In a first of its kind initiative on the African continent, Aaron Motsoaledi, South Africa’s minister of health has announced that all public health facilities starting February will offer free under-the-skin contraceptives. While this is a bold step to making contraceptives more widely accessible limiting women’s options to just one method of contraceptive is problematic because no one contraceptive can meet the needs of all women.
Mr Mostsoaledi made the announcement at a State of the Nation address earlier this week. The new policy is a move to increase non-HIV related family planning services. In the battle against HIV/AIDS, health efforts focused on condom use almost exclusively as a means of combating the disease, neglecting the family planning agenda. Elsewhere on the African continent family planning is promoted largely as a measure to reduce maternal mortality and not as a stand alone to ensuring that women have more reproductive choice and freedom.
Under the new policy any South African woman would be able to access the under-the-skin device, which can last for up to 3 years and be removed at any time. While this is a great stride towards increasing contraceptive access, it is important for the South African government to find a way to make other types of contraceptives available under the initiative. While most under-skin implants are safe and effective some women experience heavy bleeding, and other side affects that subsequently force those women to have their implants removed. If a woman in South Africa receives a free under skin implant and later decides it does not work for her will she be able to replace it with another form of contraceptive free of charge?
The implants work by releasing a small amount of hormone steadily into the blood. This prevents pregnancy by thickening the cervical mucus, which blocks the sperm from meeting an egg, and by preventing ovulation to various degrees. Users of Jadelle or Sino-implant (II) are more likely to experience irregular bleeding and frequent bleeding and spotting, while users of Implanon are more likely to infrequent bleeding.
Women’s bodies are going to react differently depending on the contraceptives offered, therefore if African government’s choose to offer contraceptives to women at no charge they should be prepared to offer different kinds. Supporting the need for diversity in the offerings of contraceptive methods is a study that found that the commonly used hormone injection that most women on the continent use as birth control may increase the risk for HIV infection.
The study, led by researchers at the University of Washington and published in The Lancet Infectious Diseases, involved 3,800 couples in Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia.
The study found that women using hormonal contraception became infected at a rate of 6.61 per 100 person-years, compared with 3.78 for those not using that method. Transmission of H.I.V. to men occurred at a rate of 2.61 per 100 person-years for women using hormonal contraception compared with 1.51 for those who did not.
While there are issues with the study, experts agree that there is enough evidence to raise concern about use of the hormone injection. It is estimated that 60 percent of married South African women between the ages 15-49 use some form of a contraceptive device. However, the numbers are much less for girls from impoverished communities who are a higher risk for unwanted pregnancies. Although fertility rates in South Africa are comparable to western developed countries, by age 19 half of all young women have given birth.
A 2009 report on teenage pregnancy focused on school going learners by the Department of Basic Education of the Republic of South Africa found that: “Over two-thirds of young women report their pregnancies as unwanted because it hobbles educational aspirations and imposes greater financial hardships in a context of high levels of poverty and unemployment.”
West African nations with lower contraceptive use rates like Ghana and Sierra Leone could look to South Africa for lessons on family planning delivery. According to World Bank indicators on health 34% of married women aged 15-49 in Ghana used contraceptives in 2010 as compared to just 8% in Sierra Leone in 2008.
Making contraceptives available to women and adolescents is not about population control as opponents fear. With Thirty-nine percent of pregnancies in Sub-Saharan Africa reported as unintended, promoting contraceptive use is rather about giving women and teenagers especially control over when and how they reproduce so they can have better lives. Women who use contraceptives can choose to have children when they are ready.
African countries looking to adopt similar measures to make contraceptives more widely used should ensure that in addition to offering free contraceptives they also provide a range of methods. Many different factors will influence the type of contraceptives a woman will choose. These may range from her age, proximity to a health center, marital status, to the stigma of being viewed as promiscuous . So making contraceptives more accessible is also making sure you can choose between IUDs, coils, the pill, safe injections, and condoms. As one public health practitioner put it, family planning is not a one size fit all.