Last month, Stembile Mugore visited a hospital in Togo, where she met a 24-year-old woman who had just given birth to her fifth child. Mugore is an advisor to Evidence to Action, USAID’s global flagship for strengthening family planning, and she had come to Togo to follow up with a group of midwives who had been trained by USAID. The new mother’s labor had been difficult, and she did not want to become pregnant again in the near future. But she also had no idea how to prevent it from happening.
“She didn’t know anything about family planning,” Mugore recalled. “She’d never heard [of it]. She’d had these babies very closely spaced.” After discussing her options with a hospital midwife, the woman decided to receive an implant — a small, rod-shaped form of birth control that is inserted into the arm, and that lasts for up to three years.
“I remember very well the smile and the satisfaction on her face after she’d had this implant,” Mugore said. “And how she wished she had known [about it sooner].”
In her unrealized desire to prevent pregnancies, this young mother is hardly alone. 867 million women living in developing countries want to avoid becoming pregnant, but around 222 million of them have unmet contraceptive needs. Every year on September 26, World Contraception Day seeks to draw attention to this gaping chasm in the landscape of contraceptive use, and to promote awareness of family planning methods so that all women can make informed choices about their sexual health. Ensuring equal contraceptive access can quite literally be a matter of life and death: everyday, approximately 800 women die from causes related to pregnancy and childbirth.
The forces preventing millions of women from accessing contraceptives vary from region to region, country to country. Unsurprisingly, a key obstacle is often a lack of funds. “Some contraceptives are still very expensive,” says Jagdish Upadhyay, Head of Reproductive Health Commodity Security and Family Planning at the United Nations Population Fund. “To provide [those] kind of resources, which can run into millions of dollars for countries, it’s a big challenge. Then you have to build a whole supply chain … to the facility so they can be distributed.”
Often, supply chains do not extend into remote rural areas, where the poorest segments of low-income populations tend to reside. The journey to a family planning facility might be expensive or physically difficult, requiring women to walk across jagged terrain. As a result, there is a steep equity gap in contraceptive use, even in some of the world’s poorest countries.
Resources — or lack thereof — can have a direct impact on the variety of contraceptive methods available in developing regions. Methods like the IUD (which mandates a cervical exam), female sterilization, and male sterilization (which require minor surgical procedures) must be administered by skilled professionals, who are relatively expensive to employ. In fact, one of the reasons that injectable contraception has become so popular in sub-Saharan Africa is because it can be administered by non-medical, front-line workers.
“Women often don’t have a choice [of contraceptive method],”says Roy Jacobstein, Senior Medical Advisor at IntraHealth International, an organization that seeks to strengthen family planning systems through service providers. “They’re choosing injectables, but they don’t have the longer acting or permanent methods available to them, generally. [Those require a] more skilled provider, more intense system, it might entail a minor surgical procedure. It’s easier from the point of view of a provider facing more than 70 or 80 people in the morning to just have them get injections.”
Jacobstein points out that limited choice of contraceptives is better than no choice, which used to be “way predominant [in some parts of the developing world] because of no availability and access.” But a broad distribution of contraceptive method use is generally considered to be a positive phenomenon, because it indicates that a given country is able to meet the individualized needs of its women and couples. In Ethiopia, for example, more than 60 percent of family planning users rely on injectables. In the United States, by way of contrast, the most common method—female sterilization—is only used by 20.8 percent of women.
A shortage of resources is not the only obstacle to ensuring that women are able to obtain a wide-ranging selection of family planning methods. Misinformation about contraceptives can run wide and deep, spreading through local populations, health care providers, and even doctors. Cultural attitudes can also be prohibitive. Studies have indicated that Punjab women in Pakistan, for example, do not seek out contraceptives because they believe doing so would conflict with their husbands’ fertility desires. A 2009 review of family planning in sub-Saharan Africa and Southeast Asia found that many women feared that hormonal contraceptives, which often disrupt the menstrual cycle, would make them infertile.
Mugore—who worked on family planning initiatives in Zimbabwe, Uganda, Kenya, and Tanzania, as well as in Togo — has witnessed such misconceptions firsthand. “Women believe that contraceptives [make them] infertile,” she said. “There are perceptions [that] they cause cancer. There are perceptions that contraception interferes with their sex life, or their libido, or the libido of their partners. Young girls who have never had children sometimes get caught up in a provider bias, where providers believe, ‘No, no, no, don’t take contraceptives because you might become infertile.’”
All of this may paint a very bleak picture for the future of contraceptive access in the developing world, but there is definite cause for optimism. According to Jacobstein, “use of contraception has gone up six-fold in 50 years, and 20-fold in developing countries.” And a number of recently-introduced methods may very well revolutionize the face of family planning in low-income regions. The Sayana Press — a reduced dose of the Depo-Provera shot packaged into an injectable system with a very thin needle — was released last year and is currently being used in 11 countries. The device is simple to administer and cannot be reused, cutting down risks of infection from sharing. The Sayana Press also costs only a dollar.
But it is the implant that might very well become the biggest game-changer in developing regions. Thanks to a global initiative called Family Planning 2020, donor volume guarantees have reduced the price of the implant by about half (it originally cost $8.50), and 40 million implants will become available to low resource countries over the course of five years. The implant is a particularly promising method because it has a longer shelf life than injectables, which only last for three months. “Any method that is low user responsibility is fairly preferable,” says Mugore. “With implants, [women] don’t have to come back to the clinic for [three years]. Women prefer those kinds of methods, because in these countries, facilities are not easy to get to.”
Of course, family planning methods alone cannot bridge the gap of unmet contraceptive need. A healthy and diverse supply of contraceptives must be made accessible and affordable. Comprehensive information on sexual health must be brought into communities. Deeply-entrenched notions of gender roles must be addressed. Achieving these goals will require collaborative efforts by governments, NGOS, the private sector, community service organizations, and advocates. It will take hard work and time. And it will be worth it.
“Family planning, it’s a human rights issue,” says Upadhyay. “It’s a prevention issue. It’s a women’s issue … We need a big movement to bring governments together, bring partners together, raising these issues [to make clear] the impact of not meeting these needs … How many women will have an unplanned pregnancy, and how many women will die because of that? [There] should be a movement all over the world.”