Contraception – Page 2 – Population Matters-USA

This graph shows the rate of covert contraception usage in Kenya

55 years ago a young patient and I were standing in the sun just outside the clinic doorway when a butterfly alighted on my left ear. “Yes, I would like to try an IUD” the patient said, amazed and apparently encouraged by the butterfly.

It was the summer between my 3^rd and 4^th years of medical school. My new wife and I were having a wonderful adventure at the Moravian Hospital in Puerto Cabezas, Nicaragua. The patient I had been persuading to try an IUD was also newly married and wanted something to keep from conceiving right away. She didn’t think her husband would approve of using birth control, however.

“If you had an IUD, he wouldn’t know about it unless you told him,” I had encouraged her. Apparently, the butterfly landing on my ear was the deciding factor, and I was able to insert a Lippes loop.

Hiding contraceptive use is a common strategy in many countries where patriarchy rules. Men in patriarchal societies usually desire large families, and don’t want their partners to make decisions about childbearing. Research has found that covert use of contraception is common in some African countries, especially for wives of polygamous marriages. As many as a third of women in some places conceal their use of birth control! Although I am certain that some women in the USA use contraception without their partner’s knowledge, I have not been able to find a study of its prevalence in this country.

Some birth control methods are easier to hide than others. A pack of pills would be easy to conceal, but it would be a dead giveaway if found. DepoProvera® shots are effective for 3 months and are easy to keep secret. A wife could go into town to shop, as usual, but also stop at the health clinic for her birth control shot. Indeed, some women have stated that is one of the reasons they chose thei method.

There is a new form of DepoProvera® that is packaged so that a woman can give it to herself at home. It is small enough that the pre-filled injection unit would be easy to conceal. Large studies in African countries have found women like this formulation, but unfortunately Sayana®Press is not available yet in the USA. There are other LARCs (Long-Acting Reversible Contraception): Nexplanon®, good for 3 years, and several IUDs, which last up to 10 years, are all easily concealed.

I do not recommend covert use of contraception. However, in some cases it is the only way that women can avoid unwanted pregnancies. Since the majority of family planning methods are female-controlled, the wife should—and can (by hiding her birth control)—have the last word about childbearing.

It only seems right that women should decide about family planning since birthing and most of the responsibilities for childcare rest on women’s shoulders. However, it is best if husbands and wives talk about whether to use contraception, and together choose the method that would be best. This is supported by a statement of friend, Dr. Stan Becker, who has studied reproductive health decisions among couples: “…reproductive health interventions that target couples are found to be more effective than those directed to only one sex.”

However, we don’t live in a perfect world—unfortunately, there are many couples where power and decision-making are not shared. Since family planning is recognized as potential driver of women’s autonomy and health, covert use of family planning can be seen as a symbol of agency for the women in these relationships.

Last month I wrote about the 5 countries I have enjoyed visiting in Africa, including citing their amazingly low per capita GDP. Although most of the population growth over the next decades is predicted to occur on that continent, I see some rays of hope.

There are two places in the world where studies have been done on ways to increase voluntary family planning, along with other important medical research. One is Matlab, Bangladesh and the other is Navrongo, northern Ghana. I had never heard of the Navrongo studies until shortly before visiting there!

Both Matlab and Navrongo have shown that community health workers can improve health significantly. In addition to family planning, the Ghanaian studies studied several successful interventions, including vitamin supplementation and mosquito nets treated with an insect repellant. Their family planning research showed that it is possible to increase contraceptive use and slow population growth even in an impoverished, poorly educated population. This is especially important research since Navrongo is close to the Sahel, and the people there are similar to Sahelians in their preference for large families.

In 1995, the beginning of the Navrongo studies, the average woman had about 5 children. Fifteen years later, in 2010, that number had dropped to a bit over 4, both in the Navrongo control group and in the country as a whole. One of the interventions decreased the fertility further, to 3.7; a significant reduction. Now, a decade later, the fertility rate for the whole country is 3.7 children per woman. That group was ten years ahead of the rest of the country! This group combined specially trained community health nurses (as opposed to stationing them at a clinic or hospital) and “zurugelu”.

“Zurugelu” means “togetherness for the common good”, and was male-centered in the past. For a better explanation, I asked one of the investigators who had worked in Navrongo what “zurugelu” meant. Here is Dr. James Phillips’ reply:

“The zurugelu approach is a social engagement strategy that involves merging the organizational system of primary health care provision with the traditional system of social organization and governance. When gender problems were evident, we attempted to turn patriarchy on end by working with women’s social groups in ways that were traditionally dominated by men. Social events, termed “durbars”, were traditionally male events that were led by traditional male social leaders. To build women’s autonomy and roles, we worked with leaders to eventually have women’s convened and women’s led durbars. We also had gender outreach activities for responding to the needs of women. As such, the “zurugelu” approach was a gender development strategy.”

(A “durbar” is a meeting of men with their chiefs.)

It is interesting that neither community health nurses nor zurugelu alone had much effect on fertility. Even though the nurses educated women about family planning and supplied the necessary materials, fertility did not decrease significantly in the regions where they were introduced but didn’t have zurugelu. Nor did zurugelu alone have much effect by itself. It took both working together for the fertility to come down.

The need for both nurses and zurugelu is a very important observation. The statement has been made frequently that worldwide over 200 million women want to limit their fertility but don’t have access to modern contraception. Since the nurses provided that access, we know that access alone isn’t enough—at least in this group of people. Apparently tradition and paternalism were significant barriers to using contraception. It took zurugelu to change attitudes before people made the most of what family planning was available.

What difference did zurugelu make? This traditionally male function opened the eyes of men to the needs of women. Furthermore, the Navrongo programs strengthen the roles of women.

Now, back to my visit in Ghana. It was dusk as we were driving from Navrongo back to Nalerigu. We passed a straw hut with smoke emerging from its roof.

“Is it on fire?” I asked.

“No”, my host replied. “She’s just cooking the evening meal.”

Although there is much beauty in northern Ghana, and everyone I met was friendly and warm, my impression is that life is difficult. Now that child mortality is a fourth of what it was 50 years ago, people will benefit from smaller families as well as more education.