Melinda Gates’ strong statement, and direct challenge to the Pope, has added much-needed logic and compassion to the public debate on worldwide access to contraception.
Discussion of contraception and its key role in maintaining the sustainability of our planet, both physically and socially, has been largely overridden by views of minorities and political correctness. This is in spite of World Health Organization figures suggesting that by 2020, 1.2 billion people, or 16 per cent of the world’s population, will be entering their childbearing years, with 90 per cent of these being in the developing world.
As Melinda Gates has enunciated so strongly, contraception is the key to so much, even beyond saving the lives of women and children.
Contraception is the key to liberation of women. Being emancipated from the likelihood of pregnancy is essential to ensuring women can access educational and employment opportunities. Indeed, the surge in the contribution of women to Western societies during the past 50 years has been largely attributable to the availability and uptake of the contraceptive pill. Women’s freedom from continuous pregnancy contributes strongly to the education of their children through increased family income. Furthermore, fewer pregnancies mean fewer unsafe abortions, and a healthier mother who is more likely to survive to see her children reach adulthood. Thanks to the recent global vaccination programs supported by the Gates Foundation, children now have increased chances of survival and so the need to have large numbers is reduced.
Ready access to contraception will also increase the overall health of communities living close to the poverty line. There is now strong evidence that undernourishment of the mother, before conception and throughout pregnancy, has a significant impact on the long-term health of the child. Near-starvation during pregnancy increases prematurity and low infant birth weight; those infants will grow to be adults with increased predisposition to serious disorders including diabetes, hypertension and obesity.
Apart from degrading the health of women and children, population growth damages the environment, with human beings now competing with most other species for space and resources. While population size is now either stable or reducing (excluding growth by migration) in most developed countries, in many places, land degradation is reducing the capacity to grow food. The availability of clean water also remains a major issue.
So what can be done to improve accessibility to and acceptance of contraception?
Women need to be given the opportunity to take responsibility for their own fertility. It is clear that there is a considerable gap between fertility desires and contraceptive practices. Increased contraceptive options and ready access to these are important issues.
There have been recent (well-publicised) cases in Africa, in which women have returned to a health clinic for their three-monthly contraceptive injections, only to find that there are no more available. We need to ensure distribution of sufficient quantities of acceptable contraceptives to even the most remote inhabited places on the planet. Alongside this, provision of community information is essential to educate communities, both men and women, on the broad benefits of contraception.
The pharmaceutical companies who produce and supply modern contraceptives need to be persuaded to provide sufficient quantities of their products at low cost to developing countries. Distribution is also an issue, and is particularly difficult in places with unstable or corrupt governments. One suggestion would be that aid agencies distribute donated or low-cost contraceptives in clinics set up alongside food distribution points in areas of famine and in refugee camps. Local people need to be trained in delivering this service.
Appropriate contraception for individual needs is also an issue. A high level of efficacy is critical. The pill, which is the most widely used method of contraception in Australia and many other developed countries, is probably not appropriate in many less developed places, since a tablet must be taken every day and cost is an impediment. Access to clean drinking water (with which to take a tablet) is a problem, also, as is the fact that the pill is not appropriate for individuals with intestinal disorders such as diarrhoea.
Interestingly, the most widely used method in China is the intrauterine device, which is effective until its removal. Long-acting progestin-only contraceptives (which include 3 monthly injections or implants which are effective for up to 5 years and can be easily removed when pregnancy is desired), have the advantage that once in place, they are highly efficacious. However, side-effects – mainly minor bleeding issues – mean that approximately 30 per cent of women discontinue use.
Among existing challenges is also an urgent need for the development of new contraceptive options that women can control. Funding for research remains a problem, as pharmaceutical companies do not prioritise contraception, partly because the profit is not likely to justify the cost, particularly if there is pressure to provide the product at low cost in many places.
National funding organisations (including NHMRC in Australia) also do not prioritise reproductive health, women’s health or contraceptive development. During the 1990s and early 2000s some research was supported through special initiatives by the World Health Organization, the Rockefeller Foundation and the not-for-profit US organisation CONRAD/CICCR, but these initiatives have now all but ceased due to lack of governmental sponsorship.
Identification of contraception as a major global issue by the Gates Foundation is welcome, and it is to be hoped that a new cohort of non-steroidal contraceptives will be developed that, together with existing methods, meet the needs of all. In particular, contraceptive options that include protection from sexually-transmitted diseases are a high priority.
Contraception is the key to so much and remains central to the rights of women. In the words of Melinda Gates “There are 200 million women who want to have access to contraception, and if we’re not serving them, that’s not right”.
Professor Lois Salamonsen, a NHMRC Senior Principal Research Fellow and Associate Professor Guiying Nie, a NHMRC Senior Research Fellow, conduct their research at Prince Henry’s Institute of Medical Research and have adjunct appointments at Monash University.