Work with women not for them, say advocates on World Contraception Day

SAN FRANCISCO — World Contraception Day presents a chance for organizations to highlight ways to reach the more than 214 million women worldwide without access to reliable family planning options. This year, the emphasis among many advocates who spoke to Devex is on the importance of starting with the girls and women they aim to serve.

One of the big initiatives announced Tuesday is a $10.5 million grant to PATH from the Bill & Melinda Gates Foundation and Children’s Investment Fund Foundation, or CIFF, to expand contraceptive options for women and adolescent girls.

Together with the public health consulting firm John Snow, Inc., the Seattle-based global health organization will form a coordination and technical assistance project to make an injectable contraceptive more widely available. The contraceptive — DMPA-SC, best known for its use in Pfizer’s Sayana Press — can be injected by health workers or women themselves just under the skin of the abdomen, thigh, or arm, rather than into the muscle. It is popular because of its high rate of efficacy and ease of use — administered every three months, with the possibility of self-injection, which is still in the process of being approved country-by-country. Sayana Press is seen as an exciting way of expanding contraceptive options for women, and the Subcutaneous DMPA Access Collaborative will work with ministries of health and partners in up to 12 countries to introduce and scale up the injectable contraceptive, as well as to share results and lessons learned.

“In recognition of women’s diverse needs, PATH has developed or introduced numerous innovations to improve contraceptive options and access, including male and female condoms, diaphragms, emergency contraception, and novel injection systems,” said Martha Brady, PATH’s Reproductive Health program leader, who explained that part of the appeal of self-injection is that it puts more control in the users’ hands. “The future of reproductive health requires innovation, not only in the form of new products like these, but also with new service delivery models — how we reach women, particularly young women, and deliver high-quality reproductive health services wherever they live.”

Putting women at the center

Research demonstrates that when a woman chooses a method of family planning for herself, she’ll use it more consistently and correctly, and for a longer period of time, said Leslie Heyer, CEO of Cycle Technologies, which creates family planning solutions.

“We have to keep innovating and we have to keep reiterating based on feedback from users,” she told Devex. “Women have been woefully underserved. They have not been, for whatever reason, the focus in the development of contraception. We need to put them at the center when thinking about contraceptive methods rather than as an afterthought.”

She talked about the organization’s past work on Cyclebeads, which allows women to track the start dates of their period, and the Dot Android app, which will tell women if they are fertile or infertile. The group is constantly testing to design for unmet needs, she said, adding that it is critical to develop solutions that meet people where they are with products that fit their lifestyle. PATH, too, has incorporated the perspectives of women, girls, and their partners in developing reproductive health technologies that meet users’ needs, said Brady, adding that when user perspectives drive product and system development, the final product is easier to use, more accepted, and better aligned with their lives.

As Adolescents 360, or A360 — a partnership project led by Population Services International — puts it, it is time to turn the traditional model of family planning inside out; not researching or programming for her, but starting with her, getting out of boardrooms and going into her world, involving girls and women as partners.

Adolescent girls are a key group whose needs must be better understood and served, advocates told Devex. According to UNFPA, 20,000 teenagers give birth every day in developing countries.

“When we let girls lead the way and [focus] on empathetically understanding their experience, we realized that the way we as a public health community have been promoting and delivering contraceptives makes them irrelevant to a lot of adolescent girls,” said Manya Dotson, project director at A360, which is also funded by the Gates Foundation and CIFF.

Traditionally, reproductive health services ask adolescents to imagine their situation far off in the future rather than addressing their needs now, running counter to all that is known about adolescent development and decision-making, she said.

“Adolescents are very emotional, present-oriented decision-makers,” she told Devex via email. “We keep assuming that the decision to use contraceptives is rational and functional — ‘I don't want to get pregnant, therefore I use a contraceptive.’ But adolescents are making decisions about how they feel now — and it feels horrible and immediately scary to go to the clinic and talk to some stranger about really private stuff. It also feels like a huge pain and takes a lot of planning to get there, not to mention that most girls are convinced that contraceptives will make them infertile and the fear of getting pregnant is more abstract. They may not want a baby right this second, but being a mom is a big part of their dreams and they feel afraid of messing that up forever. Is it any wonder that they don't find contraceptives to be relevant?”

Changing the conversation

Alongside partners including IDEO.org, A360 is working on a human-centered design process that makes girls feel seen, heard, and understood, said Dotson. The program is being piloted in 11 sites across Tanzania, Ethiopia, and Nigeria, attracting girls between 15 and 19 years old who are considered hard to reach, and achieving average contraceptive adoption rates of 28 to 59 percent after a single contact. Similarly, what will be critical to the success of the Subcutaneous DMPA Access Collaborative is leveraging user-centered design, in this case to empower women to self-inject independently, safely, and effectively, said Brady of PATH.

“We know there are at least three things that empower women,” she told Devex. “One is the access to and control of economic resources. Another is education. And the third is the ability of women to regulate their fertility, meaning that they can decide when, how, and if they have children. That’s important for women everywhere.”

It is time to change the conversation, said Rena Greifinger, who works with Population Services International on programs including A360, “demedicalizing how contraception is discussed and delivered; reframing contraception as something that has immediate relevance for girls and that protects their fertility; taking a much more holistic approach that embeds contraception (education and service delivery) within skills programming; and using highly desirable and empowering branding.”

Devex joined Greifinger on a trip to Tanzania in 2016 where experts in human-centered design and public health worked with teenage girls and medical providers to come up with the early concepts for the campaign, called Kuwa Mjanja, Swahili for “be smart.” PSI asked these experts: “How might we inspire medical professionals to be more willing, even excited, to provide contraceptive services to unmarried girls?”

“There absolutely needs to be more design thinking going into contraceptive technology and product development, especially when designing for a population like adolescents and young people,” Greifinger said.

She mentioned that everyone in the family planning space is eagerly watching the self-injection trials underway, including the collaboration announced by PATH Tuesday, to see if this will be the next major breakthrough in reducing barriers to access.

“However, breakthroughs in product development don't happen everyday,” she said. “I believe we still have immense opportunities to use design thinking to innovate the way we deliver contraceptive education, service delivery, and advocacy initiatives right now.”

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