Jessica Hinds spent her 28th birthday hunched over the toilet. 

“Things were really bad. She even lost a tooth,” her 38-year-old partner, Grant Hinds, recalls.

Jessica was pregnant and experiencing hyperemesis gravidarum (HG), a rare but particularly severe form of nausea that affects about 2% of expectant mothers. Unlike the milder form of morning sickness that commonly occurs in the first three months of pregnancy, HG can last well beyond the first trimester, and in some cases for the entire term. 

Some women lose more than 5% of their pre-pregnancy body weight because of the constant vomiting. Stomach acid reaching the mouth can also wear away tooth enamel, which could compromise a pregnant woman’s dental health. 

Grant says he can’t shake the image of his gaunt, exhausted partner that day, sweating and uncomfortable, and at her wit’s end.

Jessica was not the happy person he knew when she found out she was pregnant around four months earlier. When their daughter, JJ, was born in 2022, they agreed: they’re not going through that again.

‘It’s a family thing’

With their newborn around one month old, Grant told his partner he was thinking of getting a vasectomy. This is a form of male contraception in which the sperm-carrying tubes leading from the testes are cut.

In fact, he’d been thinking about going for the snip even before the couple met, but their experience during Jessica’s pregnancy convinced him that it was the right thing to do — for both of them. 

Grant says the vasectomy was “a no-brainer” in terms of being a way for him to support their family planning decisions. 

Using modern options for birth control, such as contraceptive pills or injections, an intrauterine device, condoms or, as in the Hinds’ case, a vasectomy, allows a couple to decide how many children they want and how far apart they should be.

Researchers analysing a sample of 4.5 million births from 77 countries found that, specifically in poorer countries, the chance of an infant dying increases if a woman has two babies less than three years apart. 

Moreover, when siblings are further apart, they may have better nutrition and be healthier, because mothers may have more money to spend on food and time to invest in their upbringing.

But data shows that in sub-Saharan Africa, about four out of 10 women’s needs for family planning are not met at the moment, with almost 30% of pregnancies in the region being unplanned.

In a 2019 study from KwaZulu-Natal about male attitudes towards family planning, health workers said that including men in the conversation could help to empower women. 

“It [family planning] ends up being a feminine thing, yet it’s not supposed to be; it’s a family thing,” said one nurse.

Partner support

Studies found that when men don’t support their partners in family planning, contraceptive use drops. The resistance could be fuelled, in part, by misconceptions about how birth control works. 

“You find that your queen [female partner] is loose like jelly, and that is caused by the injection,” said one man in a focus group discussion in the KwaZulu-Natal study. 

The fear of violent behaviour when men discover that their partners are on birth control can also cause women to use contraception either in secret or not at all. 

“I am forced not to use family planning because my partner is going to hit me,” one woman told the researchers. 

But the opposite also holds. In many cases, men’s approval of their partners using birth control can increase uptake of contraception, encourage women to keep on using it, or even help them find the best method for them. 

One woman from KwaZulu-Natal recalls her partner talking to her about the option of using a contraceptive implant.  

“We have to get it even if we are using condoms,” her boyfriend said.

 Why less will come to mean more

Lower fertility rates spur economic growth, say population studies researchers, because it increases the proportion of working-age people in a population. 

The more people who are able to work — and pay taxes — in a country, the more money governments have to spend on supporting children and the elderly, such as by building schools and hospitals and supplying electricity, water and sanitation. 

Jakkie Cilliers, who heads the Institute for Security Studies’ African Futures programme, says that when a country enters its demographic dividend, its economy starts to grow faster. 

This “sweet spot” occurs when there are 1.7 people of working age (15 t0 65) for every dependent child or elder. At that point, the amount of money a country can generate (its gross domestic product) starts to make a real difference to people’s social and economic development. 

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It also applies to how families can use their money. 

“A woman who has two children can invest in the welfare of those kids better than a woman who has five or six kids,” Cilliers notes. That means parents can feed their children better, give them better education and afford better healthcare.  

“But that’s not the situation in most of Africa,” says Cilliers. 

Researchers look at graphs called population pyramids – showing the proportion of people in different age groups – to make sense of countries’ development outlooks.

For example, in Niger “there are so many more kids than working-age people that the country can’t build schools fast enough or provide better healthcare”, Cilliers explains. 

But for a country like Mauritius, whose population pyramid “looks more like the Taj Mahal” — bulging around the middle, where the working-age population sit in the graph — there’s more money available in the state’s purse for education, healthcare and services. 

According to a report from the United Nations Population Fund, the rates of unplanned pregnancies tend to be higher in countries where men hold more power in society — likely because women in these countries don’t have a say in how many children they want to have or even the power to say no to sex.

The solution?

For starters, keep girls in school. Research shows that girls who had finished at least primary education were less likely to have unplanned pregnancies than those with no education, because girls are likely to learn about modern contraceptives at school. 

Then, create more paid jobs for women, improve health services so that fewer mothers and infants die, and target family planning education for both men and women. Women with more money tend to have a better chance at avoiding unintended pregnancies, because they’re better able to afford family planning services.

Cilliers argues that the best way for Africa to get to that demographic sweet spot is to slow the continent’s population growth. But that doesn’t mean implementing restrictive policies, like China did in the 1980s with its one-child-per-family rule.

Says Cilliers: “We’re simply talking about giving parents the power, through their using contraception, to decide on the size of their family.” DM/MC

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.