There are a variety of tools available today to prevent pregnancy including pills, intrauterine devices (IUDs), subdermal (under the skin) implants, injections, condoms, male and female sterilisation, and emergency contraception.
Statistics suggest that people in South Africa do, in principle at least, have access to and are aware of these contraceptive methods, albeit not at the desired levels.
Dr Kim Jonas is a specialist scientist in Public Health at the South African Medical Research Council whose research focuses on women and girls aged 15 to 24. In a 2020/2021 survey, Jonas and colleagues found that of 515 young women and girls that had been sexually active in the previous year, most were highly motivated to use contraception and 80% reported having easy access to contraceptives.
However, the research found that only 58% reported actually having used contraceptives in the half-year before the study. Worryingly, only 28% were using these methods effectively, meaning all or almost all the time.
The Health System Trust’s District Health Barometer (DHB) of 2019/2020, showed that South Africa’s couple year protection rate (CYPR) - a World Health Organization metric for contraceptive coverage - has dropped in recent years. The CYPR in 2019/2020 was 54%, which is 20% below the national target for that year.
The DHB also showed a significant fluctuation in CYPR between provinces, with the Free State and Western Cape being significantly above the national average, and Gauteng and Mpumalanga scoring the lowest. The lowest ranking district or metro was Johannesburg, with Tshwane and the City of Ekurhuleni also in the bottom five.
Easier in private sector?
Having private medical insurance may make access to contraceptives easier but does not guarantee that costs will be covered. Dr Noluthando Nematswerani, the head of the Centre for Clinical Excellence at the medical scheme Discovery Health, says “family planning is not a Prescribed Minimum Benefit therefore, medical schemes apply discretion on how contraceptives are covered”.
This means that while the scheme does cover a variety of contraceptives, this comes from available day-to-day benefits and is not a ring-fenced benefit. The costs are fully covered by members if their accounts are depleted or their options are not sufficient.
Discovery notes a cumulative decrease of about 29% from 2019 till now in the number of contraceptive claims. The dip is particularly acute in the last two years - which Nematswerani puts down to a reduction in the usage of healthcare services during the Covid-19 pandemic.
“Patients have feared potential exposure to Covid-19 infections while visiting health care facilities. We think this could be the reason why we have seen this reduction during this time,” says Nematswerani.
Jonas suggests this decrease is echoed more broadly in the healthcare system, including the public sector. “Trends remain pretty much the same over the past years but Covid-19 may have exacerbated the matter,” she says. “Over a third (34%) reported Covid-19 pandemic or the lockdown as the reason they were unable to access contraceptives.”
Choice of method
Melanie Pleaner, senior technical specialist in the Implementation Science Department at the Wits Reproductive Health and HIV Institute, says that the National Contraception Clinical Guidelines (2020) emphasise the importance of giving people a choice of contraceptive methods.
“We have very progressive, enabling policies and guidelines, which speak to contraceptive choice and the need for an expanded method mix because research does show that the more choice you have, the more likely women are to use methods and to continue on methods as well,” she says.
Chief Director for women and maternal health at the National Department of Health, Dr Manala Makua, says that each facility must offer at least five contraceptives, depending on choice and medical eligibility. This Western Cape government page sets out the options that should be available in the public sector and explains the pros and cons.
Jonas says that the most known and used methods in their survey were injectable contraceptives and male condoms, with only a third of people being aware of or using the pill.
The latest DHB showed female and male condom use has dropped, with use of IUDs and subdermal implants increasing. Overall, according to previous surveys, two- or three-month injectables were the most popular, with male condoms and the pill following. Female sterilisation, implants, and the IUD lag behind, respectively. (Spotlight previously reported on the very low uptake of vasectomy in South Africa.)
Marie Stopes Centres across the country provide around 5 000 women with contraceptives every quarter. Clinical Governance and Quality Director, Dr Louise Gilbert, says that one in five women choose long-term reversible methods, with the rest seeking shorter-term options like pills, injections, or patches. She explains that this popularity is a longer-term trend.
In the private sector, the mix looks strongly skewed towards hormonal oral contraceptives. Around 70% of contraceptives claimed through the Discovery Health Scheme in the last three years were contraceptive pills, such as Yaz and Qlaira. IUDs were the lowest claimed category. In total, around R400 million worth of claims were paid out.
The private sector in South Africa also offers options such as contraceptive patches, hormonal IUDs like the Mirena, and vaginal rings - not all of which are available in the public sector. Pleaner says there are intentions to expand options in the public sector into the future, including some of these methods and the self-injectable.
A personal choice
Which type of contraception is best is somewhat relative, depending not only on accessibility and costs, but on lifestyle choices, family planning needs, and individual physical reactions.
