Contraception: a pre-requisite for reproductive health

Kristina Gemzell-Danielsson, kicked off the contraception session on the final day of ESG by discussing the unmet need of contraception and its consequences. She began by emphasising that effective contraceptive methods and safe abortion care are pre-requisites for reproductive health.

There are currently 23-47,000 women dying annually due to maternal deaths in the developing regions. Around 7 million women have also been left with temporary or permanent disabilities.  Maternal deaths have shown to result in a higher neonatal death ratio and are a huge financial burden for women, their families and the health systems. It’s estimated by the WHO that 300 million USD is spent each year on treating the complications. In 2016, Lancet published a report looking into the main causes of maternal deaths that showed 18% were cause by complications of abortion, deaths that are avoidable! In humanitarian settings, unintended pregnancy and unsafe abortion risk is increased due to interruptions to health services and supplies, disrupted family and social structures and loss of livelihoods and assets.

Legality of abortion does have an impact. In Romania, when abortion became illegal there was an increase in maternal mortality but when it became legalised again the rate also dropped.  Data from WHO showed that in regions with more liberal abortion law, abortion rates have declines, whilst in areas where abortion is illegal the numbers are increasing. When abortion is available on request it results in the lowest rate of mortality, in the USA legalisation lead to a 73% decline in maternal mortality.

Key stakeholders need to remember that why there is an inverse link between abortion legality and abortion rate, there is a direct link between use of contraception and abortion. So the only definite way to prevention abortions is through education and contraception. Contraception has been shown to improve women’s welfare and the welfare of their children and society.

But do we need new contraceptive methods?

225 million women lack access to safe and accepted contraceptive methods, more than 50% of pregnancies are unintended. In order to improve uptake and compliance to contraception, we need to dismiss the myths around oral contraceptive. For example the notion that oral contraceptives cause cancer. Hannaford et al. BMJ 2007;335:361 showed in a UK study that women on the pill had a 12% lower cancer risk compared to placebo, with biggest reduction in ovarian cancer.

There are also other benefits of the pill that many women don’t know about which leads to poor adherence. So many women are negatively impacted by their bleeding cycles which could be addressed by the pill. The common trend is for people to want “natural” things, but it is important to consider if this is best. In the natural situation women give birth for the first time at 18 or younger, whereas in Europe on average women have their first child at 29 and only have 1-2 pregnancies with all children surviving compared to 12-15 deliveries in the natural setting, many of which aren’t successful.

The unmet need in contraception

We need to create improved methods for contraception on demand.  More works need to be done on non-hormonal long acting methods, methods for dual protection again STIs, HIV and pregnancy, reversible methods for men and methods with added health benefits.

The American CHOICE study, where women chose their method of contraception, showed that LARC methods were more successful in preventing pregnancy followed by pill, patch and ring but were not the most popular. Studies in Sweden showed that at younger ages, short-acting methods are more popular, with long-acting becoming more popular later in life. Analysis has also shown that if 5% of women would switch to LARC, 3, 5000 unwanted pregnancies would be prevents saving millions of euros a year.

Further work must be done to improve access to safe and effective contraceptive methods and to develop new alternatives.  As the use of modern contraceptive methods increase, abortion rates continue to decline, this is key in preventing unwanted pregnancies. With unintended pregnancies placing a substantial economic burden on healthcare systems (£382 million annually in the UK and $4.6 billion in the US) we need to achieve more widespread use of the most effective contraceptive methods such as LARCs.

In order to be successful in reducing abortion rates and maternal deaths, we need to dispel women’s fear in contraceptive methods, work on reversible male contraception and focus on support and information post-abortion around the use of contraception-more work to be done!