By Hninn Thanlwin Thit
Cross-Cutting Influences on Contraceptive Use
There is an unmet need for contraception around the world.
The World Health Organization (WHO) has reported that 214 million women of reproductive age in developing regions in 2017 who wanted to avoid pregnancy were not using a modern contraceptive method. One of the main reasons for this is having limited access to contraception, particularly among youth, people who are poorer, living in rural areas and in humanitarian crises.¹
In Southeast Asian countries where contraception is legal, it’s apparent that they are more likely to have better access to contraceptives. The most notable example would be Thailand as it has long offered free, highly accessible and convenient services to the population. The contraceptive prevalence rate (CPR) in Thailand for all methods has soared from 14.8% in 1970, prior to the 1971 implementation of the National Family Planning Programme, to 79.3% in 2012²; however, there is still a proportion of women in certain regions that do not use contraception. Thai Muslim women living in the south, in particular, have much lower contraceptive use but they are less affected by geographical accessibility but rather by religion, income and education levels in making a decision whether or not to take birth control.³
In contrast, Laos is barely starting on raising awareness and using birth control. When family planning was introduced in the late 1980s, it was only available in the capital, Vientiane. Most people were not even aware of such amenities and even in 2000 it is reported that 40 percent of couples were willing, but not able, to utilize contraceptives due to the lack of facilities or the accumulated costs of transportation and service. Nowadays, most district health centers have better access to modern contraceptives although they are still expensive for underprivileged people.⁴
Contraceptive services are, nevertheless, extremely difficult to reach in rural and remote areas where 70% of the Laos population reside. As the public health system is incapable to provide accessible services, in this case, the Laotian government and the UN population fund (UNFPA) has trained community-based distribution (CBD) workers to spread the word about family planning and distribute free contraceptives within the community; CBD workers on their motorcycles have proven to be a critical element of the country’s aim in advancing contraception through reaching scattered villages.⁵
Both cases have appeared to encourage making contraceptives widely accessible despite stark differences in the quantity and quality of nationwide family planning. While access and affordability to contraception are major issues, just making contraceptives more accessible does not ensure that women will use them. It is important to keep in mind that various factors such as educational limitations, cultural or religious oppositions and health concerns can influence a woman’s decision to turn down birth control.⁶
Governments also have an interest in promoting particular patterns of childbearing. A well-known example is China’s one child policy, implemented in 1979 and officially withdrawn in 2015, which aimed to curb China’s rapidly growing population as it peaked around 970 million in 1979. With subsequent shortages in food supply and other natural resource imbalances, this largely resulted in controversial forced abortions and sterilization of women; in its earlier years, there were even poor quality and limited choice of contraceptives, especially in rural areas which were reliant on intrauterine devices (IUDs) and sterilization.⁷
The anti-natalist policy, however, seemed to work too well as birth rates have fallen from 6.4 per 1000 in 1965 to an average of 1.7 in 2018.⁷ Now with rising concerns of an ageing population and a shrinking workforce, China is struggling to spark a baby boom, alongside Singapore and Taiwan, by permitting two children and have gone to more punitive lengths, such as making several provinces ban abortions after 14 weeks. However, there is strong public reluctance in having more children with main reasons as wanting to maintain current quality of life and bringing up children being too expensive.⁸
The mere memory of the brutal policy has, more importantly, caused women to firmly oppose China’s new attempts; for example, in 2017, the Chinese government declared to remove women’s IUDs for free which received backlash. This announcement without an indication of apology left many Chinese women outraged as they felt that the former policy was disastrous on top of having experienced grave damage to their mental and physical health from the IUD campaign because of rough surgeries and poor cleanliness.⁹
It is without a doubt that several Chinese women, after the transition to the two-child policy, felt like they were once again test subjects under the government, only living to enhance the nation’s development.⁸ Yet, more women, especially the youth, are resisting governmental insistence as contraception, especially condoms, has become widely accessible and regularly used.¹⁰ Policymakers need to realize that this is a new era of women’s control over their own reproductive desires and that they will have to do much more, in terms of maintaining living standards and voicing their regret, in order to encourage, not coerce, women and achieve national socio-economic aims.
Southeast Asia’s progress in female reproductive health, however, is still worrying which should urge us to take a look at another critical factor: society and culture. Historically, it is no surprise that women face societal pressure through encouragement in marrying at a very young age in several developing countries including Timor-Leste where procreation is favored and there is little use of contraception especially in rural areas.¹¹ With reasons such as either wanting children to provide family income or in the eyes of most men, the more children seen as a higher status symbol, the main concern lies at how women have lacked education on birth control.
