Since 2017, after having her last child *Nkhensani (38), a mother of three has been using injectable contraception in the form of Depo-Provera which she received from the Mukhoni Clinic in Collins Chabane District in Limpopo. She decided to take contraceptives after realising that she and her partner could no longer afford to raise more children. But from the beginning of lockdown in 2020, she says she could not access her contraceptive of choice because of stockouts at the clinic.
“Other clinics in Mopani and Malamulele areas have also admitted to experiencing stockouts of Depo Provera”, says Civil Society Provincial AIDS Council Chairperson, Solanga Milambo.
Everyone has a reproductive right to decide if and when they want to have children. There are various reasons one would decide to delay childbearing. Reasons may include wanting to pursue their dreams, advance their career, or further their education. A person may decide they already have enough children, they want to wait for the right time to have children, or they simply cannot afford to raise a child. It is every couple’s or individual’s fundamental right to choose when to have children. Many contraceptive options should ideally be available in the public health sector for everyone to enjoy their right to reproductive health.
Stockouts and the lack of youth-friendly services
The poor, young, vulnerable populations and those living in peri-urban and rural areas, most of whom depend on the public health sector, often bear the brunt of problems with access to contraceptives.
At the beginning of 2020, the Stop Stockouts Project called for the national department of health to intervene on the issue of ongoing contraceptive stockouts that have hit a number of provinces. Limpopo is one of the provinces that are affected by stockouts of certain contraceptives.
Over the years, the issue of contraceptive stockouts has been raised by civil society organisations such as SECTION27 and the Treatment Action Campaign during AIDS council meetings in the province. Government officials continuously commit to investigate the matter – but to no avail.
There is also an ongoing lack of youth-friendly services in most health facilities in Limpopo. The department of health in the province indicated that they have trained nurses to offer youth-friendly services, but when young adolescents visit the clinic, they report being met with judgement from the health personnel and end up unable to access sexual and reproductive health services.
One consequence of stockouts and the lack of youth-friendly services is an unintended increase in the rate of unplanned and early pregnancies. According to Statistics South Africa, rural provinces such as the Eastern Cape, Northern Cape, and Limpopo have relatively high early and unplanned pregnancies. The percentage of pregnancies in 2018 ranged from 2,4% among 15-year-olds and 24,5% among 19-year-olds.
Early and unintended pregnancy has been a long-standing issue in Limpopo and the province has seen little progress in resolving the underlying issues. For years, there have been media reports highlighting the magnitude of the issue. In 2017, Limpopo was among the top three provinces with the highest early and unintended pregnancy rates.
At the end of 2020, Ximun’wana High School in Malamulele recorded an unexpectedly high number of pregnancies in the past year. When we spoke to a group of female learners from the school, they said when they tried accessing contraceptives from their local clinic; they were asked to bring their own syringe as they had run out of equipment to administer injections. Others were told that if they took contraceptives they would get cancer. It is unclear if such incorrect information was given as a way of deterring them from having sex since they are still young or because there were no contraceptives in stock. Either way, the result is young women unable to access the contraceptives they need to prevent possible pregnancies.
The right to choose
“After returning to my clinic several times and not receiving Depo-Provera, in March this year, I was switched to Nuristrate (also an injection). I tried the mobile clinic, they too did not have my method of choice,” says Nkhensani.
Not many women are aware of the different types of contraceptives that are available to the public and that they should be able to choose among them. These options include hormonal injectable contraceptives such as Depo Provera and Nuristrate; daily oral pills and emergency contraceptives; long-acting reversible methods such as the intra-uterine device (IUD) otherwise known as the loop and implant; barrier methods such as both female and male condoms. All these different methods have their benefits and disadvantages. For instance, the implant otherwise known as Implanon, is a hormonal contraceptive that is the size of a match stick. It is inserted under the skin on a woman’s arm to gradually release the hormone that will prevent her from falling pregnant for a period of up to 3 years. However, the downside of it is that when a woman is ready to start having children and needs it removed, there are not many skilled health personnel who are able to remove it.
Women should be given all the options available at the health facilities to make informed decisions on what is best for them. Many women miss a chance to control their fertility because of the misconceptions around contraceptive use. Some healthcare providers, in trying to discourage adolescent girls and young women from taking them, spread some of these misconceptions.
A 2018 study on ‘Nurses perceptions of adolescents accessing sexual and reproductive healthcare services in Cape Town,’ found that nurses view certain behaviours by adolescent girls as irresponsible and therefore deserve the mistreatment they get from them. Negative attitudes by nurses are enough to prevent an adolescent girl from wanting to access sexual and reproductive health services even if they are aware of them. This has the potential to undermine the efforts that comprehensive sexuality education seeks to address.
No one-size-fits-all approach for contraceptives
A number of risk factors come into play when choosing a preferred contraceptive method. These include body weight; pre-existing medical conditions (such as diabetes, HIV, depression); lifestyle habits (such as smoking); reproductive conditions (such as endometriosis, breast disease, history of high blood pressure during pregnancy); convenience; and age. All women are different and therefore their reproductive health needs are not the same. There is no one-size-fits-all approach for administering contraceptives and every woman’s reproductive needs must be met.
When a woman does not receive their preferred method, being placed on a different contraceptive without evaluating their risk factors may result in unwanted side-effects or inconveniences, which may inform their decision to stop taking them.
Nkhensani reflects, “Since I have been put on the 2 months injectable, I have missed my appointment a number of times because I am used to going to the clinic every three months. I have had several pregnancy scares since my contraceptive cycle changed. Luckily they were all false.”
Negotiating safer sex in long-term relationships where condom sex is not a norm is difficult for women in unequal relationships. Such negotiations are not even possible nowadays since the stockouts have also hit condom distribution.
The risk of a baby boom and rise in HIV infections
The ongoing stockouts of contraceptives grossly violate individuals’ and couples’ reproductive rights. The contraceptive stockouts have been continuing for a long time, but alternative measures have still not been put in place.
If the issues of access to contraceptives are not dealt with, the country will face a baby boom and a rise in HIV infections at the end of the current pandemic. COVID-19 has already absorbed many of the country’s resources. It will be difficult for the government to meet everyone’s needs with the growth in population exacerbated by unplanned and unwanted pregnancies. Moreover, the current resources will not be sufficient to address the growing HIV infections as a result of the lack of access to condoms. Women of all ages deserve to have their reproductive needs prioritised to achieve gender equality and to realise their sexual and reproductive health rights.
*Mbatha is a researcher with SECTION27 and Maluleka a field community researcher in Limpopo.
Note: This opinion piece is written by employees of SECTION27. Spotlight is published by SECTION27 and the Treatment Action Campaign but is editorially independent – an independence that the editors guard jealously. The views expressed in this article are not necessarily shared by Spotlight.