Strategies for family planning going forward - Social marketing & expanding contraceptive choices package

Research suggests that a choice among several contraceptive methods, rather than between two methods, is more likely to result in the use of a contraceptive method. To increase the use of birth-spacing measures it is necessary that women, men and couples are given comprehensive information about all contraceptive options and that there is support for personal decision making regarding family planning1. Studies have also shown that countries in which all couples have easy access to a wide range of contraceptive methods have a more balanced methods mix and higher levels of overall contraceptive usage than countries with limited access to various contraceptives2. Further, it has been estimated that the addition of one method to options available in a country would be associated with an increase of 12 per cent in contraceptive usage. A balanced method mix is also an indicator that there is no “systematic limitation of contraceptive choice”2.

Use of contraceptive methods and method mix are influenced by a number of factors. These factors are (i) policies and programmes: government promotion of certain methods at the expense of others, regulatory barriers, capacity and motivation to provide range of methods, (ii) provider bias: provider preference for specific methods, (iii) history: length of time since introduction of each method in a country, (iv) property of methods: ease of distribution, high programme cost, side-effects, effectiveness, and (v) client characteristics: knowledge of alternative methods, desire for limiting vs. spacing, religious beliefs, personal preferences, age and life stage3.

There are six components to quality family planning care: (1). choice of contraceptive methods, (2). information given to the users, (3). provider competence, (4). client/provider relations, (5). re-contact and follow-up mechanisms, and (6). an appropriate constellation of services4.

The main strategies for family planning going forward should be to (a) expand the basket of contraceptives: (i) give choice to couples of contraceptive methods, (ii) information should be given to the users, (iii) provider competence, and (iv) client/provider relations; (b) expand the access, both financial and physical acceptance of contraceptive: (i) cost-effective contraceptive, (ii) more sales outlets for easy accessibility, (iii) re-contact and follow up mechanisms, (iv) an appropriate constellation of services with proper information education and communication (IEC) and interpersonal communication programs (IPC) programmes, and (v) encouraging new acceptors, retaining current users and increasing contraceptive use should increase couple years of protection and contraceptive prevalence; and (c) increase knowledge and awareness of providers and acceptors: (i) effective IEC and IPC programmes, (ii) giving out methods for free access or at a reduced price, or giving incentives could encourage more people to become new acceptors, (iii) getting men involved, it would be important to emphasize the “healthy family” aspect of family planning, and that spacing between children is good for the whole family, economically speaking and also in terms of health, and (iv) training providers in counselling and technical procedures should increase the level of knowledge around family planning. This knowledge, in turn, should translate into increased contraceptive use.

The contraceptive needs of sexually active young people remain largely unmet. Young people, married as well as unmarried, need accurate, user-friendly information and services, and multiple entry points (education, work, sports or other social activities) and settings (home, community, workplace, school or clinic) must be used to enhance access to information and services. It has been found that a raise in education level besides providing knowledge and the contraceptive methods helps in improving acceptance of family control devices5. IEC (information, education and communication) efforts to enable clients to exercise informed contraceptive choice should be increased, but inadequate collaboration between the health sector, IEC units and other stakeholders is reportedly rendering these efforts ineffective. Hence, inter-sectoral coordination needs to be vigorously promoted5.

Increasing contraceptive use is one way to encourage reduction of maternal mortality and improve both maternal and child health. It also gives women more decision-making power, empowers women, and this could have positive effects in sexually transmitted infections (STI) and HIV/AIDS prevention5. Family planning programmes, however, are in place to ensure that those who want family planning services can get it. But still, encouraging the new users remains a challenge.

There are existing options like progesterone only pills and injectables which need to be made available and promoted. In addition, there are five promising new innovations, which should be brought into India.

1. Sino-implant- II a much lower cost implant

Contraceptive implants are flexible, hormone-releasing rods made of medical-grade silicon. These matchstick sized rods are placed under the skin of a woman's upper arm, inserted and later removed in a quick, minor surgical procedure by a trained provider. Depending on the product, implants provide protection against pregnancy for three to five years. Implant rods contain a hormone that acts primarily by thickening cervical mucus and suppressing ovulation. Because implants do not contain estrogen, the method is safe for breastfeeding women (when inserted six weeks postpartum), and can be used by women with cardiovascular risk factors such as high blood pressure, as well as for those who smoke cigarettes. For women who desire to become pregnant, an implant has the advantage of an immediate reversal of the contraceptive effect upon removal6.

