On a May morning in 2024, Stella (not her real name) rushed to the Planned Parenthood Association of Ghana (PPAG) clinic at Suame, her heart pounding.

It has been her routine for some time now. 

The weight of her fears pushed her faster as she weaved through the busy streets.

Each step felt heavier, but the clinic was her only hope.

With a glance over her shoulder, she received her monthly birth control shot.

This is a secret she keeps from her husband.

Stella agreed to speak off-record.

"I need my peace of mind to concentrate on my work. How on earth do I tell my husband? He will chew me up, " she whispered.

Stella's story is not unique.

A revolution is gradually sweeping across the rural and urban spread of Ghana.

In a patriarchal society where women have little say over their bodies, women are taking control of their reproductive rights in a bid for autonomy.

This is despite their spouses denying them the right to access family planning services.

This is seen in unnoticeable visits of women to clinics, seeking family planning services in the Ashanti Region

Health workers have become allies in this struggle which is pitching women against societal norms.

Stella has been on these secret routines to the PPAG because when she broached the topic with her husband, he threatened a divorce.

He even physically abused her.

She learnt her lesson, a lesson that would not trade off her piece of mind

The economy is to blame. 

In an economy where financial strain is a daily reality, Stella works as a hairdresser to support her family, earning a meagre income that barely feeds her three children.

Her husband, a welder, does not earn much either, making their financial situation harder.

"We are struggling to even raise 1,000 cedis to pay the school fees of our second-born," Stella explained, showing the harsh reality faced by many women in Ghana.

The Right to reproductive autonomy

Under a towering mango tree at Akwatia line in Kumasi, Lariba (not her real name), agreed to speak off-record.

She shared a similar plight.

"The men in my ethnic group deny their spouses from seeking family planning services," she revealed.

In a society where discussing birth control with one's husband is an abomination, women like Lariba take control in secret.

"You as the lady are the one giving birth. You will go through the labour pains. You do not even have to discuss birth control with your husband."

Lariba's story shows how women often lack autonomy over their bodies despite their reproductive experiences.

"If you take the injections to prevent birth, who will know?" she asked rhetorically.

Lariba’s defiance tells the silent strength of women who are increasingly  defying cultural and family expectations.

The Demographic and Health Survey 2022 summary report shows that in Ghana, 36% of married women aged 15–49 use any method of family planning.

The most commonly used modern method among married women are implants and injectables (8% each)

By residence, more married women in rural areas use modern methods (29%) than urban married women (27%).

By region, modern method use ranges from 15% in the North East Region to 36% in both Ahafo and Western regions.

Family planning use among sexually active unmarried women is 63%, with 46% using modern methods and 17% using traditional methods.

Emergency contraception (12%), implants (10%), and injectable (10%) are the most commonly used modern family planning methods among sexually active unmarried women.

The Navrongo Experiment, a focus group study, in Northern Ghana tells the strains on gender relations resulting from contraceptive use.

The discussions revealed that while contraception can reconcile a husband's sexual desire with a wife's desire to space births, it also generates marital discord and physical abuse.

Men worry about their wives' fidelity and the potential conflict among multiple wives if contraception is used.

This shows the strong patriarchal tradition in the Upper East Region of Ghana, where the possibility of women acting independently is seen as a threat.

The 2022 Demographic and Health Survey report also shows that over half (52%) of married women age 15–49 make their own decisions related to sexual relations, including family planning use and reproductive care.

Participation in decision making about sexual and reproductive health is highest among women living in the Greater Accra and Western regions (69% in both regions) and lowest in the NorthEast Region (29%).

Cultural influences on health decisions

Dr. Seth Amponsah, a Senior Specialist OB/GYN at Suntreso Government Hospital and Komfo Anokye Teaching Hospital, points out the cultural factors that influence health decisions, particularly regarding contraception.

"People tend to trust long-standing relationships with family and community members over professional advice," he said.

This cultural norm can lead to a preference for advice from those they have known for years.

This makes it challenging for professionals to introduce new perspectives on health care.

Cultural and religious beliefs have further complicated reproductive health.

In the Northern parts of Ghana, family planning is culturally a taboo.

This is making education efforts challenging.

