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Sunday May 19, 2013
THE DOCTOR SAYSBy Dr MILTON LUM
Family planning is an inexpensive method of saving lives as the cost of contraceptive supplies is markedly less than that spent on saving women from maternal deaths and the consequences of unintended pregnancies.
MANY couples want to plan how many children to have and when to have them. The process of family planning is important for such couples, especially with contraceptive needs changing with the passage of time.
A method suitable for those in their teens or twenties may not be suitable in the thirties or forties.
The choice of a contraceptive depends on the age, health status, lifestyle, whether the person is in a permanent relationship with a partner, religious and cultural beliefs, and whether the family has been completed.
Contraception is a shared responsibility, but it is often the girl or woman who is left holding the baby if an unplanned pregnancy results, and pregnancy can result from a single act of sexual intercourse.
The World Health Organization defines family planning as “the supplies and services which enable individuals and couples to attain and plan for their desired number of children, and the spacing and timing of births.
“Supplies include modern contraceptive methods such as oral pills, injectables, intrauterine contraceptive devices (IUCDs), hormone-releasing implants, vaginal barrier methods, and male and female condoms, while services include healthcare, counselling, information and education related to sexual and reproductive health.”
The evidence is compelling that family planning is effective in saving women’s and children’s lives and improves the general health of mothers, children and nations.
Access to family planning, especially a range of contraceptive methods, enables women to prevent unintended pregnancies and space their pregnancies, thereby reducing deaths in childbirth and the long-term consequences of pregnancy-related problems, as well as improve children’s lives.
Saving women’s lives
Childbirth is not risk-free. Women can and do die from childbirth. It has been estimated that a woman’s lifetime risk of dying from pregnancy and childbirth is almost 100 times more in a developing country than in a developed country.
Of all the health indicators, maternal deaths show the greatest disparity between developing and developed countries. There is also evidence that the likelihood of maternal death is increased in women who have more than four children.
In 1970, there were 157 maternal deaths per 100,000 live births in Malaysia. There was a marked decrease to 29 maternal deaths per 100,000 live births in the mid-1990s.
Since then, progress has been glacial, with 27.3 maternal deaths per 100,000 live births in 2010. (Source: Ministry of Health, Health Facts 2012.) In comparison, the numbers in Indonesia, Thailand, Brunei and Singapore were 220, 48, 24 and 3 maternal deaths per 100,000 live births in 2010 respectively. (Source: WHO, UNICEF, UNFPA and World Bank, Trends in Maternal Mortality 2012.)
At the current rate of progress, it is very unlikely that Malaysia will achieve the Millennium Development Goal (MDG) target of 11 maternal deaths per 100,000 live births by 2015.
It is well documented that family planning can prevent up to a third of all maternal deaths as it permits delaying of motherhood, spacing of births, avoidance of unintended pregnancies and unsafe abortions, as well as ceasing pregnancies when the intended family size has been reached.
Saving adolescent lives
Although the mean age at first marriage in Malaysia is increasing, there are still a significant number of young women who get married early, i.e. marriage below the age of 18 years. The 2010 Population and Housing Census revealed that 84,261 girls and 74,071 boys between 15 and 19 years of age were married.
The adolescent fertility rate (the annual number of births per 1,000 women aged 15 to 19 years) decreased from 28 in 1991 to 15 in 1997, and has stagnated to date.
In terms of absolute numbers, there were 19,125 live births to adolescents below 19 years in 2009, accounting for 4% of total live births. Of this group, 214 mothers were below 15 years of age.
Adolescents are at increased risk of pregnancy complications and maternal mortality as they are not physiologically or psychologically mature. Mothers between 15 and 19 years of age are twice as likely to die from maternal causes as older women.
There are more underweight babies (less than 2.5kg) born to adolescent mothers, with rates of 22% and 20.8% in mothers below 15 years of age and between 15 and 19 years of age respectively.
An estimated 2.5 million teenagers in developing countries end their pregnancies by undergoing abortions performed by unskilled persons or in unsafe conditions, or both. Hard data on abortions in Malaysia is limited. However, there are reports of an estimated 90,000 abortions annually, with about five deaths due to unsafe abortions.
Adolescents have higher rates of unintended pregnancies because of the lack of usage of contraception. Contraceptive usage in 15 to 19 years and 20 to 24 years age groups in Peninsular Malaysia were 33.3% and 47.1%. (Source: Malaysian Population and Family Survey 2004).
