The Ethics of Contraception: Acknowledging Fundamental Human Rights in Birth Control

Adapted from: World Health Organisation. Ensuring Human Rights in the provision of contraceptive information and services: Guidance and recommendations [Internet]. Geneva: WHO Press; 2014 [cited 2014 Mar 16]. Available from: http://www.who.int/reproductivehealth/publications/family_planning/human-rights-contraception/en/

Pregnancy and childbirth, while a truly wonderful and natural process of human life, may produce an incredible source of stress and burden onto the mother, the family and the greater community into which the child will be born. A child raised in such conditions will be disadvantaged, often through a lack of resources or sociocultural rejection. In least-developed countries, 60% of women who do not wish to (currently) become pregnant still do not use any form of contraception; even lower is the proportion which use contraception effectively. The need for increased contraceptive access is highest among the vulnerable and disadvantaged populations in society; including adolescents, the poor, those living in rural areas and urban slums, people with HIV and internally displaced people (this refers to individuals who are forced to flee their home country, yet remain there regardless).

While achieving the highest attainable standard of health for all (including that of sexual and reproductive health) is the primary objective of the World Health Organisation, this cannot occur without respecting, protecting and fulfilling the fundamental human rights of the individual. This requires educating and advocating populations about gender equality, and prioritising the distribution of goods to the poor and under-served (commonly termed the inverse care law), and was highlighted in Target 5b of the Millennium Development Goals: "access to effective reproductive health should be universal by 2015".

The lack of contraception (resulting from a variety of barriers as discussed below) in developing countries is often underestimated by unknowing citizens of developed nations; according to recent WHO estimates, 222 million women are unable to use contraception. This translates to 54 million unintended pregnancies, 26 million abortions (16 million of which would be considered unsafe by international standards), 7 million miscarriages, 79,000 maternal deaths and 1.1 million infant deaths every year. While reducing maternal, foetal and infant deaths (not to mention curbing the exponential growth of the global human population) are obvious advantages of allowing access to effective contraception, it promotes sexual freedom and therefore psychological well-being.

According to WHO, 80% of global governments have embraced the legal enforcement of at least four of the principle human rights as accepted by international law. Whilst progressive movements with regards to human rights in the face of contraception have, and are constantly being made (such as increasing legal obligation to provide timely and affordable access to high-quality sexual and reproductive health education and contraceptive services whilst maintaining patient dignity, autonomy, privacy and confidentiality), this is not apparent in many countries and states around the world.

Although some progress has been made, the global improvements to women's sexual health have so far been woefully insufficient. The major barriers to effective contraception include the practical/logistical difficulty in providing contraceptive devices to certain geographical regions, the inflated prices as a result of this (unaffordable to those in need), a lack of sexual education of these populations, misunderstandings about reproductive and sexual health in women and the continued presence of gender inequities (ultimately preventing disadvantaged, uneducated women to make decisions about sexual activities). The lack of perceived choice may stem from strong social, cultural or religious pressures/outright threats to avoid contraception, or by coercive governmental policies and forces (the sterilisation of uneducated men and women alike without informed consent in developing nations is a common issue), and either way violates the fundamental human rights of an individual.

In response to the continued need for governmental regulation and guidance, the WHO have recently (March 2014) compiled an extensive list of recommendations following a systematic review of recent literature (high-quality evidence articles of the last two years, as assessed by the GRADE scale, were used to amend data of previous similar WHO guidelines) with focus upon the availability, accessibility, acceptability and quality of contraceptive health services. The reorganisation and reformulation of existing recommendations produced the 10 principles for ethical provision of contraceptive information and services as seen below;

International intervention and support of contraceptive services through implementation of these WHO recommendations may assist in reducing the negative implications of unintended pregnancy. This may be achieved through both education, reducing the stigma associated with existing social, cultural and religious beliefs, and increasing the actual physical accessibility of effective contraceptive devices. Benefits of effective contraceptive accessibility include reducing maternal, foetal and infant deaths, preventing global over-population, allowing individual sexual freedom, psychological well-being and thus greater health of the individual, family and greater community, particularly those vulnerable and disadvantaged populations.

Guy Armstrong: Medical Student

Mission Statement

Sexually transmitted infections and unwanted pregnancies place a huge burden on society at many levels. Love and Latex is an initiative by a small group of medical students, from the University of Western Australia, with a passion; to promote awareness of preventative health. The aim of this blog is to provide current, interesting and understandable information surrounding sexual health, reproductive health and contraception to help reduce the global burden of STIs and unwanted pregnancies.

Novel contraceptive method preventing HIV transmission and unwanted pregnancy

A recent (2014) publication by Kiser et. al. in the Public Library of Science: One (PLOS ONE) showed promising results for a new contraceptive device, in the form of a intra-vaginal ring, which is able to prevent unwanted pregnancies and the transmission of HIV (Human-Immunodeficiency Virus). Once in the vagina it secretes two separate drugs, levonorgestrel and Tenofovir for a period of 90days. These drugs work independently to stop unwanted pregnancy and HIV transmission. 

