Review articleNew strategies for providing hormonal contraception in developing countries
Introduction
The link between individual fertility regulation and the achievement of broader development goals is perhaps the central message for policy makers and program managers in the health and finance sectors in the 21st century [1]. But it does not happen by chance; to see the benefits, we have to provide the services in developing countries where the need is greatest. With the global population now estimated at 6.8 billion and a young age structure in most developing countries, population momentum will contribute to population growth for the next several decades, with 95% of this growth in developing countries, until we reach around 9.4 billion people in 2050 [2].
Despite the progress made in recent decades in fertility reduction in developing countries (e.g., total fertility has declined from about six to three children born per woman, on average, outside China), up to 120 million women (10–12% of married women in most regions and more than 24% in sub-Saharan Africa) in developing countries continue to report an unmet need for contraception. The Millennium Development Goal (MDG) target of universal access to reproductive health reaffirms the need for contraceptive options as well as access to other key reproductive health services, including safe abortion, to reduce maternal mortality (MDG 5) and achieve gender equity (MDG 3).
Since its introduction in the 1960s, hormonal contraception has been increasingly accessible and widely used for both spacing and limiting births in developing countries. During the past 50 years, the range of types of hormonal contraception and their distribution in developing countries, as well as quality assurance processes [3], have evolved with marked national patterns of client and provider preferences. For example, Bangladesh and Zimbabwe have large oral contraceptive (OC) markets (more than 30% of users), while Malawi and Ethiopia are experiencing high demand for injectables (about 60% of users) [4]. Hormonal products come in a range of presentations, are useful for both spacing and limiting, can be used by clients as well as being provider dependent and are generally quite effective (more than 90%) [5], [6].
Due to its early introduction in many developing countries, increased access and high unmet need in many countries have led to rapid uptake as both providers and users become familiar with OCs as one of the first methods used by women in developing countries. As a result, the OCs have the widest geographic distribution of any contraceptive method, with 9% of married women aged 15 to 49 years reporting use. Pill prevalence is relatively high, ranging from 20% to 55%, in four countries in Africa, four in Asia, 11 in Latin America and the Caribbean [4], with highest developing country prevalence in Morocco and Zimbabwe (both over 40%).
Given the cumulative nature of protection provided by sterilization and the long-term efficacy of the IUD, these two methods are the most widely used in developing countries. However, in terms of the share of hormonal contraceptives in overall contraceptive use, there are more countries where at least 30% of contraceptive users rely on OCs than there are countries where a similar share is accounted for by either female sterilization or the intrauterine device (IUD). Other modern hormonal contraceptive methods are also popular in selected regions. In East and Southern Africa, for instance, injectables and implants are the most popular methods, accounting for over 40% of overall contraceptive use [4].
The cost of commodities is a critical element for both donors and countries planning procurement. According to the UNFPA [7], contraceptive commodities required for reproductive health in developing countries cost about US$840 million per year in 2005 and will increase to about US$984.5 million by 2015 (including non-hormonal methods). The cost of contraceptive commodities will grow faster than the number of users because of the changing method mix: given the young age structure of new users, pill use and injectable use in parts of Africa should increase the fastest. The result will be that pills, costing about $3.60 per year of protection, will play a more substantial role in procurement budgets than female sterilization or the IUD, which have lower annual costs of protection but are more appropriate for users who desire longer spacing or have completed their desired family size.
Between 2000 and 2015, the use of all methods, but particularly OCs, will increase by 37% (from a base of 998.2 million cycles) and so will the use of injectables by 31% (from a base of 123.1 million per unit) [7]. Increases in contraceptive users will be seen in all regions, although the absolute numbers and the method mix will differ significantly, e.g., 51 million new users in India between 2000 and 2015. To meet this demand, some regions such as Africa may have to build new networks and scale up existing services, while others such as South Asia may see their greatest concern in commodity support. Procurements of hormonal contraceptive methods from major international donors increased dramatically for combined OC (60 to 200 million cycles per year) and injectables (from about 10 to 60 million units) from 2000 to 2008, but remained low and stable for emergency contraceptives (EC) and implants (both under 10 million units). Moreover, the combined value of these shipments of hormonal contraceptives during 2008 alone was about $120.4 million [8].
To address the need for contraceptive protection over a longer period of time with lower discontinuation, there is a renewed focus on longer acting methods of which many are hormonal based. Innovations are seen in the increasing availability of methods with either greater ease of use or provision (e.g., the use of paramedical personnel for the provision of implants Jadelle®, Implanon® and Sino-Implants®) and in the use of depot medroxyprogesterone acetate (DMPA) in Uniject®, facilitating the safer provision of injectables at the community level.
Section snippets
Major processes
Beyond demographic trends and the increasing demand for products, there are a number of processes which have profoundly affected the procurement and use of hormonal contraceptives in developing countries in the past 50 years, namely, a supportive policy environment, the adoption of evidence-based practices and increasing diversity of service delivery strategies.
Conclusions
Hormonal contraception is often the first method of exposure for young women in many developing countries, even when it does not provide protection against unwanted sexually transmitted infections as would barrier methods such as the male and female condoms. The choices from EC to the LNG IUS make hormonal methods appropriate for an array of lifestyles and needs. The clinical and non-clinical nature of the products imply that different types of training, standards of quality and diverse levels
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