Contraceptives: More awareness needed to increase uptake

Contraceptives have for long been surrounded by a myriad of myths and misconceptions that have to some extent influenced their uptake. Research has proven that women are most comfortable and likely to continue longer with contraceptives suggested by specialists, as long as they are well informed and can make their own choice. Many girls and women gather information from social circles backed up by the internet and seek confirmation and guidance from a health care provider

Contraceptives can be classified under two categories; non-hormonal and hormonal. Non-hormonal contraceptives include male and female condoms, cervical cap, or diaphragm, copper IUD (coil), natural birth control and sterilization. Sterilisation is tubal ligation in women and vasectomy in men. Among hormonal methods of birth control are pills, injections, contraceptive patches, implants and the hormonal IUD or coil.

The level of effectiveness, health, age, side effects, cost and lifestyle are some of the basic concerns looked into before deciding on a contraceptive. In line with the 2018 theme for World Contraceptive Day “It’s your life, it’s your responsibility” family planning is a personal affair.

 A major concern amongst the majority of women is weight gain for those considering a hormonal birth control.  Stories from friends may deter you from some methods. Truth is that there is no consistent effect of contraceptives on weight gain. Other factors such as genetic potential, variation in activity level, alteration in diet or change in metabolism are more likely to result in variations in weight.

There has been a lot of speculation about the effects of birth control methods on women’s libido. At present scientific evidence is conflicting as to whether contraceptives affect sex drive. Although the majority of women on hormonal contraceptives report no change in libido a very small proportion may report a reduction. However, other factors may have a greater role in this. For example, a woman’s satisfaction with the relationship, stress levels and hormonal fluctuations are critical gatekeepers to her sex drive.

Contraceptive methods are safe, provide good protection against pregnancy but nothing is perfect;   failure rates are very low and depend on the method used. For example, instances of women conceiving while on the contraceptive coil are very rare but have received most coverage. A reason can be a downward displacement, or even expulsion of the coil due to contractions of the uterus during menstruation.  As a preventive measure, women usually receive instruction on how to check for position of the coil. If there is any doubt if the coil is well positioned in the womb a visit to the clinician is required.

Another common myth is that women using coils are more prone to pelvic infections. Research evidence confirms that insertion of a coil does not increase the risk of acquiring pelvic infections. However, if a coil is inserted into a womb with ongoing, often asymptomatic infection, the infection will flare. This may lead to the mistaken assumption that the coil caused the infection.

 “Will this method make me infertile? or will it delay conception once I have stopped using it? are two common questions. No contraceptive method other than sterilization causes infertility. Contrary to this, ovulation and fertility resumes soon after contraceptive use. We advise couples to be patient and tailor their expectations appropriately. Even without prior contraceptive use a healthy couple may take a year or more to conceive. However, couples with or without history of contraceptive use are advised to have a check-up just to be sure all is well if they have not conceived after a year of regular unprotected intercourse.

Emergency contraceptive pills (e-pills) are among the most misunderstood and hence abused contraceptives in the Kenyan market. There are several emergency contraceptive pill choices. However the most commonly used e-pill contains the hormone Levonorgestrel. It is 98 per cent effective in preventing pregnancy if taken at the earliest but within 72 hours of sexual activity. The e-pill is more likely to fail if taken after 72 hours of sex, in obese women or if taken repeatedly over short durations. Unknown to majority of people the copper coil is an alternative emergency contraceptive that is more than 99 per cent effective and works if fitted up to five days after unprotected intercourse. Whether inserted as an emergency contraceptive or at a regular visit the copper coil continues to offer long-term reversible contraception.

Here is a run through the commonest birth control options. Natural birth control methods is a group of methods that work primarily based on understanding the female reproductive cycle and the fertile window. They offer a choice for couples not willing or able to use other contraceptive options. Because these methods require a very predictable, regular cycle, partner co-operation and a lot of consistency, their typical failure rate fluctuates significantly and can be quite high. Condoms have the advantage of being widely available, especially for the male condom, as well as being able to help prevent both pregnancy and sexually transmitted infections (STIs).

However they fail on average about a fifth of the time mostly due to inconsistent or incorrect use. Implants are small flexible plastic rods about the size of a matchstick embedded with hormones that are implanted under the arm skin. They can last 3 or 5 years. They are amongst the most effective contraceptive methods preventing pregnancy more than 99.9 per cent of times.

The commonest contraceptive injection is the three monthly ‘depo’ injection. It is related to the implants in hormone content but is slightly less effective. The contraceptive patch is a good substitute for those who may wish to take contraceptive pills but are unable to sustain daily taking. The woman sticks the small adhesive patch on her skin and changes it every seven days. If fixed on dry skin it will withstand taking a bath and even swimming.

Male and female sterilization are permanent birth control options for couples who do not wish to have more children. They entail a small cut to block the fallopian tubes in women or semen passages in men. Both can be performed in an outpatient clinic. Sterilization if fraught with many misconceptions. The commonest are that tubal ligation diminishes a woman’s libido, causes excessive lubrication during sex or causes menopause. For vasectomy, men express fear that it will diminish their ‘maleness’ and libido. None of these is true.

There are many couples who although not on any form of contraception, do not wish to conceive now. This high unmet need for family planning is due to many factors including lack of knowledge, fear of side effects and partner or religious opposition. These barriers affect adolescents worse than any other age bracket. Additionally, frequent stock-outs of some or all methods and lack of subsidisation for some methods e.g. hormonal coils, reduces alternatives available to couples especially in the lowest income brackets. There is need for policy and implementation dialogues to address these gaps to increase uptake of contraceptives.

Dr Mukaindo A. Mwaniki is a Consultant Obstetrician Gynaecologist at Aga Khan University Hospital in Nairobi