Saving children’s lives
It is a fact that when the birth interval is short, infant mortality is increased. International data reveals that babies born less than two years after their next older siblings are twice as likely to die in the first year of life compared to those with a birth interval of three years.
It is estimated that globally, more than two million infants and children’s lives would be saved annually if births are spaced.
As such, doctors recommend that women should wait at least two years before attempting to get pregnant again. This gives women more time to recover physically and nutritionally between child-births.
As at December 2011, Malaysia had 94,841 HIV and 17,686 AIDS cases, with 14,986 deaths. The epidemic is concentrated among certain groups, i.e. injecting drug users (IDU), men who have sex with men, sex workers and the transgender population.
However, an increasing number of women are infected with HIV. The female to male ratio changed from 1:99 in 1990 to 1:10 in 2000 and to 1:4 in 2011.
During the earlier phase of the epidemic, IDU was the primary mode of transmission. This trend has changed with time, from only one sexual transmission for every nine IDU in 1990 to two sexual transmissions for every eight IDU in 2000 and five sexual transmissions for every five IDU in 2010.
As at December 2011, there were 9,494 women reported to have HIV. (Source: Ministry of Health Global AIDS response Country progress report 2012.)
Family planning reduces the transmission of HIV and consequently deaths from AIDS. The consistent and correct use of condoms reduces transmission of HIV, avoids unintended pregnancies (which are likely to be of high risk) and reduces transmission of HIV from mother to child.
There is a strong economic case for family planning in HIV prevention. Health economists have estimated that there is a potential savings of US$25 (RM75) on HIV care and treatment for every US$1 (RM3) spent on family planning.
It has been reported that family planning has prevented more than half a million unintended pregnancies annually in HIV positive women in sub-Saharan Africa, where the epidemic is most severe.
The unmet need for family planning is defined by the World Health Organization as “the number of women with unmet needs for family planning expressed as a percentage of women of reproductive age who are married or in a union. Women with unmet needs are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of their next child.”
The obvious outcome of the unmet need for family planning is unintended pregnancies. It is estimated that about 40% of the world’s 210 million pregnancies annually are unintended, of which an estimated 20 million unsafe abortions are performed annually, resulting in about 67,000 unnecessary deaths.
Family planning can prevent many of these deaths by reducing the number of unintended pregnancies. There are numerous examples in which the increasing use of family planning has led to reductions in abortion rates.
Data on contraceptive usage among Malaysians is sparse. The usage of all contraceptive methods has stagnated around 50% in the Malaysian Population and Family Surveys (MPFS) of 1984, 1994 and 2004.
Data on the unmet needs in the young and unmarried is unavailable as the MPFS in 2004 only studied usage among the married, and the National Population and Family Development Board does not provide services to the unmarried.
However, an internet survey by a pharmaceutical firm in 2009 among 100 persons aged 18 to 21 years revealed that more than 50% were not familiar or confused about the different contraceptive methods, and about 60% either did not or found it difficult to discuss contraception with their partners prior to having sex for the first time.
More than 20% of the women did not use contraception because they did not like it and more than 20% did not use it because of their partners’ objections.
Apart from the Ministry of Health’s National Adolescent Health, Plan of Action, 2006-2020, most of the government’s policies have not addressed the sexual and reproductive health (SRH) needs of the young, including the need for family planning.
Policies like the National Family Planning Policy and National Policy on Reproductive Health and Social Education have not been specific about SRH services for the young and have been ambiguous about the availability of information and services for the unmarried.
There is mention of the provision of comprehensive healthcare, but no recognition of the need for SRH services.
Investing in the future
Family planning is an inexpensive method of saving lives as the cost of contraceptive supplies is markedly less than that spent on saving women from maternal deaths.
The provision of family planning to HIV positive women results in huge savings. In a study of 14 countries, the cost of family planning services to women accessing HIV services was USUS$4mil (RM12mil) compared to a savings of US$72mil (RM216mil) from not having to prevent mother-to-foetus transmission or support for orphans.
Family planning also leads to savings in the health, education and environmental sectors. There are many such examples from developing countries.
The issue of SRH (including family planning services) has to addressed in a specific, inclusive, pragmatic and evidence-based manner if the country is to achieve all its MDG goals.
> Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail email@example.com. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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