Regional Public Health Nurse of the Ghana Health Service, Bernice Osei says "Education about family planning is very low especially in the northern parts of the country. Women in these regions hide their contraceptive use, fearing backlash from their spouses and communities,”

Health policies and patriarchy

Professor Easmon Otupiri, an Associate Professor at the School of Public Health at the Kwame Nkrumah University of Science and Technology, says "Health policies in Ghana favour the use and access to contraceptives without requiring partner approval. However, this is challenged by strong patriarchy where women have limited autonomy,"

Despite policies supporting reproductive rights, societal norms often dictate otherwise.

This is pushing women like Lariba and Stella to seek covet solutions.

Discrete access and confidentiality

Amidst societal expectations, healthcare providers like Nurse Nuakoh (confidentially addressed by her surname), a midwife since 1998, have become allies in women's access to reproductive healthcare.

"I keep cards of clients hidden,so spouses won't find out." she revealed.

Her commitment is to safeguard women's right to choose.

This right often comes with a risk.

For women who need to keep their contraceptive use a secret, the best option are methods that can easily be concealed.

Wendy Oduro, a teacher, chose a contraceptive implant placed under the skin of her upper arm to avoid her husband's scrutiny.

"I touch the spot, and I can feel the implant. I don't want any questions from my husband, so I mostly wear long sleeves," she explains.

Wendy is considering an IUD, which would be even less detectable.

Unmet contraceptive need leading to unsafe abortions

The National Library of Medicine states that unmet contraceptive needs lead directly to increased unwanted pregnancies and subsequent unsafe abortions.

Abortions, particularly septic ones, are a cause of maternal morbidity and mortality.

Akosua (not her real name), a 22-year-old girl, experienced this reality.

After attempting an unsafe abortion, she was brought to the PPAG Health Facility in Suame, Ashanti Region, bleeding heavily and in pain.

Her story shows the length some women go to avoid unwanted pregnancies.

Regional Public Health Nurse of the Ghana Health Service, Bernice Osei, tells the importance of public education on sexual health.

"By the time we reach teenagers in rural areas, they have either become single mothers or attempted a pregnancy termination which could have gotten out of hand. Initiatives like "Safety Net" and "Me Daakye Nti" are designed to provide sexual education and vocational training to teenagers, but the reach is still limited”. she said.

The fear of reprisal

The fear of reprisal from male spouses is a threat.

For Nurse Nuakoh, she faced threats from male spouses of her female clients, when she was at post at the Amansie Central District in Ashanti Region.

The threats were not only verbal.

In one incident, she was physically attacked by the spouse of a woman who had undergone a Bilateral Tubal Ligation.

"My client came to me in the morning. After a few minutes in the consulting room, the husband barged into the consulting room. He held me by my dress, and threatened to beat me up. I am sure someone gave him a tip off" she recalled.

Abigail Okyere, a second-hand clothes seller at Ashtown in Kumasi, revealed she suffered a similar assault from her husband.

Her husband discovered a post-pill mini pack in her wardrobe, he accused her of infidelity and subjected her to physical abuse.

"He beat me and pushed me against the wall. For days, he was not eating my food. He reported me to my father-in-law. My father-in-law and my husband say I am seeing someone else. I am not having sexual relations outside of my marriage. I have never cheated on my husband. I just do not want to get pregnant again and abort it. My children are four now." Abigail explained.

Such violence tells the harsh environment faced by women seeking family planning services and the healthcare providers aiding them.

Myths, misconceptions, and mistrust

Misconceptions about contraceptives are numerous.

From fears of fibroids to heart problems, these myths deter many from seeking family planning services.

The Ashanti Regional Office of PPAG, previously stigmatised as "the abortion clinic," now faces the challenge of dispelling these myths while providing reproductive health services.

Dr. Seth Amponsah says there is a common tendency to focus on the potential side effects of contraception while overlooking its benefits.

He says concerns about side effects of family planning often overshadows the risks associated with pregnancy.

“The fear of contraception is prevalent despite evidence from countries like China where contraception has been used widely with minimal adverse effects,” he said.

The duty also falls on healthcare providers to clearly explain the side effects of family planning.

"Some patients bleed or feel dizzy, and they come back to say they will not do it again. Proper education on side effects and the assurance that it is normal could improve birth control," Bernice Osei said.

Affordability of reproductive health care services

Affordability is a basis of the Planned Parenthood Association of Ghana’s mission.

For many women in Ghana, especially those from lower-income backgrounds, the cost of contraceptives can be a barrier.

Project Coordinator at PPAG, Rexford Owusu-Banahene, explains a single visit can cost as little as 5 to 20 cedis.

This can even be accessed by those who earn meagre wages.

