Not your typical door-to-door sales: the family-planning ladies of Nigeria
| Kano, Nigeria
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.
鈥淭here are condoms, there are pills, there are implants, there is a shot,鈥� she says cheerily, unsnapping a box of samples to show two potential customers. 鈥淚t all depends on the type of method you鈥檙e looking for.鈥�
Why We Wrote This
鈥淢eet people where they are.鈥� It鈥檚 a common adage. But workers with MS Ladies take that literally. For women who aren鈥檛 comfortable visiting a clinic, or can鈥檛, home visits mean more than simply getting birth control.
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鈥檛 鈥� or won鈥檛 鈥� 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 , and about 94 percent of partnered women here don鈥檛 use any form of contraception. Nigeria as a whole has one of the world鈥檚 fastest rates of population growth, a boom that is expected to make it by 2050.
But if many women 鈥� and men聽鈥� here take great joy in raising big families, they also, increasingly, are seeking control over how those families are formed.
鈥淵ou know, there鈥檚 still a taboo 鈥� people are afraid to be doing this thing in a public place, like at a hospital,鈥� Abdullahi says. But between the walls of their own houses, with women from their own community, she says it鈥檚 a different story. 鈥淵ou can be frank with people. You can laugh with them and chat with them, and they begin to trust you.鈥�
Health care at home
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.
鈥淭hat makes it more sustainable for us because there are no salary costs,鈥� says Effiom Effiom, the country director for Marie Stopes Nigeria. Instead, Marie Stopes provides the supplies to its saleswomen 鈥� all of them trained health professionals聽鈥� 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鈥檛 pay, Marie Stopes does.
Most of the MS Ladies have day jobs as nurses or community health-care workers, so the money isn鈥檛 the main reason for their work. Still, it doesn鈥檛 hurt.
鈥淓very month, I buy my mother a chicken,鈥� 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. 鈥淚t鈥檚 money I can spend without asking anyone鈥檚 permission.鈥�
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.聽
鈥淚 just want a rest for now,鈥� 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 鈥渕y small army.鈥� She wouldn鈥檛 change it, she says, but she鈥檇 like to hit pause, at least for a while.聽
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.
鈥淚 used to think there鈥檚 some hidden agenda with this birth control thing,鈥� Abubakar says. 鈥淚 thought maybe it鈥檚 something that came from Europe to stop African women from having children.鈥� 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.
鈥楩or the sake of my family鈥�
Abubakar鈥檚 husband knows she鈥檚 having a three-year birth control implant inserted. They talked about it, and he likes the idea. But that isn鈥檛 always the case.聽
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鈥檛 home, and she doesn鈥檛 want him to know what she鈥檚 about to do.
鈥淢y husband is a difficult man. He doesn鈥檛 work 鈥� he just goes away all day and leaves me with the kids,鈥� she says, her voice sharpening. 鈥淪o I decided to take this choice for the sake of my family. I prefer not to involve him.鈥� And if he finds out? It鈥檒l be better, she says, to ask his forgiveness than his permission.聽
Samira has six kids, including twins born a month ago. Her eldest daughter, Rabi, who is聽19, gave birth to her second child the following week. [Editor鈥檚 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 鈥� daily pills, quarterly injections, three-year implants.
Like many of Abdullahi鈥檚 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鈥檚 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鈥檛 know and asks them, quietly, if they know about child spacing.
That鈥檚 the way she phrases it, she says, because the idea isn鈥檛 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.聽
That choice has proved powerful. Local women now pass her number furtively among themselves, so that Abdullahi鈥檚 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鈥檛 pay, can you help?
Marie Stopes currently has 115 Ladies in Nigeria, a number that鈥檚 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.
鈥淲e could train a thousand of these women [in Nigeria] and it still wouldn鈥檛 be enough,鈥� Mr. Effiom says. That, indeed, is the program鈥檚 biggest limitation: Its highly personalized nature means it can鈥檛 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 whom Marie Stopes provided with contraceptives in 2017.
In Rano, Rabi sits in the courtyard shushing her newborn daughter as she examines the implant鈥檚 tiny puncture marks on her upper arm.
鈥淚 don鈥檛 want my daughters to suffer like I did,鈥� she says. 鈥淭hey will finish school. And when they are married, I will tell them about this family planning.鈥�
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鈥檚 wondering, she says, if the nurse has a few more minutes?聽
She鈥檇 like to talk, too.
