The issue of family planning has been put firmly on the global agenda, first by the London Summit on Family Planning in July last year and, more recently, by the 2013 Women Deliver conference held in Kuala Lumpur two weeks ago.
The fifth goal outlined in the United Nations millennium development goals is to improve maternal health, but there has been significant neglect of family planning, especially in sub-Saharan Africa.
Health Minister Aaron Motsoaledi has said that this neglect is the result of the HIV epidemic, as well as a greater emphasis on condom distribution rather than on contraception and family planning. The minister's view is supported by the World Health Organisation, which reported that prevalence of contraceptive use in Africa was a mere 20% compared with 63% in Latin America, with the rate of unmet need for contraception highest in sub-Saharan Africa.
What is family planning?
It is a broad term that encompasses the provision of contraception methods to sexually active women and includes fertility planning, for example spacing and management of infertility, and termination of pregnancies. The provision of appropriate and adequate family planning services in South Africa is critical in a context of high rates of teenage pregnancies, as well as high rates of mother and child mortality and HIV.
In South Africa, according to Statistics South Africa in its estimates of the 2013 population of just less than 53-million people, the total fertility rate had dropped from 2.7 children per woman in 2002 to 2.3 children per woman in 2013.
The total fertility rate of a population is the average number of children that would be born to a woman over her lifetime.
Many factors influence the fertility rate, including urbanisation, female educational levels, infant mortality, costs of raising children, cultural and religious beliefs as well as the use of contraception.
In South Africa, estimates show that about two thirds of sexually active 15- to 49-year-old women use a modern contraceptive method. This usage contributes to the decline in the total fertility rate.
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Lowering the fertility rate is associated with improved quality of life for women and children. Most developed countries have a fertility rate of 2.0 or less, which means that they are below replacement value level – the point at which the numbers of children being born are equal to the number of deaths. South Africa as a whole is rapidly approaching the point of zero growth, although there are marked differences between provinces, ranging from a fertility rate of 1.9 in Gauteng to 2.7 in the Eastern Cape.
Although rates of teenage pregnancies continue to fall, they are still high, particularly among those teenagers who come from poorer socioeconomic backgrounds. A 2009 report on teenage pregnancy by the department of basic education found that: "Over two-thirds of young women report their pregnancies as unwanted because it hobbles educational aspirations and imposes greater financial hardships in a context of high levels of poverty and unemployment."
Despite high levels of knowledge about modern methods of contraception, many young people do not use contraception, and others use it inconsistently and incorrectly. One intervention that is required is for contraception to be made easier for young girls who are sexually active to access.
Fertility planning is also important in the context of a significant prevalence of HIV. With the high rates of HIV infection in South Africa, many HIV-positive young women who wish to have children need to be provided with a safe way of conceiving and delivering healthy babies. They need to be able to plan when they will have children so that both their own health and that of their babies is prioritised, and they need specific contraception choices.
What is South Africa doing?
Although every public health facility in South Africa provides basic contraceptive services, it is recognised that these services have been neglected amid the attention focused on HIV and tuberculosis.
Contraceptive services have focused almost exclusively on hormonal methods (especially on long-term injectable methods) and condom distribution. Other methods, such as implants, are either not available in the public sector or, with methods such as intra-uterine contraceptive devices, are provided at only a few facilities. In addition, the skills and in-service training of front-line health workers has been neglected.
In many cases, especially in relation to adolescents, health workers have reportedly had judgmental attitudes to their patients.
In order to reinvigorate these contraceptive services and to get them in line with international best practice, a new contraceptive policy will be launched by the health minister before the end of the year. The policy proposes five elements that need to be put in place.
First, high-quality contraceptive health services need to be provided. This requires a health system that has health workers who are well trained, have the requisite skills and are empathetic to the needs of their patients.
It requires that an expanded choice of methods of contraception be readily and continuously available in the health services, which must be easily accessible and available to the women who use them. The new methods that the policy will introduce include additional long-acting contraceptive methods. Examples of these are the reintroduction of the copper intrauterine device and the introduction of hormonal implants that are inserted just below the surface of the skin through a small procedure.
Communication, condoms and collaboration
Second, those women who should be using contraception need to be informed of its availability and supply. Therefore, both individuals and communities need to understand the importance of contraception and planning for healthy pregnancies, the range of methods available and where they can be obtained.
This will require advocacy and demand creation, underpinned by effective communication strategies, which will encourage informed decision-making and contraceptive use.
Third, the unique South African context of extremely high prevalence rates of HIV, with nearly one-third of all sexually active women infected with HIV, requires the promotion of "dual protection". In addition to preventing unwanted pregnancies, women also need to protect themselves against HIV infection, as they bear the brunt of the disease. This requires barrier protection in the form of condoms, male and female, as a means of preventing the transmission of the HI virus.
Fourth, optimal contraceptive practices require multisectoral collaboration. South Africa needs to expand access beyond traditional public sector health facilities, especially for targeting adolescent girls and other specific groups such as sex workers. To achieve this will require vibrant, responsive partnerships between the public health sector and civil society, as well as the private sector and development and implementing partners.
Last, the new contraception policy implementation needs to be guided by evidence. There must be ongoing monitoring and evaluation, and the policy should be modified, if necessary, to reflect and incorporate local and international research and feedback.
The policy takes into account developments in the range of contraceptives that are available. It also takes into account the needs of women in South Africa in 2013 and beyond, as well as the specific needs of women infected with HIV.
It is hoped that this contraceptive policy will continue to lower the overall fertility rate so that South African society as a whole can benefit. As importantly, if not more so, it is also hoped that this contraceptive policy will enable each individual woman of child-bearing age to have only a child when she wants to, and that, consequently, every child is wanted.
Dr Yogan Pillay is the deputy director general in the department of health. Peter Barron is an honorary senior lecturer in the School of Public Health, University of the Witwatersrand
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