“The economic benefits go beyond the immediate cost of contraceptives. By helping women to plan their lives, they can invest more in their children's education and well-being. This will break the cycle of poverty,” he explains.

At the Kwame Nkrumah University of Science and Technology campus, a condom vending machine was installed to promote and provide access to safe sex.

For just 10 pesewas, students could easily obtain condoms from the machine, ensuring privacy and convenience.

However, since February 2024, the machine has been out of service.

The breakdown occurred after some students attempted to forcefully extract condoms without inserting a coin.

This caused damage to the system.

Interestingly, while male students patronised the vending machine freely, female students were often more reserved.

Many feared being mocked or stigmatised for using the machine.

This reflects the rooted societal taboos around female sexuality.

But the vending machine was a step towards normalising conversations about safe sex and reproductive health.

Male spouses' involvement

Interestingly, some male spouses are beginning to embrace birth control, though with reservations due to religious affiliations.

Moses Boateng fellowships with the Saviour Church of Ghana.

His 27 year old wife Rita Mensah is pregnant with their 6th child and currently unemployed.

He says he is unwilling to put his wife on birth control despite advice from nurses anytime he accompanies his wife for antenatal care.

“ The nurses try to advise my wife and I anytime we give birth. I have warned my wife not to listen to them. Besides, I can take care of all my 6 children including my parents. Are we complaining of hardships? Our religion frowns against birth control. It is God who takes care of us,” he said.

Francis Kwarteng, a farmer at Amansie Central in Ashanti Region, agreed to speak off record.

He fellowships with the True Faith Church and currently faces a dilemma due to his religious affiliation.

"I do not want any more children. Eight is a large number," he admitted.

Despite the religious ban, he plans to put his second wife on birth control.

“I cannot stick to the calculation of safe period days for my wife. She is mine and I should be able to engage her anytime I want to”

When asked if he will consider male birth control options to prevent conceptions, he said,

“ I am a man. I am supposed to give birth and populate the earth. Birth control is for women. Do you want me to lose my manhood? “

Francis is aware of the financial burden of raising many children.

The National Population Council is also promoting male spousal involvement in family planning, while shifting cultural perceptions and promoting reproductive rights for women.

Family planning as a tool for career growth

SEND Ghana, a non-governmental organisation known for its mandate to promote equality and advocate for sexual and reproductive health rights is encouraging women to engage in open, informed conversations about family planning to avoid unplanned pregnancies that could disrupt their careers and life aspirations.

Country Director Harriet Agyeman tells the importance of women being proactive about their reproductive health.

"Every woman should take control of her health and initiate conversations with her husband on the number of children they want to have. Family planning allows for a balance, so you can continue enjoying your relationship without jeopardising your career or body," she said.

The issue of unplanned pregnancies is a pressing concern, especially for young women like 27 Rita Mensah whose career has stalled due to the demands of childcare.

“ I completed University of Ghana in 2018. I was offered Business Administration but till now I have not landed a job. Anytime i go for interviews, I am either pregnant or have freshly delivered. My husband takes care of me, but sometimes I wish I had a job. I am at home now,”

According to Harriet Agyeman, bosses may not be as tolerant of employees who frequently take maternity leave, creating a significant barrier for women in professional spaces.

"It's unfortunate, but some employers hesitate to retain or promote women who seem to be having babies every year. Women must understand that by planning their pregnancies, they are preserving their careers." she said

Initiatives and strategies

With the 1994 International Conference for Population and Development in Cairo, Dr. Amponsah points out three critical areas of delay in women’s access to reproductive health care: the decision to seek care, the availability of transportation, and receiving appropriate care upon arrival.

These delays contribute to the conversation on reproductive rights and access to health services.

The Ghana Health Service, with support from Non-governmental organisations, is intensifying public education on sexual health in all communities.

Projects like "Safety Net" and "Me Daakye Nti" in the Ashanti Region are to educate teenagers on sexual health and assist them in entering various vocations.

As Ghana strives for gender equality, the role of men in family planning is a necessity.

"Every child should be a wanted child," Abena Adubea Amoah of PPAG says.

The struggle for reproductive autonomy in Ghana is riddled with challenges, from cultural barriers to threats of violence.

Yet, women like Stella and Lariba are determined to claim autonomy over their bodies.

Family planning is about controlling birth rates and women claiming their right to make decisions about their own bodies.

As healthcare providers and policymakers work to support these women, the hope is for a future where reproductive autonomy is not a battle but a right.