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Expanding Contraceptive Choice FAMILY PLANNING EVIDENCE BRIEF Expanding contraceptive choice “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 POLICY AND PROGRAMME CONSIDERATIONS Approximately 214 million women of reproductive age in developing regions who want to avoid pregnancy are not using a modern Establish and maintain well- contraceptive method and are considered to have an unmet need functioning supply chains for an (1). Expanding contraceptive options for voluntary family planning is expanded choice of contraceptives: critical to addressing this need for several reasons. First, needs may vary throughout the reproductive life-course, and individuals have Introduce new contraceptive different desires depending on their personal and family context; 25% of technologies to satisfy the women want to space their pregnancies, reflecting a need for shorter- diverse preferences of women term or reversible methods, compared with 14% of women who wish and their partners. to cease childbearing and thus limit future pregnancies (2). Second, some women discontinue contraceptive use even though they want to Overcome access barriers avoid pregnancy (3, 4). Reasons for discontinuation include side effects, to existing methods such as myths, contraceptive failure, or the service environment, including adverse economic and social service quality and availability of a sufficient choice of methods (4). circumstances, including gender norms. Use of modern contraception increases when more methods Maximize the potential of become available: analysis of evidence from 1982–2009 expanded contraceptive choice by ensuring a robust supply chain and improving provider training and counselling. CURRENT METHODS OF CONTRACEPTION Having a wide choice of contraceptives will meet the needs Expand provider base Method Gender Hormonal Provider dependent of some discontinuers if they have the option of switching; Task-shifting or task-sharing is the redistribution of broadened method availability can reduce contraceptive Female Male Yes No Yes No contraceptive counselling and service provision among discontinuation by 8% (5). Third, three-fifths of women different health worker cadres. For example, enabling Short-acting contraceptives (62%) with unmet need have never used contraception (5), community health workers (CHWs) to provide injectables, and a wider range of options may be appealing enough Male condom X X X like Sayana® Press, and implants has expanded access to to some women to try contraception. The addition of one and increased voluntary use of both methods in many Female condom X X X new method to the available method mix can increase countries (18, 19, 20). Expanding provision to drugstore contraceptive prevalence by as much as eight percentage and pharmacy staff has also increased access to oral points (6). Finally, expanding method choice can ensure contraceptive pills, including those for emergency Injectables (DMPA X X X that methods are available for those wanting to protect contraception, and injectables, especially for underserved subQ in Uniject) against both pregnancy and sexually transmitted infections populations (21). Increasing the variety of providers allows including HIV. users to choose convenient and accessible service delivery points. Finally, user-initiated contraceptives like fertility Injectables (other) X X X CONSIDERATIONS FOR EXPANDING awareness methods and pills are increasingly empowering Pills X X X women’s independent use of contraceptives, further CONTRACEPTIVE CHOICE expanding access. Vaginal rings X X X Diaphragm X X X STRATEGIES TO EXPAND MAXIMIZING THE POTENTIAL Long-acting reversible contraceptives (LARCs) CONTRACEPTIVE OPTIONS OF EXPANDING CONTRACEPTIVE Implants X X X Proven strategies to expand contraceptive options OPTIONS include introducing new contraceptives to family planning IUD – hormonal X X X programmes, expanding access to existing methods, and The following actions are essential to ensuring that these IUD – copper X X X expanding the provider base. strategies are successful and lead to greater contraceptive access, uptake, and continuation: Permanent contraception Introduce new contraceptive technologies Tubal ligation X X X Ensure a robust supply chain New contraceptive technologies have been developed Vasectomy X X X to satisfy the diverse preferences of women and their Ensuring availability of contraceptive supplies at points partners and to overcome the challenges of providing some of care that are close to clients is essential. Robust methods in low-resource settings. For example, studies supply chains that eliminate stock- outs and engage multiple manufacturers to ensure high-quality, low- ACHIEVING FP2020 GOALS 7 Burke, H.M, M.P. Mueller, C. Packer, B. Perry, L. Bufumbo, have shown that DMPA subQ in Uniject (Sayana® Press) D. Mbengue, B.M. Daff, and A. Mbonye. 