Developing a new male contraceptive might seem like a daunting challenge. But, novel approaches, identification of new genetic targets and more expansive research on acceptability could lead to the development of a game-changing male contraceptive in our lifetime. In recognition of World Contraception Day 2016 (September 26), we are pleased to share this five-part blog series, Keeping Male Contraceptive Research Front and Center. In this series, the Contraceptive Technology Innovation (CTI) Exchange brought together experts in the field to discuss the state of the science. Over the next several months, the CTI Exchange will continue hosting other guest authors who will offer insights on this subject. The CTI Exchange is a knowledge-sharing portal managed by FHI 360 experts.
Youth and contraception: two words that when used together excite visceral responses throughout the world. The response is even more fraught when we consider long-acting, reversible contraceptives (LARCs) for youth. Both intrauterine devices (IUDs) and implants are LARCs, and the challenges for young people who wish to use them — lack of access, myths and misconceptions, provider bias and community stigma — are pervasive. We have to understand more about these challenges in order to overcome them.
In late May 2015, FHI 360 and partners — U.S. Agency for International Development, PSI, MSI and Pathfinder International’s Evidence to Action project — sponsored a symposium, called “For Youth, a Healthy Option With LARCs” in Washington, DC. The meeting convened more than 100 experts from around the world, including program advisors and implementers, researchers, health providers, donors and advocates, as well as young people themselves. The meeting’s goal was to encourage participants to share experiences, tackle tough questions and advocate for wider access to LARCs for young women.
To optimize opportunities to make groundbreaking advances in contraceptive research and development (R&D), the global health community must help connect the dots to facilitate new partnerships between groups that often work in silos. For example, there is the company in the United States that is developing a promising drug delivery platform but hasn’t yet considered applying the research to contraceptive products. There is the university scientist who has an idea for a new contraceptive product but is unsure whether similar investments are being made in the private sector. There is the small company based in the global South that wants to enter the international market but lacks experience registering its contraceptive products in sub-Saharan Africa.
Imagine the potential if each one of the 600 million adolescent girls in developing countries could have full control over her reproductive life. She would be able to stay in school, delay marriage, postpone pregnancy, and support herself and her community. Yet, approximately 16 million girls between the ages of 15 and 19 give birth each year and one-third of girls give birth before their 20th birthday.
To advocate for young people’s access to safe, reliable contraceptive information and services, FHI 360 co-hosted a meeting today on youth and long-acting reversible contraceptives (LARCS). With participants including the LARC and Permanent Methods Community of Practice Secretariat, Population Services International, Marie Stopes International and Pathfinder, the meeting highlighted the range of highly effective contraception methods available and provided a platform for tackling tough questions about how to effectively promote LARCs for youth.
What is the true value of a 10-cent (US$) pregnancy test? In many countries, women are routinely denied same-day provision of family planning methods if they arrive at the clinic on a day when they are not menstruating. When it comes to ensuring reliable access to contraception, it turns out that simple, low-cost pregnancy tests can be extremely valuable.
Sonia, a 49-year-old woman in Rwanda, is a long-time user of Depo-Provera, the popular three-month injectable contraceptive. She explains that women who are not menstruating are often turned away for family planning services because health care providers are concerned that these women might be pregnant. Many are told to return during their next menses, leaving them at risk of unintended pregnancy in the meantime. Sonia says, “When you get there, they ask if you are having your period. When it is ‘no,’ they give you another appointment. When it is ‘yes,’ they give you cotton wool and you go somewhere discreet to put some blood [on it] and come back to show it to the provider. It is only then that the provider shows you the methods.”
As elsewhere in Africa, a woman in rural Malawi often must walk for miles to reach the nearest health clinic. When she finally arrives, long queues await and a preferred contraceptive, Depo-Provera®, is often unavailable. Even if the barriers of distance, long waits and stock-outs did not exist, a busy clinic would not be an ideal venue for those who seek contraception in a private setting away from the prying eyes of neighbors and acquaintances. Many women use Depo-Provera because it is effective, requires only a single injection every three months and can be used without the knowledge of a sexual partner.
In many villages in Malawi, and other countries, an auxiliary nurse sells a wide variety of over-the-counter medicines, as well as condoms and oral contraceptives, in a small drug shop. Women in these villages wish that injectable contraceptives were as easily and discreetly available as the pills and condoms in the drug shop.
This situation may soon change with the arrival of a new, lower-dose formula of Depo-Provera called Sayana® Press. Sayana Press provides the same three months of safe, effective pregnancy prevention as Depo-Provera but comes in an easy-to-use, pre-filled injection device designed to allow low-level health workers, and even users themselves, to inject the product. To further simplify the injection, the long needle formerly required for deep muscle injections has been replaced by a much shorter needle for a simple injection just beneath the skin.
