The Bumpy Road to a Contraceptive Revolution: Medical Barriers and Sayana Press™
Twenty-five years ago, The Lancet published a seminal article by Jim Shelton, Marcia Angle and Roy Jacobstein. “Medical Barriers to Access to Family Planning”1 had a huge influence, galvanizing global efforts to improve access to contraceptive services. That same year, 1992, Depo Provera (depot medroxyprogesterone acetate [DMPA]) was finally approved for contraceptive use by the U.S. Food and Drug Administration, after decades of controversy.
In 1992, the idea of putting DMPA into a pre-filled, non-reusable Uniject™ device—a product now called Sayana Press—was still a gleam in the eye of scientists at PATH, USAID, Becton Dickenson and Upjohn Pharmaceuticals. Today we are on the verge of a new contraceptive revolution, led by Sayana Press, low-cost implants and the levonorgestrel-releasing intrauterine system. Many eyes are on Sayana Press, in particular, to see if it really will be a “game-changer,” as promised. The potential for a “new game” is certainly there, but, ironically, only if Sayana Press is not derailed by the “old game” of medical barriers we were warned of a quarter-century ago.
Just what are “medical barriers” to family planning? Shelton et al. defined them as “practices, derived at least partly from a medical rationale, that result in a scientifically unjustifiable impediment to or denial of contraception.” They have also been described as obstacles that present themselves once an individual is “inside the door” of the service provider. In 1995, Bertrand et al.2 identified seven separate types of medical barriers: contraindications, eligibility barriers, process and scheduling hurdles, service provider qualifications, provider bias, inappropriate management of side effects and regulatory barriers.
Many of the barriers noted in 1992 are still common today. For example, family planning providers in many countries still unnecessarily require that women be menstruating to receive injectables and other hormonal methods. Many providers are also far too strict about the timing of reinjections, denying services to women who are more than a few days late for their quarterly “jab.” In many places, family planning providers still require women to prove their fertility before receiving contraceptive injections, denying services to adolescents and any women without children. And, in India, DMPA is still considered risky enough that, until last year, it was unavailable though the country’s giant public health system.
Happily, though, much progress has been made in the last quarter-century in reducing medical barriers. For example, laboratory tests are no longer required before receiving a contraceptive injection, nor is permission from one’s spouse. And remarkable progress has been made in the more than a dozen countries that now allow community health workers to provide injectables.
What will it take continue the progress already made?
Progress in reducing medical barriers has been steady but arguably far too slow. Today, the introduction of Sayana Press should add new urgency to efforts to eliminate these harmful practices. We must keep reminding providers and policy-makers that:
- Age and parity requirements are unnecessary for providing injectables (and other methods as well).
- Sayana Press clients can be up to four weeks late for re-supply visits and still receive an injection without a pregnancy test.
- Sayana Press and other contraceptives are safe for adolescents and just about everyone else.
- Clients need not be menstruating to receive Sayana Press, as long as pregnancy can be ruled out with reasonable certainty.
- Trained lay health workers can safely provide Sayana Press (as well as regular intramuscular DMPA).
A Real Revolution
The measures above are all important, but, for Sayana Press to be a true a game-changer, we need a real contraceptive revolution, not just a patchwork of gradual de-medicalization. We need to make fundamental changes that truly put effective contraception into the hands of women. This revolution will happen:
- When Sayana Press (and less expensive generic versions of subcutaneous DMPA) are socially marketed not only in urban pharmacies, but also in rural drug shops.
- When Sayana Press is sold without a prescription requirement, as oral contraceptives are in many countries.
- When a visit to a family planning clinic for Sayana Press routinely involves instruction in self-injection.
- When providers think less in terms of who CAN’T use Sayana Press, and more in terms of who CAN.
A few weeks ago, I had the privilege of attending a meeting in Dakar, Senegal devoted to thinking about the future of subcutaneous DMPA, including Sayana Press. Global experts and representatives from 18 developing countries spent three days focusing on the introduction of Sayana Press in their countries and comparing notes on their own introduction programs. Two things jumped out at me. On the one hand, these champions were very comfortable with both socially-marketed Sayana Press and self-injection, two innovations that will take us partway down the road to a contraceptive revolution. On the other hand, most seemed quite leery of removing prescription requirements for DMPA, and of training pharmacists and drug shop operators to safely provide Sayana Press.
We are moving toward a contraceptive revolution, but, from all indications, the road may be a bumpy one.
1. Shelton JD, MA Angle, and RA Jacobstein. 1992. Medical barriers to access to family planning. The Lancet, 340,8831:1334–1335.↩
2. Bertrand JT, Hardee K, Magnani RJ, Angle MA. 1995. “Access, quality of care and medical barriers in family planning programs,” International Family Planning Perspectives, 21:64–69,74.↩