Choice: Know Your Options - A Conversation with Dr. Fabio Castaño (Part Two: World Contraception Day)
Choice: Know Your Options - A Conversation with Dr. Fabio Castaño (Part Two: World Contraception Day)
Today, September 26, is World Contraception Day. The Family Planning 2020 (FP 2020) Initiative says the vision for the day "is a world where every pregnancy is wanted. Its mission is to improve the awareness of contraception to enable young people to make informed decisions on their sexual and reproductive health." We share part two of our interview with Dr. Fabio Castaño, MSH’s global technical lead of family planning (FP) and reproductive health, in celebration of World Contraception Day. Join the conversation on social media with hashtag #WCD2014.
What do you see on the horizon for FP?
Interesting things are happening on the horizon in family planning–like introduction of new technologies, contraceptives, and systems to increase the methods mix–because, as I said before–this is about choice. People have the right to be offered methods that accommodate their specific needs.
What's the priority for the future?
In the next two to five years, the priority will be to reach the goal of FP2020—to provide access to 120 million more women—which is feasible yet challenging. The international community knows what [the problem] is—we just need to pull everyone in the same direction and get countries to lead. We know where these women are—for instance 46 million are living in India.
We need to help countries and governments with their commitments—making sure they have the commodities and the policies in place, so more women can be reached.
We need to be able to help those additional 120 million women and beyond—more than 220 million have unmet need—to get access to modern contraceptives that make sense for them. To do this governments need to understand their role promoting healthy markets and functional systems; the private & public sector need to work together; universal health coverage would be ideal; and more safe, quality and affordable methods should be ready.
How is MSH leading and supporting these efforts?
MSH is leading and contributing to the future of FP in many different ways. Because MSH supports and strengthens health systems platforms, we can help scale-up evidence-based and promising approaches and technologies. For example, our EVIDENCE project –a partnership funded by USAID [US Agency for International Development] and led by Population Council, with PATH, IPPF [International Planned Parenthood Federation], PRB [Population Reference Bureau] and others–will generate, synthetize, and share evidence to accelerate implementation and scale up of high impact practices and approaches.
Donors such as USAID, DFID [Department for International Development], UNFPA [United Nations Population Fund], and Gates help MSH and other partners play a crucial role in helping countries use evidence to strengthen health systems that make FP services available to everyone. For instance, research has shown that community health workers [CHWs] providing injectables is feasible, safe, and cost-effective. Sister organizations performed the research, and we supported the scale-up of the implementation in countries such as Guinea, Uganda, and Rwanda.
And we have worked with other partners to implement task-sharing & task-shifting that support expansion of injectables as a family planning option. This is where the need for country-level appropriate and conducive policies comes in. In many countries CHWs are not allowed to provide injectables—and policies need to be updated. When CHWs are trained to provide injectables safely to women, more women will have that as an option at the community level. In FP, it is clear that providers can share or shift tasks; and these programs are helping to bring FP closer to the community.
The same thing happens with long-term methods, like implants, which can be provided by mid-level health workers. And even non-reversible methods like female and male sterilization can be safely provided by trained non-physicians. That’s a game-changer that requires the commitment of the government to change some policies and the commitment of the professional organizations.
What role will new technologies provide in the future?
Right now, new contraceptives are being introduced in several countries. The sub-cutaneous injection aimed at improving contraceptive continuation and reducing service delivery costs is suited to home and self-injection. Intravaginal devices, such as contraceptive vaginal rings—small plastic rings that release hormones—and diaphragms, provide women with new ways to self-manage their own sexuality and reproduction goals. A one-year vaginal ring may be available soon and could be the first long-acting, reversible contraceptive that a woman can control herself. More sophisticated devices, such as remote-controlled “micro-chips” that sit just under your skin, may be part of the options in some years.
Hormonal male contraceptives—the “male pill”—, gels and injections are under research and could hit the market within a decade. Our children and grandchildren—hopefully for my generation, too—will experience a variety of new condoms—and not just different colors or flavors—that people finally will love to use, because they will feel like wearing nothing and be pleasure enhancers—research on graphene condoms in underway.
Maybe in the future, twenty years from now, we will have many other options. For sure in the future, women will have more control over the contraceptives requiring minimal intervention from providers—and less control from husbands. As you know, one of the cultural barriers, social barriers, is husbands, or male partners, controlling the decisions about FP and reproductive health. So, when women have more access to methods that they can control, we will see an important change in the sexual dynamic with husbands. I think that’s going to be important for the future.