Tenofovir is an anti-retroviral drug commonly used in treatment of HIV infection. It belongs to the class of drugs known as nucleoside reverse transcriptase inhibitors (NRTIs). Tenofovir stops HIV from reproducing in the human host cells by inhibiting its ability to insert its viral genome into our human genome [More information on this pathway here]. Thus the virus is unable to reproduce and the infection is transient; by the same mechanism Tenofovir also blocks genital herpes virus (HSV-2) infection.

Levonorgestrel is a drug commonly known as 'the morning after pill'. It is generally taken orally within 72 of unprotected sex to avoid unwanted pregnancy (with a time-dependent decrease in efficacy). Recently it has shown efficacy as a pregnancy prophylactic in women, as it prevents unwanted pregnancies when applied to in the vagina at 20ug/day by intra-vaginal rings in women. 

Kiser et. al. have combined the two drugs into one ring. Both drugs are secreted at clinically appropriate levels for 90 days, meaning that to be protected year round women would have to change their rings quarterly. While this study was only a test of efficacy of the drugs in rabbits, translation to human medicine is promising due to previous successes of levonorgestrel-secreting intra-vaginal rings.

Why Do We Care?

According to the WHO one of leading causes of death in low and middle-income countries of women aged 15-19 years is from complications arising from pregnancy and childbirth. These same women are also 50% more likely to have stillbirths than mothers over 20 years old. The use of contraception to prevent early pregnancy could improve the individual's life span and quality of life.. 

Physical and social barriers to contraception are present throughout the world, but are especially prevalent in the developing world. 2014 WHO contraceptive guidelines indicate that as many as 222 million women who want access to contraception do not have it. This is most common in vulnerable populations (the poor, those living with HIV, people in low and middle income countries). The reasons are many, but are often are due to lack of contraceptive availability and the cultural practices around contraception. Senior author on these WHO guidelines Dr Marleen Temmerman speaks out about the what it can be like to seek contraception with these social pressures:

"Many women are coerced in their decision to be pregnant or not to be pregnant by their family, their father, the mother, the husband, the mother-in-law, the society, the community, by cultural and religious obstacles. But sometimes also by the governments, who are forcing tubal ligation, forcing sterilization onto some women and not giving access to others." (Dr. Temmerman, WHO)

The potential advantage of the device being trialed by Kiser et. al. is that it may provide some more autonomy and self-determination for women seeking birthing control. Once the product has been inserted intra-vaginally there is no outward notification of contraception, potentially alleviating social pressures on the woman whilst simultaneously providing protection. Nevertheless, despite the development of effective, discreet contraceptives, the social and cultural paradigms of contraceptive use need to be shifted to ensure viable use of contraception in 'at risk' sub-populations.

"It is not just about increasing [access], it’s also about increasing knowledge. It is vital for women—and men—to understand how contraception works, be offered a choice of methods, and be happy with the method they receive.” (Dr. Temmerman, WHO)

In 2011 there were 34 million people living with HIV globally, 1.7 million of which died from Acquired Immunodeficiency Syndrome (AIDS)-related illnesses. Unfortunately the prevalence of HIV is generally higher amongst people from lower socio-economic areas, often in developing countries (see figure below), perhaps due to inadequate contraception access.

Prevalence of HIV by WHO region, 2011. http://www.who.int/gho/hiv/en/

Whlist pre-exposure prophalactics (PrEP) are available (taken prior to exposure, they reduce the risk of HIV infection) in addition to preventative barrier methods, the benefits of use are minimal due to difficulties in drug adherence and inadequate access. While this intra-vaginal ring reduces adherence problems by supplying the dose directly for up to three months, accessibility to these 'at risk' populations remains unclear.  

In the developed world HIV transmission and unwanted pregnancies still contribute an incredibly significant burden on people (social and cultural stigma, financial cost, relationship deterioration) and the healthcare system (extensive financial burden). Kiser et al's rings can be directly compared to the implantable, etonogestrel containing, 'Implanon' contraceptive, yet it has the additional advantage of providing resistance to HIV infection. This would allow discordant couples (where one partner is HIV positive and the other is negative) to have 'unprotected' sex without transmitting the virus and having unplanned pregnancies.  

Limitations

Primarily the applicability of this study is limited by the fact that so far efficacy has only been shown in rabbits. Further research is needed to show the same levels of prevention in human females. 

Secondarily the new contraceptive method fails to address other sexually transmitted infections (STIs) such as hepatitis viruses, syphilis and chlamydia. Condoms remain the best method to prevent STIs and unwanted pregnancies (with an estimated 99% protection rate if used properly). 

Summary

The amalgamation of a preventative device for both unwanted pregnancy and HIV transmission by Kiser and colleagues provides a novel method to tackle these related problems; further research is necessary to establish efficacy in human females. In the future, the intra-vaginal ring  may allow discordant couples to practice safe unprotected sex. Use of this contraceptive device in the developing world may provide protection for women in social structures that do not openly support contraceptive use, thereby reducing HIV infection within these high-risk groups and subsequently in the developed world. It is evident that access to novel contraceptive methods is simply not enough; sexual education is a necessity in changing social and cultural practices around contraceptive use.