Options and choice

Even as the Reproductive Health Law remains stuck in the labyrinth of the Supreme Court, falling in line behind a string of other lawsuits, with the issue of its “constitutionality” still hanging in the air, elsewhere reproductive health technology marches on.

There is no denying the urgent need for reproductive health services and commodities. On the occasion of World Contraception Day last Sept. 26, the International Partnership for Microbicides declared that “a woman’s health and livelihood are threatened when modern family planning methods are out of her reach.” Authors Judy Manning and Zeda Rosenberg issued the reminder that “unintended pregnancy is a major contributor to maternal and infant death and disability around the world, and a recognized obstacle to global development.”

Consider this statistic: “Forty percent of pregnancies worldwide are unintended,” with 222 million women facing an “unmet need for modern contraceptive methods.” “Unmet need” measures the number of women and their partners who say they no longer want to have children, or want to postpone or delay the next pregnancy, but for one reason or another are unable to act on their desires. Access to modern contraceptive methods, say Manning and Rosenberg, “would enable women to plan and space their pregnancies, leading to improved health, educational and economic outcomes for themselves and their families.”

Financial constraints are not all that stand between a woman’s reproductive goals and outcomes she may not have wanted or planned. The Guttmacher Institute has said fully 70 percent of unmet need “stems from method-related concerns.” These include “concerns about the safety and potential side effects of hormonal methods; appropriate options for women who have infrequent sex, or who are postpartum or breastfeeding; and opposition from their partners to specific approaches.” Where a woman lives (how long and how much will it take her to visit a health center?) and access to health services (can she afford even the nominal fees for a consultation and for commodities?) are also barriers to modern contraception, say the writers.

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BUT there is good news on the horizon, apart from new money that has been programmed for reproductive health services by international donors and international agencies.

One such piece of good news is in the form of new sexual and reproductive health innovations that, say Manning and Rosenberg, “have the potential to revolutionize women’s options by diversifying delivery forms, varying product duration, and targeting multiple health risks simultaneously.”

There is no “magic bullet,” no one-size-fits-all solution to problems. But, the writers say, “when it comes to sexual and reproductive health, women face obstacles that are unique to their circumstances, but if women have a range of affordable and appropriate products to pick from, they may use them more consistently, which in turn will allow them to better protect their health.”

One such “cutting-edge technology” now in development is a biodegradable contraceptive implant that does not require removal. Funded by USAID, the product, say Manning and Rosenberg, “could fill a critical gap in low resource settings where women may not have access to trained health workers.” (One problem with present-day implants is that the health system has to keep track of all the women who use the implants and monitor them so that they come back to health centers to have the implants removed when these lose their contraceptive effectiveness.)

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EVEN more exciting are multipurpose prevention technologies (or MPTs) that “can help address women’s overlapping health needs in a single product.” The authors cite women in areas with high rates of HIV who often have the greatest unmet need for family planning, “creating a double burden of risk.” (If a woman cannot even negotiate with her partner for the use of a condom for HIV protection, then it stands to reason that she cannot negotiate either for contraceptive use, much less abstinence!)

The International Partnership for Microbicides, with support from USAID and other funders, is developing, for instance, a 60-day MPT “ring” (inserted into the vagina) that offers dual protection against HIV and unintended pregnancy. The ring is being designed to provide sustained release of an antiretroviral drug called dapivirine along with the contraceptive hormone levonorgestrel.

In many parts of the world, sexually transmitted infections (STIs) such as herpes simplex virus, human papillomavirus and bacterial vaginosis are of greater public health concern than HIV. For such settings, an MPT is being developed that “combines the new one-size-fits-most SILCS diaphragm with tenofovir gel—the first antiretroviral drug shown to help prevent both HIV and herpes (still undergoing trial).”

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MPTs are among the most promising developments in reproductive health because they can result in significant health gains for women “by broadly addressing their sexual and reproductive health needs, and reducing the rates of maternal and newborn death associated with both unintended pregnancy as well as STIs.” The authors say MPTs may also provide another benefit: Combining two or more products into one may make protection more appealing and acceptable to women, and therefore increase their use.

Still, the authors warn: “No single product will address every woman’s sexual and reproductive health needs, so it will take a portfolio of methods to ensure that women have options to choose from that are appropriate for their individual circumstances.” Two key words: “options” and “choice”.