Today, with our lives almost entirely absorbed by the media and internet in the 21st century, we still deeply lack in essential contraceptive knowledge and this, perhaps, reflects the terrible portrayal of contraceptive experiences, especially of women, in what we see in mainstream media. With contraception already taboo enough to generally discuss in Southeast Asia, we can top it off with how it would be often under-depicted or misrepresented in a negative light on television⁶; despite very little study on this, we can presume that they might neglect the actual reality of birth control through misinformation, even if unintended, and instead, cause adolescents to suffer in figuring out about their reproductive health.¹²
It’d be wrong to blame contraception misconceptions only on the encompassing mass media; we, at the heart of society, need to realize that we must view contraception differently. Women are shamed and maltreated for using contraception and this puts their health and lives at risk.¹³ It’s crucial for us to erase this hurtful negative stigma and its devastating impacts, one of which is indirectly supporting abortion restrictions, and instead, approach with an open mind and learn the benefits it provides for both individuals and society. Remember, contraception gives women the ability to arrange, prevent, and space pregnancies which creates a pathway to more educational and economic opportunities for themselves and others.¹⁴
These current harsh times of the pandemic, unfortunately, has put strains on global access to contraceptives which may lead to millions of unplanned pregnancies while governments and organizations strive to uphold their goals amid Covid-19 complications.¹⁵ We ourselves might not be able to provide contraceptive services through long journeys on motorcycles to isolated villages nor might we be able to take the position of an insightful policymaker and implement effective measures to enhance contraceptive access. But we sure can, as a community, show solidarity for improving contraception access through raising awareness of its actual uses, effects and experiences: this way, the once major game changer that contraception has been can evolve into a basic human right in reproductive healthcare.
[1] WHO. (2019, December 10). Contraception. https://www.who.int/health-topics/contraception
[2] Tangcharoensathien, V., Chaturachinda, K., & Im-em, W. (2014). Commentary: Thailand: Sexual and reproductive health before and after universal health coverage in 2002. Global Public Health, 10(2), 246–248. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318085/
[3] Saelim, J., Santibenchakul, S., & Jaisamrarn, U. (2017). Comparison of the knowledge, attitudes toward, and practices of contraception between Thai Muslim women living in Bangkok and those living in the southernmost provinces of Thailand. Asian Biomedicine, 10(4), 351–359.https://content.sciendo.com/configurable/contentpage/journals$002fabm$002f10$002f4$002farticle-p351.xml#d142883e21879_w2aab3b7b6b1b6b1aab1c16b5aAa
[4] Rosalia Sciortino. (2010). Achieving Contraceptive Security and Meeting Reproductive Health Needs in Southeast Asia. Asia Pacific Alliance for Sexual and Reproductive Health and Rights. https://www.rhsupplies.org/uploads/tx_rhscpublications/contraceptivesecurityreproductivehealthneedsweb.pdf
[5] Anne Isabelle Leclercq. (2015). Going the last mile to provide family planning in Lao People’s Democratic Republic. UNFPA — United Nations Population Fund. https://www.unfpa.org/news/going-last-mile-provide-family-planning-lao-peoples-democratic-republic
[6] Najafi-Sharjabad, F., Zainiyah Syed Yahya, S., Abdul Rahman, H., Hanafiah Juni, M., & Abdul Manaf, R. (2013). Barriers of Modern Contraceptive Practices among Asian Women: A Mini Literature Review. Global Journal of Health Science, 5(5), 181–192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4776867/
[7] Alice Zhang. (2020). Understanding China’s Former One-Child Policy. Investopedia. https://www.investopedia.com/articles/investing/120114/understanding-chinas-one-child-policy.asp
[8] Kuo, L. (2019, March 5). Can China recover from its disastrous one-child policy? The Guardian. https://www.theguardian.com/world/2019/mar/02/china-population-control-two-child-policy
[9] Wee, S. (2017, January 7). After One-Child Policy, Outrage at China’s Offer to Remove IUDs. The New York Times. https://www.nytimes.com/2017/01/07/world/asia/after-one-child-policy-outrage-at-chinas-offer-to-remove-iuds.html
[10] Büchenbacher, K. (2017). What type of contraception does China’s younger generation prefer? Global Times. https://www.globaltimes.cn/content/1070279.shtml
[11] ReliefWeb. (2005, August 2). DHS surveys says Timor-Leste has highest birth rate and child mortality has declined 50% — Timor-Leste. https://reliefweb.int/report/timor-leste/dhs-surveys-says-timor-leste-has-highest-birth-rate-and-child-mortality-has
[12] Kevanishvili, E. (2018). Breaking taboos around sexual and reproductive health in rural Georgia. UNFPA — United Nations Population Fund. https://www.unfpa.org/news/breaking-taboos-around-sexual-and-reproductive-health-rural-georgia
[13] Zeigler, H. (2018). Opinion | Don’t stigmatize birth control. The Breeze. https://www.breezejmu.org/opinion/opinion-don-t-stigmatize-birth-control/article_916f6f86-d7dd-11e8-bf44-6371cab129a7.html
[14] Ehrlich, G. (2017, March 8). Opinion: Birth Control Gives Women the Power to Decide. NBC News. https://www.nbcnews.com/news/latino/opinion-birth-control-gives-women-power-decide-n730751
[15] UNFPA. (2020, September). Three things you need to know about contraceptives and COVID-19. UNFPA — United Nations Population Fund. https://www.unfpa.org/news/three-things-you-need-know-about-contraceptives-and-covid-19
[16] Kane, P., & Choi, C. Y. (1999). China’s one child family policy. BMJ, 319(7215), 992–994. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116810/