2. Progesterone only contraceptive - for improved access and greater user control

Injectables provide one to three months of contraceptive protection by suppressing ovulation. Injectables are highly effective; if women return within the required timeframe for an injection, less than three in 1,000 will become pregnant. In actual use, the failure rate of injectables is about three per 100 users, less than half that of the oral pill7.

Depot medroxy progesterone acetate (DMPA) is inexpensive and can be used by breastfeeding women as early as six weeks postpartum8. It has been reformulated to be administered subcutaneously, using a much shorter needle than is required for intramuscular injection. This makes it easier for trained pharmacists and community-based health care workers to provide the injections.

An additional innovation now being assessed is to provide Depo-SQ in a prefilled uni inject single-use syringe8. This mode of delivery will allow community-based access to be scaled up, and open up greater possibilities for at-home and even self- administration8.

3. NES-EE (nestorone-ethinylestradial) - a long acting vaginal ring

The NES-EE One-Year Contraceptive is a silicone ring with a circumference of approximately 2 inches (5 centimeters) which is inserted by the woman into her vagina. Because the exact placement of the ring is not critical, the ring does not require fitting by a provider. The ring continuously releases a low-dose combination of a new progestin (nestorone) and an estrogen that act to suppress ovulation. After three weeks, the user removes the ring to allow a week for bleeding, and then reinserts it. A single NES-EE ring can be reinserted monthly for one year9. The vaginal ring is not appropriate for breastfeeding women or women over age 35 who smoke. Women found it easy to use and were not concerned about reusing a single ring for a year. The NES-EE ring has also been shown to have potential as an emergency contraceptive when inserted shortly after unprotected intercourse. The NES-EE 12-month ring does not require refrigeration before use and may be attractive to women with limited access to health facilities10.

4. The Silicon Barrier Contraceptive- One size fits most

The diaphragm, a cervical barrier made of latex or silicone that prevents pregnancy by blocking sperm from entering the uterus, is the oldest manufactured contraceptive for women. The diaphragm is used only during intercourse, has no method-related side effects, and can be used by some women without the knowledge of a male partner. It can be put in place several hours in advance so that insertion does not interrupt sex, and should be left in place for six to eight hours afterward. The diaphragm is suitable for women who are breastfeeding. A diaphragm is relatively inexpensive to produce and the cost can be distributed over several years of use. However, currently available diaphragms come in multiple sizes and the required fitting by a provider adds considerably to the expense11.

5. Standard days method (SDM) with cell phone alerts

The SDM has been integrated into family planning programmes in more than 25 countries. Most SDM users rely on Cycle Beads, a colour coded string of beads to help them keep track of where they are in their cycle and which days they are potentially fertile. Each day of the cycle, a rubber ring is moved from one bead to the next. When the ring is on a white bead, the woman knows she is in her fertile period and must avoid unprotected intercourse. The SDM requires the cooperation of the male partner. Some couples choose to abstain on fertile days while others rely on condoms. Because the method does not require resupply and the only cost is a one-time expense for Cycle Beads12.

The SDM can help reduce unmet need and improve contraceptive security. In addition to its low cost and lack of side effects, the SDM is popular because of its convenience and the ease with which it can be incorporated into multi-method programmes. Many women who use the SDM subsequently switch to another modern method, demonstrating that the SDM can bring new users to family planning13.

A diverse contraceptive method mix increases the likelihood that individuals will find an appropriate product to meet their unique needs and circumstances. A compelling need continues for new contraceptives, particularly non-surgical methods for male and female sterilization, and there is little doubt that existing methods (excluding female sterilization) are underutilized.

User-controlled, community-based, and over-the-counter availability of next-generation contraceptives offers many advantages for women. With methods that do not require screening and follow up by a health care provider, women will be more dependent on pharmacies and community-based programmes to meet their information needs, such as whether these methods provide protection against STIs and HIV.

Much work remains to address factors contributing to this underutilization, including restrictive policies, tariffs, and provider biases. But soon, programmes can also take advantage of the innovations in contraceptive technology to diversify their programmes, attract new users, ease logistical constraints, and reduce cost. By doing so India can reap more of the benefits that family planning offers as a “best buy” for economic and social development.