For so many in the developed world, the root of African problems – poverty, malnutrition, famine – seems to lie with the large families which are so common here. The proposed solution is contraception – it sounds so simple.
Clearly, limiting family size can alleviate problems of limited resources, but in many African countries large families are commonly perceived as a solution - an apparent contradiction.
Here in DRC, families with 10 children or more are not unusual. In an environment with high infant and child mortality, having a large number of children is a way of ensuring some survive and are able to earn money or to produce food for the rest of the family, and ensure aging relatives are cared for.
The culture of large families is reinforced by church teaching that contraception is wrong – churches and pastors are a key part of the community and hold considerable influence.
A large number of children not only exacerbates the poverty in a family, but having children close together is a common cause of malnutrition, as the older baby is weaned early and has to compete with the rest of the family for food from the communal pot. Of course, there is also the impact of multiple pregnancies on the health of women.
Some women may want contraception. They may recognise the damage that repeated childbearing does to their health. Some men recognise this too, and also understand the economic strain a large number of surviving children puts on the family.
Paul (not his real name), a young Congolese MSF nurse, recounted his own current situation. His wife comes from a large family – she is one of 12 children. For her, then, this is a normal size family, and she also wants at least 10 children. This despite her also being a nurse trained in midwifery, so intellectually, she knows the risks this poses for her health. Paul, in turn, does not want a big family, he was happy to settle for two, they now have three. He hopes he and his wife can come to a compromise, he is hopeful that she will agree to stop at five.
Congolese law recognises the right of women to control the number of children they have. Women have the right to decide on contraception. But the prevailing culture is far from this ideal.
In reality, women who decide to use contraception are often stopped by their husbands, parents, in-laws, and all the extended family, as well as by the community and the churches. MSF offers several contraceptive options; implants are popular, but a proportion of women are obliged to return to have them removed.
A crucial part of MSF work is health education, and family planning has crept up the agenda.
It is clear that targeting women is not enough – the entire community, and church leaders, must also be part of the conversation. It has recently become apparent that our own national staff are not setting good examples – not many are like Paul - they too celebrate large families.
So if we are trying to send a message to the rest of the population, we must convince our own staff first. After all, economically, they are in a strong position compared with most of their compatriots; they are well educated, have stable jobs, with reliable income.
So, a session was organised with one of our (national staff) health educators. He described the risks of large families, and the benefits of limiting family size. He then went through the different methods available, to considerable hilarity, especially when the wooden penis was brought out to demonstrate correct condom use.