To mark World Contraception Day 2023, Professor Shahin Rahman Chowdhury reflects on the importance of universal access to quality contraception care for gynaecological health and women’s rights.
Unmet need for contraception
Worldwide, there is a huge unmet need for contraception and the statistics are staggering: out of the 923 million women of reproductive age in low- and middle-income countries (LMIC) who want to avoid having a pregnancy, 218 million have an unmet need for modern contraception—that is, they want to avoid a pregnancy but are not using a modern method. [1] This burden falls disproportionately on women in low- and middle-income countries (LMIC) with more than half of the women and girls with unmet need for contraception living in sub-Saharan Africa and South Asia. [2] A lack of access to quality contraception counselling and supplies has far-reaching implications for women and girls’ health and rights, including the right to gynaecological health.
Gynaecological health and contraception
A lack of access to contraception leaves women and girls without the means to make decisions about their life plans, including whether and when to get pregnant. Each year, 111 million unintended pregnancies occur in LMICs, and they account for 49% of all pregnancies in those countries. [3] Put plainly, a higher rate of unintended pregnancy means higher rates of maternal mortality and morbidity. We know that there are higher rates of unsafe abortion (especially in contexts where access to quality abortion care is limited) and women and young people are not able to make healthy decisions about the timing and spacing of their pregnancies.
In low- and middle-income countries (LMICs), unmet need for modern contraception is highest among adolescent girls aged 15–19. [4] Delaying the first pregnancy is a key intervention for the prevention of obstetric fistula and other birth-related gynaecological conditions. Therefore, quality abortion care must be accessible for young people and it should be part of a wider programme comprehensive sexuality education. Sexuality education with an evidence-based curriculum and well-trained providers is an effective tool for dismantling the stigma around young people’s sexuality and tackling early and forced marriage. This careful guidance should continue throughout the life course to realise every woman’s right to reproductive choice and to prevent birth-related gynaecological conditions [5]. As we have seen in the Gynaecological Health Matters programme, this means health workers of all levels need to be equipped with the resources and knowledge to offer quality contraception services in primary care and as part of perinatal care. With a focus on informed consent and rights-based counselling, community outreach services and post-partum contraception services can support women to make healthy decisions about whether and when to have children.
Secondly, having access to barrier methods of contraception and advice on how to use them is vital for preventing sexually transmitted infections (STIs) and HIV. We know that meeting the need for STI prevention would also have an important knock-on effect for gynaecological health. That is because untreated STIs can cause gynaecological conditions like pelvic inflammatory disease, infertility and subfertility, as well as put women at a greater risk of gender-based violence. If all contraception needs were met 3.5 million cases of STI-caused infertility would be avoided [6]. Investment in contraception services is the key to a prevention-first approach. Equipping nurses and non-specialist doctors with the knowledge and resources to provide gynaecological care and contraception services at the primary level has huge health benefits for patients and eases pressure on our health systems down the line. That is the rationale behind the Gynaecological Health Matters programme and we are already seeing the impact in Bangladesh [7].
Lastly, contraception methods such as the combined oral contraceptive and long-acting reversible contraceptives (LARCs) are helpful for the management of hormone and menstrual conditions. Treatments for chronic conditions such as polycystic ovarian syndrome (PCOS), heavy menstrual bleeding (also called menorrhagia) and endometriosis urgently need investment and research. In the meantime, hormonal contraception can be a welcome option for symptom management. Without management, these so-called ‘benign’ gynaecological conditions have a profound and long-lasting impact on the health and wellbeing of those effected and can be related to other non-communicable diseases in later life such as heart problems [8] and diabetes [9]. Physical symptoms include severe pain, anaemia and nausea and these conditions are linked to school absenteeism, mental health issues and social exclusion. Estrogen-based hormonal therapies can also improve health and quality of life for women in the perimenopausal and menopausal phases of life. [10] Contraception services, therefore, must be accessible for women and girls throughout the life-course. Moreover, service providers should be trained to tackle stigmatising ideas linking contraception to sexual promiscuity that often prevent young people and older people from accessing contraception services.
Conclusions: a call for quality gynaecological and contraception care
Access to quality contraception care is essential to realizing everyone’s right to gynaecological health, as well as their bodily autonomy. It is not only a part of family planning but also an essential healthcare service throughout the life course.
We have seen that quality contraception care includes access to the full range of methods and rights-based counselling that tackles stigma and misinformation. We have also seen that access to quality contraception care alone is not enough: contraception services must be provided as part of a comprehensive package of sexual and reproductive health and rights (SRHR) services. This should include quality abortion care, comprehensive sexuality education and gender-based violence prevention services.
This is only possible within an enabling environment. To realise the aims of World Contraception Day, laws and regulations must follow medical evidence, not stigma and politicisation; healthcare workers should be adequately trained in SRHR and essential gynaecological skills; and contraception services must have stable and sufficient funding.
About the author
Prof Rahman Chowdhury is a Fellow of the RCOG and senior member of the Obstetric and Gynaecological Society of Bangladesh (OGSB). She is a Professor in the Department of Gynecology & Obstetrics at Holy Family Red Crescent Medical College & Hospital and a Clinical Lead on the RCOG’s Gynaecological Health Matters programme in Bangladesh.
References
[1] https://www.guttmacher.org/fact-sheet/investing-sexual-and-reproductive-health-low-and-middle-income-countries
[2] Haakenstad A. et al. (2019). Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, Vol. 400, Issue 10348, 295–327. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00936-9/fulltext
[3] https://www.guttmacher.org/fact-sheet/investing-sexual-and-reproductive-health-low-and-middle-income-countries
[4] Coulson J, Sharma V, Wen H. Understanding the global dynamics of continuing unmet need for family planning and unintended pregnancy. China Popul Dev Stud. 2023;7(1):1-14. doi: 10.1007/s42379-023-00130-7. Epub 2023 Apr 5. PMID: 37193368; PMCID: PMC10075166.
[5] https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-020-01008-4
[6] https://www.guttmacher.org/fact-sheet/investing-sexual-and-reproductive-health-low-and-middle-income-countries (data from 2019)
[7] https://www.rcog.org.uk/about-us/global-network/centre-for-womens-global-health/gynaecological-health/our-gynaecological-health-matters-programme/
[8] Mishra SR, Chung HF, Waller M, Dobson AJ, Greenwood DC, Cade JE, et al. Association Between Reproductive Life Span and Incident Nonfatal Cardiovascular Disease: A Pooled Analysis of Individual Patient Data From 12 Studies. JAMA Cardiol [Internet]. 2020 Dec 1 [cited 2022 Nov 28];5(12):1410–8. Available from: https://pubmed.ncbi.nlm.nih.gov/32936210/
[9] Pandeya N, Huxley RR, Chung HF, Dobson AJ, Kuh D, Hardy R, et al. Female reproductive history and risk of type 2 diabetes: A prospective analysis of 126 721 women. Diabetes Obes Metab [Internet]. 2018 Sep 1 [cited 2022 Nov 28];20(9):2103–12. Available from: https://pubmed.ncbi.nlm.nih.gov/29696756/