2014. “Provider cost contraceptive products are critical for uptake and can be provided by grassroots health cadres and by users AND BEYOND acceptability of Sayana® Press: Results from community continuation (22). themselves, thus reducing reliance on healthcare systems Expanding the range of contraceptive options helps health workers and clinic based providers in Uganda and (7, 8). Studies also suggest that women find Sayana® Press individuals to make choices appropriate to their needs and Senegal,” Contraception, 89(5): 368–373. to be a feasible and acceptable choice of contraception Improve provider training and counselling circumstances, allows them to switch from one method 8 Burke, H.M., M.P. Mueller, B. Perry, C. Packer, L. Bufumbo, which is currently being introduced, scaled- up, or piloted Providers should be trained in client-oriented service to another if desired, and reflects a programme focus on C. Mbengue, I. Mall, and B. Mamadou. 2014. “Observational in more than 15 FP2020 countries (9, 10, 11, 12). Other new provision for a range of methods in both clinical and quality and rights. study of the acceptability of Sayana® Press among product categories include vaginal rings that women can community settings (23, 24). Comprehensive and accurate intramuscular DMPA users in Uganda and Senegal,” insert themselves, and can be offered through various counselling allows clients to learn more about contraceptive Contraception, 89(5): 385–395. supply outlets ranging from drug stores to tertiary-level options, including managing side effects, benefits, and REFERENCES 9 Cover. J., A. Namagembe, J. Tumusiime, D. Nsangi, J. Lim, facilities (13, 14). The levonorgestrel (LNG) intrauterine possibility of switching (25). Users can then choose a 1 Guttmacher Institute. 2017. “Adding It Up: Investing in and D. Nakiganda-Busiku. 2018. “Continuation of injectable system and emerging technologies such as a biodegradable contraceptive that best suits their need, or switch methods Contraception and Maternal and Newborn Health, 2017.” contraception when self-injected vs. administered implant, longer-lasting injectables, microCHIPS remote- if they so desire. Addressing lack of provider knowledge New York: Guttmacher Institute. https://www.guttmacher. by a facility-based health worker: A nonrandomized, controlled contraceptives, and multipurpose prevention of underutilized methods, like no-scalpel vasectomy, could org/fact-sheet/adding-it-up-contraception-mnh-2017. prospective cohort study in Uganda” Contraception, technologies (MPTs) for contraception and HIV and/or STI also increase contraceptive access (26). 2 Van Lith, L.M., M. Yahner, and L. Bakamjian. “Women’s https://doi.org/10.1016/j.contraception.2018.03.032 prevention hold the promise of an even wider choice of growing desire to limit births in sub-Saharan Africa: 10 Cover, J., M. Ba, J. Lim, J.K. Drake, and B.M. Daff. 2019. methods. In addition to vasectomy and tubal ligation, more Generate demand meeting the challenge,” Global Health, Science and “Evaluating the feasibility and acceptability of self- affordable, safer, and simpler permanent contraceptive Practice. (1): 97–107. doi:10.9745/ GHSP-D-12-00036. injection of subcutaneous depot medroxyprogesterone options for women and men should also be considered, Even with a well-informed provider base, an expanded 3 Ali, M.M., J.G. Cleland, and I.H. Shah. 2012. Causes and acetate (DMPA) in Senegal: A prospective cohort study,” given that there is substantial unmet need for limiting. method mix can only reach its full potential with continued Consequences of Contraceptive Discontinuation: Evidence Contraception, 96(3): 203–210. demand from users. For example, despite vasectomy’s from 60 Demographic and Health Surveys. WHO: Geneva, 11 Shelton, J.D. and V. Halpern. 2014. “Subcutaneous DMPA: Expand access to existing methods well-recognized benefits including high effectiveness, Switzerland. A better lower dose approach,” Contraception, 89(5): convenience, permanence, relative ease of provision, 4 FP2020 and Population Council. 2015. “Contraceptive 341–343. Overcoming barriers to existing methods such as policy, few side effects, and high levels of satisfaction, use of discontinuation: Reasons, challenges and solutions. 12 “FP2020 in Countries: Delivering High-Quality and Rights- geography, and adverse
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