More people are turning to family planning in Tanzania's semi-autonomous island of Zanzibar as the government seeks to improve access to reproductive healthcare. Funding, however, remains a challenge.
“We have been moving on well in the recent months as the turn-up for family planning by both men and women is impressive. Acquiring enough contraceptives for our clients remains the biggest challenge,” Hanuni Ibrahim Sogora, the director for family planning in Zanzibar’s Ministry of Health and Social Welfare, told IRIN.
Health officials say a culture of polygamy and low male contraceptive use has limited the number of women accessing reproductive healthcare services.
"The major problem is a lack of male involvement in family planning. For example, if a mother comes to the clinic with her baby, there is no harm if the husband can escort her because whatever information is given is important for both,” Kassim Issa Kirobo of the Zanzibar reproductive health programme, told IRIN. “The men say we are busy looking for a livelihood.”
Kirobo, the programme's behaviour change officer in charge of communication and information, said: "The women may also want to use the [family planning] services but the men have the last word."
Regarding low male contraceptive use, Kirobo said: "People say, why do I need to use a condom with my wife?
“There is a view that condoms are just for STI [sexually transmitted infections] control, not for preventing pregnancies,” he said. “If there was a contraceptive for men, besides condoms, maybe that would work.”
However, in the past three years, there has been a positive uptake of the services, according to Sogora.
"The number of women and men going for family planning has been growing. We now frequently have implants and Depo-Provera out of stock because of the growing demand,” she said.
Implants are tiny rods containing hormones that are inserted under the skin to prevent pregnancy. Depo-Provera is a form of birth control whereby a synthetic form of the hormone progesterone is injected every three months.
Sogora said over-reliance on donor funding was a problem, with the government only providing a small amount of funds.
The population growth rate on the islands is 3.1 percent, says the chief government statistician, with 1.2 million people in 2008 from 981,750 in 2002, according to a demographic survey citing Zanzibar's 2002 census. Immigration is also a factor.
Mzee K. Juma of the municipal council said the average household size in the Zanzibar municipality was 5.6 persons, with the population growth rate higher there at 4.5 percent.
Modern contraceptive use in Tanzania increased from 17 percent in 1999 to 20 percent in 2004-2005 among married women. Unmet family planning needs remain, however, especially in rural areas.
Across Zanzibar, health officials are involved in awareness-raising to enhance the use of reproductive health services and religious leaders are being trained to reach the men.
Some men are changing their attitude. Ahmed Mussa, 41, said: “Previously, I was anti-family planning, but last year  I accepted the idea after having four children in a short period of six years.
“[When] my wife decided to go for family planning, I supported her and [I ] think we can now decide to either remain with the four children or have two more with the required gaps."
Sabah Salum, a mother of two, said: “I think it is good to help mothers plan their family. It is tiresome to have children almost every year.”
Islam is the main religion in Zanzibar.
Issa Zidy, an Islamic scholar and lecturer at the State University of Zanzibar, said: "Islam encourages family planning because it promotes having another baby after two to three years."
But even for those who plan their families, challenges remain.
According to 2009 health estimates, the maternal mortality rate in Zanzibar was 377 per 100,000 live births. The deaths were mainly due to severe bleeding and eclampsia, exacerbated by inadequately skilled attendants and lack of facilities in primary healthcare units.
Kirobo noted that rural primary healthcare centres often lacked comprehensive delivery facilities, with women needing caesarian services being transferred to towns.
Delivery costs are a barrier. "People say if I go to the TBA [traditional birth attendant] I do not have to pay anything," Kirobo said.
He said the government was training TBAs and providing life-saving skills to maternity ward attendants.
Asha Aboud Mzee, secretary of the Catalyst Organization for Women’s Progress in Zanzibar, said other challenges facing women included HIV/AIDS, domestic violence and poor representation in decision-making.
"Sometimes at the Shehia [lowest administration] level, we find few of the committee members are women; there is no one to talk about women’s and children’s issues."
Zanzibar recently passed a law seeking to increase female representation in parliament.
"We don’t just want numbers; we want to send [women] to parliament who will actually represent us. [They] should understand women’s problems, not just sit [in parliament] and listen. Women have many needs,” Mzee said.