So future family planning options could mean more control over sexuality and reproductive health?
Yes, we will see improvements, I expect, also, in making sure that women know more about how to manage the side-effects of some contraceptives using mHealth technology. Side effects are one of the causes for discontinuation of FP. And we as a global community haven’t done a great job improving this aspect of contraceptive use. So, the discontinuation of FP is one of the key barriers to efficacy. Most of the time, this is due to lack of understanding of how to manage the side effects. That may be because of a lack of counseling from the providers, but it’s also about how to make sure that people get the right information, at the right time, so they can decide for themselves.
So now–and in the near future—through communication devices, social media, and internet—people, especially young people, can reach out to others who are using a given method, or reach specialized sites or groups, that can provide the right information at the right time. It’s likely that will change the whole equation and so people will have the chance to really control better. It’s leading toward more self-care. And the expertise of organizations such as MSH would be instrumental to help people do it right.
The public health community recently celebrated “Global Female Condom Day.” Female condoms are promoted as a method that give women more control. How do female condoms fit with MSH’s philosophy?
The female condom is one of the three commodities included in the UN’s life-saving commodities list—along with emergency contraceptives and implants— so that tells how important it is. These are methods not only demonstrated to be very effective, but also methods that protect against HIV and other sexually-transmitted infections.
And the female condom has additional benefits: it gives women the power of deciding, controlling their own sexuality and contraceptive needs. That’s why it’s a very important method that goes along with the right to choose.
Because MSH works on the management of medicines and commodities in general, we promote, along with other methods, female condoms. But, traditionally, there have been some cultural barriers around using or promoting female condoms, because the method had been used in certain contexts, in programs for HIV, basically with specific at-risk groups, like commercial sex workers. So, it had that kind of connotation in the past.
Also, in some cultures, because women do not have the right and command of their own sexuality, using condoms is stigmatized. So of course there is still a lot to do. There is a huge potential in using and promoting them—again, as an additional method from which people can choose.
IUDs is another method that has been stigmatized. IUDs had been a wonderful method, one of the most effective methods. There is a lot to do in that regard, as well: understanding the cultural barriers and working with the providers themselves and the policymakers. The same could be true for new technologies that may come out later.
There’s always a need to work at different levels, hand in hand with people who manage and who understand more the social aspects of expanding family planning; and also the ones that manage the procurement, the logistics, making sure that they reach the right people.
Fortunately enough, MSH has experience in all those areas, because our approach is comprehensive and we can bring everyone together.
How do we support this innovation in technology?
In terms of development and introduction of new technologies, MSH partners with others to bring new technologies to new markets, to new countries, and to more users ensuring access and choice. For instance, recent initiatives to halve the cost of implants such as the Jadelle Access Program have resulted in more women having access to MSH-supported services in Uganda.
Improving old methods and inventing new ones is part of the equation to achieve choice. Women need contraceptives that are effective and also have fewer side effects and are easier to use. Choice is also related to de-medicalization, meaning including more contraceptive options that women can use and manage themselves with no or little assistance from providers. And of course, choice also involves making sure that supply chains are managed well enough so all options are always available at the right time, and the right places where people need them. In this MSH has years of experience helping countries.
Women and couples throughout the lifecycle may have needs for different contraceptives. The idea is that, at any given point in their lives, people can access the contraceptive that is best for them at that time. A younger person who has sex occasionally or infrequently, for instance, may require an on-demand pill that can be taken right before or after sex–which is being tested now. Those who are at risk of getting pregnant from unprotected sex—they may need to have the option of using emergency contraception. Couples in monogamous relationships may want to space or limit pregnancies and have options that support their decision. People may experience side effects with one contraceptive and not with another. Serodiscordant (one living with HIV, and one without) and HIV-positive couples may require double protection.
People need multiple options—and people’s contraceptive needs may change over time.
Why is family planning crucial for global health and development? How does FP support the overall health of women, communities, countries?
FP helps improves women’s health in general and empowers women. If you think about all the challenges women face in developing countries, and even in developed countries, related to not having the chance to decide about their own lives—the possibility of having more time to develop themselves as human beings—that’s really the other side of this story.
The story that we should also celebrate is World Contraception Day! Know your options and share what you know.
- Five Promising Innovations in Contraceptives (USAID Impact Blog)
- Your-Life.com (Part of the WCD campaign, Your-Life.com is intended to provide information about contraception and sexual health to an international audience outside of the USA and UK. It also contains resources for teachers, parents and healthcare providers.)
- Family planning resources from MSH