Family planning evidence brief: expanding contraceptive choice
Publication date: 2017
EVIDENCE B R I E F “Expanding options and choices for the poorest women and adolescent girls is the most important thing we do. By empowering them to make their own decisions about the timing and spacing of pregnancies, we open an important pathway towards their economic security and independence, as well as the realization of all the Sustainable Development Goals.” —Dr. Natalia Kanem, Executive Director of the United Nations Population Fund Approximately 214 million women of reproductive age in developing regions who want to avoid pregnancy are not using a modern contraceptive method and are considered to have an unmet need (1). Expanding contraceptive options for voluntary family planning is critical to addressing this need for several reasons. First, needs may vary throughout the reproductive life-course, and individuals have different desires depending on their personal and family context; 25% of women want to space their pregnancies, reflecting a need for shorter- term or reversible methods, compared with 14% of women who wish to cease childbearing and thus limit future pregnancies (2). Second, some women discontinue contraceptive use even though they want to avoid pregnancy (3, 4). Reasons for discontinuation include side effects, myths, contraceptive failure, or the service environment, including service quality and availability of a sufficient choice of methods (4). Expanding contraceptive choice POLICY AND PROGRAMME CONSIDERATIONS Establish and maintain well- functioning supply chains for an expanded choice of contraceptives: Introduce new contraceptive technologies to satisfy the diverse preferences of women and their partners. Overcome access barriers to existing methods such as adverse economic and social circumstances, including gender norms. Maximize the potential of expanded contraceptive choice by ensuring a robust supply chain and improving provider training and counselling. FAMILY PLANNING Use of modern contraception increases when more methods become available: analysis of evidence from 1982–2009 Having a wide choice of contraceptives will meet the needs of some discontinuers if they have the option of switching; broadened method availability can reduce contraceptive discontinuation by 8% (5). Third, three-fifths of women (62%) with unmet need have never used contraception (5), and a wider range of options may be appealing enough to some women to try contraception. The addition of one new method to the available method mix can increase contraceptive prevalence by as much as eight percentage points (6). Finally, expanding method choice can ensure that methods are available for those wanting to protect against both pregnancy and sexually transmitted infections including HIV. CONSIDERATIONS FOR EXPANDING CONTRACEPTIVE CHOICE STRATEGIES TO EXPAND CONTRACEPTIVE OPTIONS Proven strategies to expand contraceptive options include introducing new contraceptives to family planning programmes, expanding access to existing methods, and expanding the provider base. Introduce new contraceptive technologies New contraceptive technologies have been developed to satisfy the diverse preferences of women and their partners and to overcome the challenges of providing some methods in low-resource settings. For example, studies have shown that DMPA subQ in Uniject (Sayana® Press) can be provided by grassroots health cadres and by users themselves, thus reducing reliance on healthcare systems (7, 8). Studies also suggest that women find Sayana® Press to be a feasible and acceptable choice of contraception which is currently being introduced, scaled- up, or piloted in more than 15 FP2020 countries (9, 10, 11, 12). Other new product categories include vaginal rings that women can insert themselves, and can be offered through various supply outlets ranging from drug stores to tertiary-level facilities (13, 14). The levonorgestrel (LNG) intrauterine system and emerging technologies such as a biodegradable implant, longer-lasting injectables, microCHIPS remote- controlled contraceptives, and multipurpose prevention technologies (MPTs) for contraception and HIV and/or STI prevention hold the promise of an even wider choice of methods. In addition to vasectomy and tubal ligation, more affordable, safer, and simpler permanent contraceptive options for women and men should also be considered, given that there is substantial unmet need for limiting. Expand access to existing methods Overcoming barriers to existing methods such as policy, geography, and adverse economic and social circumstances including restrictive gender norms will expand access to existing methods. For example, expanding access to implants through mobile outreach programmes and reducing the price through a volume guarantee resulted in significant increases in use (15, 16). Similarly, socio- cultural barriers to providing services to adolescents can be overcome in many ways including via comprehensive sexuality education, gender-transformative programming, adolescent-friendly services, and providing contraceptives through a variety of service outlets (17). Expand provider base Task-shifting or task-sharing is the redistribution of contraceptive counselling and service provision among different health worker cadres. For example, enabling community health workers (CHWs) to provide injectables, like Sayana® Press, and implants has expanded access to and increased voluntary use of both methods in many countries (18, 19, 20). Expanding provision to drugstore and pharmacy staff has also increased access to oral contraceptive