“Long-term reversible contraceptives are really great for contraception as they last for many years,” Gilbert explains, saying this does not require consistent medication adherence or regular clinic visits. However, barrier methods like male and female condoms provide protection against sexually transmitted infections as well as pregnancy. “We, therefore, recommend that couples practice dual-contraception (the use of a contraceptive method together with a barrier method).”
Pleaner explains the main factors around choosing contraception are efficacy and continuation. For instance, “both the IUD and the implant are very effective and have high continuation rates, and they require [fewer] visits to the clinic”
But, while there was a push towards IUD usage and information, the usage has stayed low. Overall, it appears that shorter-term methods remain more popular, even while longer-term options are becoming more accessible.
From a national perspective, Makua is positive overall. “We don't really have issues except that people have been not accessing the contraceptives because of the issues with the lockdown, but we don't really have issues with contraceptives anymore.”
Barriers to access
Limitations to how people access contraceptives are many-faceted. As with other medications in the healthcare system, stockouts have been a challenge.
According to the Stop Stock Outs Project website, around 170 stockouts of contraception and hormonal therapy medicine have been reported this year, with the vast majority in the North West province. The organisation has repeatedly reported on persistent problems in this field in several provinces, calling on the government to review and improve supply chain management and put better systems in place to manage stockouts.
Makua acknowledges that stockouts have previously been a problem, but says that commodities are currently available everywhere.
Different contraceptive options being on the clinic shelves does not necessarily mean they are accessible to healthcare users. This is because healthcare workers at the specific facility may not have received sufficient training, for example, on inserting and removing IUDs or implants.
Pleaner says there are many misconceptions by staff around some of these methods. “For me, those are some of the issues which create barriers to contraceptive use, which means that staff [members] go back to a default position of the tried and tested method which is the injectable.”
Jonas says that side effects or fear of unpleasant side effects were keeping women from accessing contraceptives, with a portion believing that the contraceptive pill would make their body change in unpleasant ways, and the majority believing this about the injectable. Similarly, there were fears about the implant causing irregular bleeding while inserted, and infertility once removed.
In addition, she says access may be limited by “long queues at health facilities, young women feeling embarrassed to be seen at the clinic for contraceptives, lack of parental approval and support, [and] lack of boyfriend or partner’s approval and support”. “About 14% of young women who ever used contraceptives reported they did not receive the contraceptive method of their choice,” says Jonas.
Marie Stopes encounters nervousness about IUDs in terms of pain or the device being noticeable as well as their effects on periods, says Gilbert. She dispels these worries but urges women to inform themselves about side effects.
Makua says that challenges with contraceptive uptake mainly relate to over-presentation of contraceptive side effects. This relates to societal impressions of teenage pregnancy and how poverty levels create a “dependency on male counterparts to make decisions about reproductive health needs”.
She says that preferences are often more based on the patient’s knowledge and not counselling services, or based purely on what is available. She says that lack of information is still a significant concern despite existing government efforts.
“We've realised that there's a lot of peer pressure when it comes to the choice of methods to an extent that in case the method that they choose is not eligible for them, they prefer not to use an alternative method. And that's where it looks as if the access is limited,” she says.
Makua says that government interventions are focused on a “multi-sectoral approach to reduction in unplanned pregnancies, issues of gender-based violence, economical dependency, and educational levels of women”. In terms of awareness programs, Makua explains that peer educator programs have focused on “the benefits of avoiding unplanned pregnancy and dangers of high-risk pregnancies such as teenage pregnancies”.
Jonas recommends that school-based interventions focused on contraceptives and adolescents’ sexual and reproductive health and rights could be helpful, including in preventing sexual violence. “Health systems interventions to address the socio-cultural beliefs, existing myths and misinformation about contraceptives that undermine access and use of contraceptives among adolescent girls and young women are needed.”
This could include community mobilisation and education campaigns, including the involvement of guardians and men.
She says free contraception should be more accessible beyond healthcare facilities, in safe community spaces, including schools, and retail pharmacies.
“Health workers should provide comprehensive contraception counselling and information services that are person-centred, and they need to work with adolescent girls and young women to discuss their concerns about side effects and help them find the contraceptive method of choice.”
Jonas also says that research shows that incentives, including financial ones, can promote adherence to medication, and this could be considered to up the consistency of contraceptive use.
Gilbert calls for interventions around healthcare worker training. “We require more healthcare workers to be trained in the use and insertion of long-term reversible contraceptive methods and we also require contraceptive counselling to be of better quality.”
Pleaner says that the Department of Health “certainly is on the right track”, for instance, through a new online staff training course in contraceptive methods. She cautions, however, that this must be matched with clinical oversight and resources.
“There actually needs to be a basket of services,” says Pleaner, “but we're still seeing quite a lot of vertical provision at health facilities.” She recommends more integration of contraceptive care into the provision of related healthcare services, such as HIV, abortion, sexually transmitted infections, and post-natal services.
*This article was produced by Spotlight - health journalism in the public interest.