Global barriers to effective contraception

Consequences of unmet need. Image courtesy of Marie Stopes International

Globally there is a need for the provision of effective contraceptive methods. Each year it is estimated by the World Health Organisation (WHO) that: 500 million people have been infected with one of the four main curable sexually transmitted infections (chlamydia, gonorrhoea, syphilis and trichomoniasis);¹ there are 54 million unintended pregnancies; 16 million adolescents (aged 15-19) give birth;² 26 million abortions (over half of which considered unsafe by international standards); 7 million miscarriages; 79,000 maternal deaths; and 1.1 million infant deaths³. Despite this great need there remains a plethora of barriers to the provision contraception.  

Socio-cultural factors

Societal attitudes are formed through a culmination of culture, religion, politics and education. The attitude held by a society towards contraceptive use has a major impact on its implementation. This was well demonstrated in a 2010 study by Yee and Simon. They suggest that young women in low income minority communities in America rely heavily on contraceptive advice from their family and social network; and that they place a higher value on this information than that provided by health providers.⁴

Some of the socio-cultural barriers that can affect the provision of contraception globally include:

·         Age: When the person seeking contraception is an adolescent many countries require parental consent prior to provision of contraception, this may impede uninterrupted contraceptive use in young adult populations. It is important to note that this population group is most at risk of sexually transmitted infections.^5,6

·         Marital status: This topic intermingles with age. In many cultures pre-marital sexual activity is taboo, this has resulted in discriminatory laws and in some cases attitudes among healthcare providers which limit contraceptive access. In many societies women in particular find access to contraception more readily available via family planning services once wed.^5-7

·         Gender Inequality: In social constructs where women are not empowered there is often a lack of awareness regarding the availability of contraceptive methods and inequitable access to them.^6,7 Examples of disempowerment include:

o   Decreased female autonomy: In some cultures gender roles are unequal and women do not make decisions for themselves or their families. This lack of autonomy compromises access to continual family planning services which provide contraception.^5-8

o   Social seclusion: In some societies women are secluded meaning that their knowledge of and access to contraception is inhibited.^6,7  

·         Religion: Some religious groups do not condone the use of contraceptives by their followers. A recent study by Rahman et. al. notes variation of knowledge regarding the emergency contraceptive pill amongst participants of differing religious affiliations in India.⁹

·         Other myths and misconceptions: Many myths and misconceptions, regarding the use of a contraception or their side effects, are rife within society. When the only form of contraceptive education obtained by a person is from their social network, inaccurate information is shared. This may lead to contraceptive avoidance or misuse.⁴

Education: The provision of correct sexual and reproductive health education is pivotal to combating the myths and misconceptions held by individuals, families and communities.⁷ Many unintended pregnancies occur due to women assuming indifference or invulnerability to pregnancy,⁴ but many others are due to a lack of access due to ignorance.² Comprehensive sexuality training has been associated with  delayed sexual activity initiation (where appropriate), sexual partner number reduction and increased condom or contraceptive use.¹⁰ Interestingly abstinence-only education does not alter initiation time of sexual activity for young adults but it is noted that these individuals are less likely to use contraception.¹¹

Improving the global society’s sexual and reproductive health literacy is only part of the battle. Higher education levels have been linked to the practice of innovative behaviours, such as contraceptive use.⁶ It also encourages a greater knowledge surrounding contraceptives, their availability and how to acquire them.⁶  

Access: The two greatest limiters to contraceptive access are geography and economy. Currently the level of global investment in family planning is approximately half of what it needs to be.¹² This in combination with logistic problems results in commodity shortages on the ground, typically in the areas that need them most.¹² In some nations contraception has been left to private-sector suppliers leading to higher market prices and thus further reducing access.¹³

Conclusion

Ultimately, the main barriers to effective contraception are a lack of accessibility (whether at a socio-cultural, geographic or economic level) and poor levels of education around sexual and reproductive health. Improving global access to contraception alone is not enough. To effect a real change we also need to change the attitudes of our global society through improved sexual and reproductive health education.

References

1. World Health Organisation. Global incidence and prevalence of selected curable sexually transmitted infections – 2008 [Internet]. Geneva: World Health Organization, Department of Reproductive Health and Research; 2012 [Cited 30 Mar 2014] Available from: http://www.who.int/reproductivehealth/publications/rtis/stisestimates/en/index.html .

2.       World Health Organisation. WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries [Internet]. Geneva: World Health Organisation, Department of Maternal, Newborn, Child and Adolescent Health; 2012 [cited 2014 April 7]. Available from: http://whqlibdoc.who.int/publications/2011/9789241502214_eng.pdf?ua=1

3.       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/

4.       Yee L, Simon M. The role of the social network in contraceptive decision-making among young, African American and Latina women. J. Adolesc. Health. 2010:47:374-380.

5.       Brown SS, Burdette L, Rodriguez P. Looking inward: Provider-based barriers to contraception among teens and young adults. Contraception. 2008:78(5):355-357.

6.       Oyedokun AO. Determinants of contraceptive usage: lessons from women in Osun State, Nigeria.  J Hum Soc Sci. 2007:1(2): 1-14.

7.       Culwell KR, Vekemans M, de Silva U, Hurwitz M, Crane BB. Critical gaps in universal access to reproductive health: Contraception and prevention of unsafe abortion. Int J Gynaecol Obstet. 2010:110:S13-S16.

8.       Bentley R, Kavanagh AM. Gender equity and women's contraception use. Aus J Soc Iss. 2008:43(1):65-81.

9.       Rahman H, Khalda E, Kar S, Kharka L, Bhutia GP. Knowledge of, attitudes toward, and barriers to the practice of emergency contraception among women in Sikkim, India. Int J Gynaecol Obstet. 2013:122(2):99-103.

10.   Kirby D. Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases [Internet] Washington (DC). The National Campaign to Prevent Teen and Unplanned Pregnancy; 2007 [cited 2014 April 7]. Available from: http://www.urban.org/events/thursdayschild/upload/Sarah-Brown-Handout.pdf

11.   Rosenbaum JE. Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers. Paeds. 2009:123(1):e110-e120.

12.   Singh S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: The costs and benefits of investing in sexual and reproductive health [Internet] New York (NY). Guttmacher Institute and United Nations Population Fund (UNFPA), 2009 [cited 2014 April 7]. Available from http://www.guttmacher.org/pubs/AddingItUp2009.pdf

13.   Guttmacher Institute. Facts on barriers to contraception use in the Phillipines [Internet] New York (NY).  Likhaan center for women’s health and Guttmacher Institute; 2010 [cited 2014 April 7]. Available from: http://www.guttmacher.org/pubs/FB-contraceptives-philippines.pdf