pills, including those for emergency contraception, and injectables, especially for underserved populations (21). Increasing the variety of providers allows users to choose convenient and accessible service delivery points. Finally, user-initiated contraceptives like fertility awareness methods and pills are increasingly empowering women’s independent use of contraceptives, further expanding access. MAXIMIZING THE POTENTIAL OF EXPANDING CONTRACEPTIVE OPTIONS The following actions are essential to ensuring that these strategies are successful and lead to greater contraceptive access, uptake, and continuation: Ensure a robust supply chain Ensuring availability of contraceptive supplies at points of care that are close to clients is essential. Robust supply chains that eliminate stock- outs and engage multiple manufacturers to ensure high-quality, low- cost contraceptive products are critical for uptake and continuation (22). Improve provider training and counselling Providers should be trained in client-oriented service provision for a range of methods in both clinical and community settings (23, 24). Comprehensive and accurate counselling allows clients to learn more about contraceptive options, including managing side effects, benefits, and possibility of switching (25). Users can then choose a contraceptive that best suits their need, or switch methods if they so desire. Addressing lack of provider knowledge of underutilized methods, like no-scalpel vasectomy, could also increase contraceptive access (26). Generate demand Even with a well-informed provider base, an expanded method mix can only reach its full potential with continued demand from users. For example, despite vasectomy’s well-recognized benefits including high effectiveness, convenience, permanence, relative ease of provision, few side effects, and high levels of satisfaction, use of the method is plagued by low demand among men (27). Family planning program experience suggests that demand generation through media campaigns and mobile services can increase contraceptive use and intention to use modern contraceptives by improving community and individual knowledge and attitudes and promoting partner communication (28). Satisfied contraceptive users who speak to others about their experience are also highly effective in generating demand and changing social norms related to voluntary family planning (28). ACHIEVING FP2020 GOALS AND BEYOND Expanding the range of contraceptive options helps individuals to make choices appropriate to their needs and circumstances, allows them to switch from one method to another if desired, and reflects a programme focus on quality and rights. REFERENCES 1 Guttmacher Institute. 2017. “Adding It Up: Investing in Contraception and Maternal and Newborn Health, 2017.” New York: Guttmacher Institute. https://www.guttmacher. org/fact-sheet/adding-it-up-contraception-mnh-2017. 2 Van Lith, L.M., M. Yahner, and L. Bakamjian. “Women’s growing desire to limit births in sub-Saharan Africa: meeting the challenge,” Global Health, Science and Practice. (1): 97–107. doi:10.9745/ GHSP-D-12-00036. 3 Ali, M.M., J.G. Cleland, and I.H. Shah. 2012. Causes and Consequences of Contraceptive Discontinuation: Evidence from 60 Demographic and Health Surveys. WHO: Geneva, Switzerland. 4 FP2020 and Population Council. 2015. “Contraceptive discontinuation: Reasons, challenges and solutions. 5 Jain, A., F. Obare, S. RamaRao, and I. Askew. 2013. “Reducing unmet need by supporting women with met need,” International Perspectives on Sexual and Reproductive Health, 39(3): 133–141. doi: 10.1363/3913313. 6 Ross, J. and J. Stover. 2013. “Use of modern contraception increases when more methods become available: Analysis of evidence from 1982-2009,” Global Health Science and Practice, 1(2): 203–212. 7 Burke, H.M, M.P. Mueller, C. Packer, B. Perry, L. Bufumbo, D. Mbengue, B.M. Daff, and A. Mbonye. 2014. “Provider acceptability of Sayana® Press: Results from community health workers and clinic based providers in Uganda and Senegal,” Contraception, 89(5): 368–373. 8 Burke, H.M., M.P. Mueller, B. Perry, C. Packer, L. Bufumbo, C. Mbengue, I. Mall, and B. Mamadou. 2014. “Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal,” Contraception, 89(5): 385–395. 9 Cover. J., A. Namagembe, J. Tumusiime, D. Nsangi, J. Lim, and D. Nakiganda-Busiku. 2018. “Continuation of injectable contraception when self-injected vs. administered by a facility-based health worker: A nonrandomized, prospective cohort study in Uganda” Contraception, https://doi.org/10.1016/j.contraception.2018.03.032 10 Cover, J., M. Ba, J. Lim, J.K. Drake, and B.M. Daff. 2019. “Evaluating the feasibility and acceptability of self- injection of subcutaneous depot medroxyprogesterone acetate (DMPA) in Senegal: A prospective cohort study,” Contraception, 96(3): 203–210. 11 Shelton, J.D. and V. Halpern. 2014. “Subcutaneous DMPA: A better lower dose approach,” Contraception, 89(5): 341–343. 12 “FP2020 in Countries: Delivering High-Quality and Rights- Based Services.” http://progress.familyplanning2020.org/ en/fp2020-in-countries/delivering-high-quality-and-rights- based-services 13 Merkatz, R.B, M. Plagianos, E. Hoskin, M. Cooney, P.C. Hewett, and B.S. Mensch. 2014. “Acceptability of the nestorone®/ethinyl estradiol contraceptive vaginal ring: Development of a model; implications for introduction,” Contraception, 90(5): 514–521. 