Impact of social and monetary costs on family planning behavior in a rural impoverished locality of northern Ghana

Background: This paper reviews the implications of social and monetary costs of family planning for the strategies that women pursue to implement reproductive preferences in a rural traditional setting of Sahelian Ghana where gender stratification remains pervasive and pronounced.

Methods: A qualitative study comprised of 16 male and female community-member focus groups, and 68 in-depth interviews of community leaders, frontline workers, and managers was conducted in Ghana's Upper East Region between June and September 2012.

Results: Women were positive about fertility regulation owing to perceptions that more children are surviving and expenses associated with raising children are rapidly increasing. Male reluctance to regulate fertility nonetheless remains high. In response to this preference gender gap, women often practice contraception covertly, employing tactics that mask their actions such as visiting nurses at irregular hours and locations, denying use among kin, and avoiding modalities that could betray use. Monetary service fees complicate surreptitious use because women have constrained autonomy to finance services, obligating them to negotiate with men or elder women for resources for fees when they would prefer to keep such matters secret.

Conclusion: Women offset social costs of family planning with complex strategies that combine contraceptive secrecy with dependence upon workers to defer payment of fees. Contraceptive use would be facilitated by mitigating the interplay of social and monetary costs by promoting family planning via male social networks, diminishing psycho-logistical costs by delivering care to women in non-clinical settings, and removing fees for services and supplies.