Several countries in Africa, such as Senegal and Uganda, are beginning to use Sayana Press in their family planning programs, especially those in which community health workers provide contraceptives. More importantly, a few countries will soon begin stocking Sayana Press in pharmacies and perhaps rural drug shops.
Sexual and reproductive health, which includes access to family planning and HIV prevention and treatment, is increasingly being linked to progress across all areas of development. As the United Nations Open Working Group (OWG) on Sustainable Development comes closer to finalizing the post-2015 global development goals, a growing crescendo of voices is commenting on where we stand with regard to meeting the sexual and reproductive health needs of the world’s girls, women and couples and is offering ideas on how to move ahead. We are also seeing important shifts in policy.
There are many examples that illustrate the lively dialogue that is now happening on sexual and reproductive health.
An article in the journal Contraception acknowledges that although significant, measurable progress on sexual and reproductive health has been made in the two decades since the International Conference on Population and Development (ICPD), momentum on key areas of family planning has slowed in recent years.
New commentaries in the Bulletin of the World Health Organization and The Lancet summarize the evidence for why universal access to family planning should be a key component of the post-2015 development agenda. Additional commentaries in The Lancet and Global Health: Science and Practice Journal offer actionable recommendations for meeting global demand for family planning. Finally, Womenatthecenter.org, an exciting new website, is sharing “inspiring, interconnected stories of women’s reproductive health and rights, empowerment and environmental sustainability.”
In 1971, the world was a different place demographically. Our planet was mostly agrarian, family sizes were large and birth control was unavailable. That year, FHI 360’s heritage organization, the International Fertility Research Program, was created to perform clinical trials of emerging contraceptive technologies, such as oral hormonal contraception and intrauterine devices (IUDs). These studies helped jump-start global family planning programs, creating health services for women where none had previously existed.
1994: Setting a new agenda
Fast forward to 1994, the year of the International Conference on Population and Development (ICPD). This pivotal global event caused a seismic shift in family planning, from concern about population growth to a commitment to reproductive rights and justice. Women’s empowerment took center stage. Issues related to sexually transmitted infections, especially HIV, were folded into the sexual and reproductive health agenda.
The ICPD also strengthened voluntary family planning as a fundamental human right. This enabled women and couples to determine the timing and spacing of their pregnancies. With control over their fertility, women improved both their personal health and their career aspirations. Family size preferences decreased, and the demand for more effective, longer-acting contraception increased.
Family planning drives development
Today, the shift from larger to smaller families represents one of the most important transformations in developing regions. This shift was made possible in large part by the increased availability of modern contraception. Demographers have traditionally defined “modern” as any method other than “traditional” (for example, natural family planning and withdrawal). During the past two decades, evidence has demonstrated the contributions that family planning can make to global health and development, including progress toward the Millennium Development Goals.
Albertine,* a 34-year-old mother of five, was determined to get a long-acting family planning method. Because she lives in a remote part of Benin, a country of around 9 million in West Africa, she needed to travel many kilometers in the hot sun with her youngest child on her back to reach a health facility that provides contraceptives. Although she lives in an area where less than 1 percent of women use a modern family planning method, a community health worker had counseled and referred her to the health facility using a mobile phone-based tool (a service provided through the PRISE-C project, which is supported by University Research Co., LLC’s Center for Human Services and funded by the U.S. Agency for International Development).
Once she reached the health facility, Albertine insisted on getting what she called “the five-year method,” the two-rod Jadelle implant that is effective for five years of continuous use. She waited until the late afternoon — when the day’s immunization services were complete — before the midwife could see her. In a scene not uncommon in rural settings, Albertine lay across a small exam table and nursed her son on her right side while the midwife swabbed her left arm, injected the anesthesia, positioned the trocar and inserted the rods one by one. When the insertion was complete, Albertine smiled, took her implant card, and said she would be back in five years for another one!
Family planning can have remarkable effects on women, children and families. When women are able to decide how many children to have and when, they are more able to meet their own educational, health and economic goals. Planning the number and timing of pregnancies also allows women to plan their finances and invest in the children they have. Unfortunately, not every woman has access to the contraception necessary to decide when to have children and how many to have. Perhaps the answer lies in an expanded role for community-based health workers.
Many governments and nongovernmental organizations have turned to community-based family planning programs to expand access to contraceptives.These distribution programs have been credited with advancing family planning endeavors in otherwise underserved areas in Africa, Asia and Latin America. Despite the progress made there is room for improvement. One challenge community health workers encounter is the fact that, while national policies in many countries permit community health workers to provide condoms and oral contraceptives, they are not allowed to administer injectable contraceptives. This is particularly problematic in sub-Saharan Africa, where injectable contraceptives are a preferred method of contraception for women.