What’s left unspoken: If you’re expecting your healthcare provider to lay out your birth control options, you may be in for a long wait.
When I was training to become a doctor, I regularly witnessed hospital health workers administering the birth control shot widely known as Depo-Provera to women who had just delivered a baby or undergone an abortion.
Many women weren’t asked whether they wanted it. Sometimes they received no information about the birth control method they had just been injected with.
If they were lucky, they were told to visit their local clinic three months later. And when they did, the consultation went around in circles.
Women who hadn’t realised they had already been given a three-month dose of this birth control method, struggled to understand what this seemingly routine three-month follow-up visit was about: Was it about their health, or to talk about contraception?
As a young doctor I came to know just how unethical it was not to give women/people real choices.
These experiences informed my choice to become an advocate for women’s health and rights because they represented bigger issues about autonomy, the right to choose and information.
Today, with more than 10 years’ experience as a clinician, I still question why Depo-Provera is so widely used.
Also known as depot medroxyprogesterone acetate, it is a contraceptive that relies on the synthetic hormone progestin to prevent pregnancy.
In the United States, it is strictly regulated. Prescribing information approved by the Food and Drug Administration warns it should not be used for more than two years continuously because patients may see a reduction in bone density.
More questions than answers
For almost three decades, research has also suggested that Depo-Provera may be linked to an increased risk of HIV infection. A 2016 research review in the journal AIDS found that use of the contraception drug may increase people’s risk of HIV infection by about 40%.
But although studies included in previous reviews revealed an association between use of the shot and a higher risk of infection, they were not designed to show that Depo-Provera caused this increased risk.
To prove this, scientists would need to conduct a randomised controlled clinical trial in which people were randomly assigned one of several contraceptives. This randomisation ensures that any other risk factors for HIV infection, such as some sexual behaviours, are spread evenly among the groups. When this happens, differences in HIV infections rates between the groups can be attributed to the contraceptive method used with more certainty.
A large consortium was formed in December 2015 to launch the randomised controlled clinical trial, the Evidence for Contraceptive Options and HIV Outcomes (Echo) study, which is expected to provide a more definitive answer with the release of results in 2019.
Despite all the questions about Depo-Provera, it remains the contraceptive of choice for donors and philanthropists that work in sub-Saharan Africa.
The World Health Organisation (WHO) maintains that progesterone-only injectable birth control drugs such as Depo-Provera, can be used by women at a high risk of HIV infection because their benefits outweigh “the possible, but unproven, increased risk of HIV acquisition”. But the body strongly recommends women be counselled about the possible heightened risk of HIV infection and about how they could minimise their chances of contracting the virus.
Governments and international organisations have examined research about the increased HIV risk possibly associated with Depo-Provera for more than 25 years. At the same time, they have bemoaned the high rates of HIV infections among adolescent and young women in sub-Saharan Africa. The disconnect between the two is unacceptable.
Many South African women don’t know there’s an alternative to injectable contraceptive methods. A national household survey published in the South African Medical Journal found that, although 92% of participants knew about “the shot” and almost an equal proportion were aware of birth control pills, only about 60% knew that intrauterine devices (IUD) could prevent pregnancy. Only about one in two people had heard of emergency contraception or “the morning after pill”.
Two-thirds of participants had an unintended pregnancy in the past five years, a quarter of which were as a result of contraceptive failures, the research showed.
One common thing among South African women, an equaliser of sorts, is the very low health literacy about wellness and disease, and a myth-laden knowledge about our bodies and specifically vaginal health, menstruation and contraception.
The reality is that many health workers have not been sufficiently trained on comprehensive sexual and reproductive rights and health, including the ethics involved.
They might not know enough to be able to tell you about factors that might make your birth control more likely to fail. They might not be able to answer your questions about sexual pleasure, or be equipped to help you manage contraceptive side-effects, which, for Depo-Provera, may include a decreased interest in sex, depression and irregular periods.
And, as many studies have shown, their attitudes regarding contraception may be enough to stand between you and exploring birth control options.
Six ways to get ready for your next check-up
But they don’t have to be in control. Take the power back and be the advocate for your own reproductive rights. You can start by preparing for your next consultation by:
- Compiling a list of the questions you have for your health provider and remembering to take this along to your next appointment;
- Keeping track of your cycle, such as the number of days you have a bleed, the presence of clots, any associated pain, the first day of your bleed;
- Asking questions about the different contraceptive methods available to you and their “failure rates”, or how often they have been shown not to work;
- Talking with your healthcare provider about the factors that might make it hard for you to regularly use a contraceptive. This can help you decide whether your lifestyle is better suited to taking daily pills, or if you should consider an IUD that could prevent pregnancies for multiple years.
- Finding out what kind of medical conditions run in your family. You may be certain of your own medical history, but you’ll want to be able to tell your healthcare provider if your family has a history of, for instance, cancer, blood disorders or cardiovascular events such as strokes.
- Being honest about your use of alcohol, smoking and herbal detoxifiers. You’ll need to confess to these to avoid risks associated with them while on particular contraceptive methods.
Remember, don’t be embarrassed or nervous to ask for a referral for a second opinion. This is your right.
Once you have become your own activist, you can get involved with advocacy groups to fight for better access to sexual and reproductive health services. You can start by asking policymakers to commit to improving services in hospitals and clinics. You can also put pressure on them to expand the range of contraceptive options available.
When they do, they should strive to do more than, for instance, count condoms. They need to be track how birth control methods improve users’ quality of life. It starts with you but it can’t end with you. The reproductive justice agenda is intersectional and inclusive by definition.
It’s only when policy meets the realities of our lives and places at the centre people who are marginalised by, for instance, race, gender and migration, that we will we have justice.
[9:35am 6 February 2018. This article was amended to correct an error introduced in the editing process. The piece originally misattributed findings that suggested Depo-Provera was linked to a 40% increased risk of HIV infection to a 2018 study in Endocrine Reviews. This figure should have been attributed to a 2016 research review in the journal AIDS. An additional explanation regarding randomised controlled clinical trials was also added.]
Dr Tlaleng Mofokeng is a United Nations special rapporteur on the right to health and the author of Dr T: A Guide to Sexual Health and Pleasure. She's the former vice-chairperson of the Sexual and Reproductive Justice Coalition and also a former member of the Commission for Gender Equality in South Africa.