Family planning in challenging environments

JOAN SUMMERS: Marie Stopes is an organisation that works in 37 countries around the world, providing contraception and abortion services. Last year, we served 18 million women. The challenges when delivering family planning services are– there are challenges in every environment that you are delivering services. Sometimes we think about it in terms of being challenging environments in which we’re providing these services as Marie Stopes. But actually, even in Britain, women are required to get a prescription in order to get a birth control pill, whereas in other parts of the world, you’re able to get birth control pills across the counter. So even in Britain there are challenges in providing family planning services.

In addition, it’s an issue that is close to– we’re talking about sexuality. And so we’re talking about something which is a challenge for many people to talk about openly and to address. I think when we think about challenges, we need to think about both the supply side, in terms of the provision of services, but also the demand side. Because there are social, political, cultural issues that we need to address when we’re talking about family planning services or contraception. There are many political issues to be addressed when we’re talking about contraception and family planning services. There are also policy issues at almost every country level in terms of who can provide the services.

So, for example, intrauterine devices in many countries must be provided by a qualified doctor or a senior medical practitioner, when, in fact, the procedure is actually technically quite simple, and can be provided very safely by trained community health workers, or trained lower level medical staff. And that then means you have much greater access in very rural areas. So it’s often difficult to get a doctor out to the rural areas of Punjab in Pakistan, for example. There are many cultural barriers to provision of contraception or family planning services. We need to look at those both in terms of the supply side as well as in terms of the individual acceptance of family planning.

In many countries, for example, a woman’s role within the family– she’s not the decision maker. She’s not in a position to actually make the decision about what she is eligible to use. And so her whole family are involved in that decision. Often, her husband is making that decision. And culturally, there are issues around, what is the appropriate family size? When should a woman have her first child. So a lot of pressure for women in Asia, for example, to have the first child within the first year of marriage. Once we’re beyond that, then there’s more options in terms of what’s appropriate, and how a woman might plan her family.

In addition, there are issues around, what is a woman’s role within the community? And how much her role as a mother and as bearing children is part of her identity as a woman. There’s also issues around the role of religion, the role of culture in terms of, what is appropriate practise?

When do women have children, how many children do they have is often dictated by the society within which she lives. And therefore, her choices are much more limited in terms of what she’s able to decide, even if she personally might want to delay the first birth of her child in order to finish her education, or wants to be more engaged in economic issues within her family. I think there are also cultural barriers in terms of the providers. So the women who are providing– or the service providers share those same cultural positions. And so a young woman might come and ask for a family planning service or a conception service. And she’ll get, tuts and “Oh, oh, is that appropriate?

Should you really be doing that?” “What about your husband? What about your brother? What about your whatever?” So those things really do influence a woman’s choice in terms of making a decision about her contraception methods. There are many barriers in terms of ensuring a continuous supply of commodities to women, particularly in isolated or rural communities. Budgetary constraints, for example, become a big issue in the availability of contraception– allocation of health budgets to preventative care rather than to curative care. So contraception supplies are preventative and when you have to make choices about immediate life and death verses something that’s in the future, often that preventative piece gets a lower priority. Other issues around supply relate to the supply of the provider.

Having an adequate supply of adequate trained individuals who can provide an intrauterine device, or who can provide a implant as certain qualifications are necessary for that– or certain training to ensure that it’s safe are needed.

On the other side, on the other issues around supply are, who are the providers who are making those choices? And in many countries, the level of training is– or the ability to get the training out to lower level providers and having, as I said earlier, political choices around only certain people are able to provide. That puts real barriers and limits on ability of women to access contraception. Addressing the challenges of access to contraception need to be both on the demand side, as well as the supply side.

We need to make sure that women know what their options are, and what their choices are, and that they are aware enough about how their body works, what this will mean in terms of the specific– what might some of the side effects might be. So that once she begins to use a particular method and experiences something slightly different in her body that she knows to expect that. So it’s really important that we have very good counselling, and counselling that actually is focused on what does a woman need? What will be appropriate to her life and her lifestyle so that she’s able to engage with that choice.

It’s not good enough for us as providers to make that decision for a woman, and say, ah, well, I think this is the best method for you. This is what you should use. You should use an IUD. Or you should use a pill. You want to get pregnant in six months. You should use a pill.

We have for many years often been driven by what we thought was the expert advice, rather than really working with women around what is actually appropriate, and what’s going to work for them as an individual. I think then the other issues that we need to address are around the biases of our providers. Our providers live in the culture that the women are in as well, and often share the same myths and misconceptions about particular methods. The second thing I think that’s really important is that you need to address the kind of environment and cultural situation that you’re working in. So you need to work at the level of building partnerships with those who are gatekeepers.

In countries where religious leaders play an important role, like in Afghanistan, where the mullahs play a very important role in community affairs, MSI– Marie Stopes– has been working very closely to train mullahs to be the promoters of child spacing and healthy families, so that we engage with the communities that we’re working with. The same is true in Ireland, for example, where we’re working on policy issues, where we working with Catholic priests who are pro-choice. And they would be working with us to try and change the legislation to make abortion services more accessible to women in Ireland.

I think the last thing I would say is that to really have an effective contraception service, you need to work at the supply side, and ensure that women have access to the commodities that they need, that they have access to the kinds of counselling that will promote those services, they have access to education that will help them really understand what contraception means, and what the implications of that are for her. And we need to address the policy environment which then positions the delivery of those services to be able to be accessible to all. Once a woman has access, she depends it again. She really needs and wants that to continue.