2 3 Method Gender Hormonal Provider dependent Female Male Yes No Yes No Short-acting contraceptives Male condom X X X Female condom X X X Injectables (DMPA subQ in Uniject) X X X Injectables (other) X X X Pills X X X Vaginal rings X X X Diaphragm X X X Long-acting reversible contraceptives (LARCs) Implants X X X IUD – hormonal X X X IUD – copper X X X Permanent contraception Tubal ligation X X X Vasectomy X X X CURRENT METHODS OF CONTRACEPTION 14 RamaRao, S., H. Clark, R. Merkatz, H. Sussman, and R. Sitruk-Ware. 2013. “Progesterone vaginal ring: Introducing a contraceptive to meet the needs of breastfeeding women,” Contraception, 88(5): 591–598. 15 Duvall, S., S. Thurston, M. Weinberger, O. Nuccio, and Nomi Fuchs- Montgomery. 2014. “Scaling up delivery of contraceptive implants in sub-Saharan Africa,” Global Health Science and Practice, 2(1): 72–92. 16 Christofield, M. and M. Lacoste. 2016. “Accessible contraceptive implant removal services: An essential element of quality service delivery and scale-up,” Global Health Science and Practice, 4(3): 366–372. 17 Chandra-Mouli, V., D.R. McCarraher, S.J. Phillips, N.E. Williamson, and G. Hainsworth. 2014 “Contraception for adolescents in low and middle income countries: needs, barriers, and access,” Reproductive Health, 11:1. http://www. reproductive-health-journal.com/content/11/1/1. Accessed July 13, 2017. 18 Charyeva, Z., O. Oguntunde, N. Orobaton, E. Otolorin, F. Inuwa, O. Alalade, D. Abegunde, and S. Danladi. 2015. “Task shifting provision of contraceptive implants to community health extension workers: Results of operations research in northern Nigeria,” Global Health Science and Practice, 3(3): 382–394. 19 High-Impact Practices in Family Planning (HIPs). 2015. “Community health workers: Bringing family planning services to where people live and work.” Washington, DC: USAID. http://www. fphighimpactpractices.org/resources/ community-health-workers-bringing-family-planning- services-where-people-live-and-work. 20 Hoke, T., A. Brunie, K. Krueger, C. Dreisbach, A. Akol, N.L. Rabenja, A. Olawo, and J. Stanback. 2012. “Community- based distribution of injectable contraceptives,” International Perspectives on Sexual and Reproductive Health 38(4): 214–219. 21 High-Impact Practices in Family Planning (HIP). 2013. “Drug shops and pharmacies: Sources for family planning commodities and information. “Washington, DC: USAID. http://www.fphighimpactpractices.org/resources/ drug-shops-and-pharmacies-sources-family-planning- commodities-and-information. 22 High-Impact Practices in Family Planning (HIPs). 2012. “Investing in contraceptive security and strengthening health systems.” Washington, DC: USAID. 23 Costello, M., M. Lacuesta, S. RamaRao, and A. Jain. 2001. “A client- centered approach to family planning: The Davao Project,” Studies in Family Planning, 32(4): 302–314. 24 Sathar, Z., A. Jain, S. RamaRao, M. ul Haque, and Jacqueline Kim. 2005. “Introducing client-centered reproductive health services in a Pakistani setting,” Studies in Family Planning, 36(3): 221–234. 25 Jain, A. 2016. “Examining progress and equity in information received by women using a modern method in 25 developing countries,” International Perspectives on Sexual and Reproductive Health, 42(3): 131–140. 26 Shattuck, D., B. Perry, C. Packer, and D. Chin Quee. 2016. “A review of 10 years of vasectomy programming and research in low-resource settings,” Global Health: Science and Practice, 4(4): 647–660. http://doi.org/10.9745/ GHSP-D-16-00235. 27 Shelton, J.D., and R. Jacobstein. 2016. “Vasectomy: A long, slow haul to successful takeoff,” Global Health: Science and Practice, 4 (4): 514–517. http:// dx.doi.org/10.9745/ GHSP-D-16-00355. 28 Belaid, L. A. Dumont, N. Chaillet, A. Zertal, V. De Brouwere, and V. Ridde. 2016. “Implementation and effects of demand generation interventions in low- and middle- income family planning programs: A systematic review,” Cahiers REALISME, No. 6, April. http://www.equitesante. org/cahiers- realisme-numero-6-implementation-and- effects-of- demand-generation-interventions-in-low-and- middle- income-family- planning-programs-a-systematic- review/. Authors: Heather Clark, Saumya RamaRao, Catherine Unthank, Population Council; Kazuyo Machiyama, London School of Hygiene and Tropical Medicine; Nandita Thatte, World Health Organization This is one of seven Family Planning Evidence Briefs prepared for the Family Planning Summit held in London on July 11, 2017. The briefs highlight evidence and provide research and programme considerations for improving access to family planning and reducing unintended pregnancy. Programme considerations are based on the expert views of the authors, who undertook desk reviews drawing on existing evidence. Family Planning Evidence Briefs • Accelerating uptake of voluntary, rights-based family planning in developing countries (overview) (Updated October 2018) • Family Planning Financing (Updated October 2018) • Reducing early and unintended pregnancies among adolescents (Updated October 2018) • Improving family planning service delivery in humanitarian crises • Ensuring contraceptive security through effective supply chains • Expanding contraceptive choice (Updated October 2018) • Partnering with the private sector to strengthen provision of contraception The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. Family Planning Evidence Brief – Expanding contraceptive choice WHO/RHR/17.14 Rev.1 © World Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license. For more information, please contact: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland E-mail: email@example.com Website: www.who.int/reproductivehealth Twitter: @HRPresearch This material has been funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government’s policies. Prepared July 2017. Updated October 2018 4
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