Not your typical door-to-door sales: the family-planning ladies of Nigeria
Note: MS ladies are trained health extension workers. Nigeria committed to task shifting to FP2020 and through their Family Planning Blueprint for 2014–2018, which included a roadmap for training Community Health Extension Workers (CHEWs) on implants insertion/removal. The Rapid Response Mechanism supported the process through two grants.
Three times a week, Aishatu Abdullahi slips on a flowy blue hijab, slings a bulging backpack of supplies over her shoulder, and sets out to sell her wares, door-to-door, to the women in her neighborhood.
In another time, in a different place, she might have been an Avon Lady, unzipping her bag to reveal tiny samples of lotions and lipsticks to neighborhood homemakers. But in northern Nigeria, in 2019, her powers of persuasion are directed toward unloading a very different kind of product.
“There are condoms, there are pills, there are implants, there is a shot,” she says cheerily, unsnapping a box of samples to show two potential customers. “It all depends on the type of method you’re looking for.”
Mrs. Abdullahi is part of a team of door-to-door contraceptive saleswomen hired by the family-planning charity Marie Stopes International to bring birth control to women here who can’t – or won’t – get it elsewhere. The model is part traveling saleswoman, part community health worker, a network of mobile midwives and health workers with a unique selling point. They come to you.
On average, a woman here in Kano state has 7.7 children, according to 2016 data from the National Bureau of Statistics, and about 94 percent of partnered women here don’t use any form of contraception. Nigeria as a whole has one of the world’s fastest rates of population growth, a boom that is expected to make it the world’s third-most populous country by 2050.
But if many women – and men – here take great joy in raising big families, they also, increasingly, are seeking control over how those families are formed.
“You know, there’s still a taboo – people are afraid to be doing this thing in a public place, like at a hospital,” Abdullahi says. But between the walls of their own houses, with women from their own community, she says it’s a different story. “You can be frank with people. You can laugh with them and chat with them, and they begin to trust you.”
Marie Stopes began the program, called the MS Ladies, in 2009 with a pilot program in Madagascar. In 2015, it expanded into several other countries, and now has more than 730 women working in 15 countries, most of them scattered across Africa. And like the Avon Ladies, or the Tupperware party hostesses of yore, they work on commission, turning a small profit for every contraceptive they provide.
“That makes it more sustainable for us because there are no salary costs,” says Effiom Effiom, the country director for Marie Stopes Nigeria. Instead, Marie Stopes provides the supplies to its saleswomen – all of them trained health professionals – at a steep discount. The cost is about 60 cents for a three-year birth control implant, for instance, and about 8 cents for a monthly supply of pills, so that providers can sell them cheaply to their clients but also still make a bit of cash. And if a customer can’t pay, Marie Stopes does.
Most of the MS Ladies have day jobs as nurses or community health-care workers, so the money isn’t the main reason for their work. Still, it doesn’t hurt.
“Every month, I buy my mother a chicken,” says Rakiyya Adamu, an MS Lady working on the outskirts of Kano, who says she makes between $10 to $20 a month selling birth control. “It’s money I can spend without asking anyone’s permission.”
And for women here, the birth control she sells buys an even greater freedom. Whether or not she gets pregnant, after all, often dictates if a young, newly married woman is able to finish school or not. Space between babies, meanwhile, can allow women to work outside the home, or simply focus on the children they already have.
“I just want a rest for now,” says Sakina Abubakar, a 33-year-old mother of seven boys, with a tinkling laugh that fills her small bedroom. She had her first son at 15, and since then, she has thrown herself headlong into the chaos of raising “my small army.” She wouldn’t change it, she says, but she’d like to hit pause, at least for a while.
Behind her, Mrs. Adamu is smoothing a brown tarp onto the floor and laying out rows of sterile steel instruments in neat, glinting rows. She slips off her blue hijab, which is emblazoned with the words CHILD SPACING SAVES LIVES, and balls it up in the corner. Then she motions for Mrs. Abubakar to lie down.
“I used to think there’s some hidden agenda with this birth control thing,” Abubakar says. “I thought maybe it’s something that came from Europe to stop African women from having children.” But Adamu was a woman she had seen at the mosque, in the market, walking with her children to school. If she believed in this, Abubakar thought, maybe it was all right.
Abubakar’s husband knows she’s having a three-year birth control implant inserted. They talked about it, and he likes the idea. But that isn’t always the case.
An hour outside Kano, in a town called Rano, Abdullahi is paying a house call to a slight woman in her early 30s named Samira. She has instructed the MS Lady to come now because her husband isn’t home, and she doesn’t want him to know what she’s about to do.
“My husband is a difficult man. He doesn’t work – he just goes away all day and leaves me with the kids,” she says, her voice sharpening. “So I decided to take this choice for the sake of my family. I prefer not to involve him.” And if he finds out? It’ll be better, she says, to ask his forgiveness than his permission.
Samira has six kids, including twins born a month ago. Her eldest daughter, Rabi, who is 19, gave birth to her second child the following week. [Editor’s note: Samira's and Rabi's last names have been omitted for their privacy.]
Now, both women sit rapt as Abdullahi cycles through their options – daily pills, quarterly injections, three-year implants.
Like many of Abdullahi’s clients, these women spend most of their days behind the four walls of their family compound, pounding yams, jiggling babies, and doing battle with the massive heaps of tiny clothes piled in the corner. So she’s learned to hustle her products at the few public events that bring women together, like weddings and baby-naming ceremonies, where she often sidles up to women she doesn’t know and asks them, quietly, if they know about child spacing.
That’s the way she phrases it, she says, because the idea isn’t to wag a finger at women who want big families. Abdullahi herself has seven kids, and says her only goal is to give women control over when they get pregnant.
That choice has proved powerful. Local women now pass her number furtively among themselves, so that Abdullahi’s phone is constantly lighting up with unknown numbers. Can you come to my house tonight? Can I have it done at your place? I can’t pay, can you help?
Marie Stopes currently has 115 Ladies in Nigeria, a number that’s set to double this year. Last year, they made about 37,000 house visits across the country. And worldwide, the 730 women in the program made nearly 800,000. But the need remains vast.
“We could train a thousand of these women [in Nigeria] and it still wouldn’t be enough,” Mr. Effiom says. That, indeed, is the program’s biggest limitation: Its highly personalized nature means it can’t expand access to contraceptives as quickly as programs that target hospitals or the public health system. Currently, MS Ladies account for a tiny sliver of the 27 million people around the world whom Marie Stopes provided with contraceptives in 2017.
In Rano, Rabi sits in the courtyard shushing her newborn daughter as she examines the implant’s tiny puncture marks on her upper arm.
“I don’t want my daughters to suffer like I did,” she says. “They will finish school. And when they are married, I will tell them about this family planning.”
Inside, Abdullahi is gathering up her supplies, getting ready to leave for the next house. Just then, a woman in a floral pink hijab pokes her head into the room. She’s wondering, she says, if the nurse has a few more minutes?
She’d like to talk, too.