having a service and ensuring that young people know about and can access it.

We need to continue to make such services visible and accessible. Youth-friendly facilities can also be located in places young people already visit, including malls, lounges, and other accessible locations. Services can also be supported through private telephone and digital channels.

In your practice and your day-to-day relationship with women coming to the clinic, what are the most common misconceptions you encounter about contraceptive methods?

The misconceptions have not changed very much over time. One of the strongest is the belief that contraception causes infertility. Some people believe that if you use contraception, you may not be able to become pregnant later. Unfortunately, even some service providers may tend to furnish clients with confusing or incorrect information.

Other misconceptions include the belief that contraception causes breast cancer or excessive weight gain. Cultural and religious concerns are also strong. Some people believe that using contraception encourages promiscuity.

Then there are concerns about side effects. People may experience changes in their bleeding patterns or other temporary effects and interpret these as something more serious. Fear of side effects and fear of infertility remain major issues.

If a woman uses contraception, will she become infertile?

No. Some contraceptive methods may cause a temporary delay in the return of fertility or resumption of the monthly period after stopping. Return of fertility may not be immediate for some methods, but that does not mean the woman has infertility. The contraceptive methods commonly used today are low-dose and, when appropriately prescribed, are considered safe. They do not cause permanent infertility.

Can every woman take contraceptive pills? Can every woman use an intrauterine device or implants? And can every man use condoms?

No. Contraceptive use should be tailored to fit individual needs and peculiarities. Two physically similar people may have completely different contraceptive needs and preferences. One woman may use an IUD without any complaints, while another may feel very uncomfortable with any such device inside her.

Some women may have an IUD for many years and find it very convenient. Others may not tolerate it. Individuals vary in what they can use and what they prefer. That is why counselling is key.

You must treat every client as a separate individual. Provide full counselling and education, and allow them to make an informed choice. Informed choices do not have to be the same, even among people in the same family. There is potentially a suitable method for everybody.

Is contraception a women’s issue?

No. Contraception is not simply a women’s issue; it is a couple’s issue. It is a misconception to think that contraception is a woman’s problem. Men are critical partners in sexual and reproductive health. However, their involvement must support, not override, women’s autonomy.

Male engagement can improve continuation and satisfaction with methods when men understand method safety, possible side effects, and the shared benefits of family planning. Counselling can help couples align their reproductive goals and reduce method discontinuation caused by partner concerns. But requesting the husband’s consent where it is not medically necessary can undermine a woman’s autonomy.

Looking ahead, if Nigeria truly wants “a choice for all,” what are the most important changes healthcare providers, government, and communities need to make so that every person can make an informed and voluntary contraceptive decision?

To realize a choice for all, three areas need to change: providers, government, and communities. First, healthcare providers need to provide rights-based, non-coercive family planning; improve the quality of counselling; eliminate unnecessary restrictions; and make it easier for clients to initiate or switch methods when appropriate.

Second, government and health authorities need to support contraceptive security, reduce out-of-pocket costs, expand the range of available methods, and integrate family planning into primary healthcare.

Third, communities need to help normalize family planning through trusted leaders and gatekeepers. Community leaders, religious leaders, and other trusted voices can provide accurate, culturally appropriate information.

We also need outreach, education, and awareness programs through the media and online platforms. We need to take services closer to the people, particularly where transportation and other costs make facility-based access difficult.

If contraception is supposed to be free, we also need to reduce the additional hidden costs that people still have to pay at healthcare facilities. All these things are important if we want to get contraception to the people and enable them to make informed choices.

Finally, if you could correct one misconception about contraception among Nigerians today, what would it be? And what would you want every woman and every man to know?

The misconception I would correct is that contraceptives cause permanent infertility. Most women regain fertility after stopping contraception. Some methods may cause a temporary delay in the return of fertility, but that is not the same as infertility.

Contraception is about preventing, spacing, or limiting pregnancy; it is not about permanently stopping fertility. What every man and woman should know is that contraceptive methods come in different forms, and the appropriate method for an individual depends on their health, life plans, and preferences. People can also change methods when necessary.

Depending on the method, contraception can have benefits beyond pregnancy prevention, including cycle regulation, reduced anemia, and reduced risk of some cancers.

Men’s support matters, but it should support women’s autonomy. Coercion undermines health and trust.

So contraception is about spacing and limiting pregnancies, rather than infertility?

Yes. Contraception and infertility are two different things. Infertility is the inability to become pregnant. Contraception is deliberately preventing pregnancy, and it is not only about limiting the number of children; it is also about spacing pregnancies.

Spacing is important. Allowing adequate time between childbirth gives the woman time to recover from a previous pregnancy and gives the family time to prepare for the next pregnancy financially and otherwise.

When a couple has had the number of children they want, they may decide to limit further pregnancies.

For people who want long-term pregnancy prevention without permanent sterilisation, there are long-acting reversible contraceptive methods. The word “reversible” is important. These methods can be highly effective and convenient, and they prevent pregnancy for long periods. When they are stopped, fertility returns.

In conclusion, large multi-centre studies globally have confirmed that families who use contraceptives and engage in family planning tend to be healthier and wealthier in their day-to-day living than their counterparts who don’t.