Dr. Mengistu Asnake has spent the past 25 years working to increase contraceptive access for women in Ethiopia — and has seen a startling change in how women use birth control.
In the early 2000s, the Ethiopian government began to train and employ thousands of women to do something incredibly important: deliver effective, modern birth control straight to women's doorsteps. The results, Asnake says, are astounding: Ethiopia's use of modern contraceptives has essentially tripled over a decade.
What's more, women in Ethiopia are having fewer children (the fertility rate fell from an average of 6.5 children per woman in 2000 to 4.6 currently), maternal deaths are in decline, and more women are staying in school longer. Plus, more women are opting for long-acting reversible contraceptives (LARCs) instead of more traditional short-term methods like birth control pills or condoms.
"If you asked me 15 years ago, there were only 600 health centers and all in very urban areas, but today there are more than 3,500," said Asnake, who is the country representative for Pathfinder International in Ethiopia. "And the health extension program started as a pilot program but now reaches every rural village in the country."
Numerous countries, in the developed and developing world, are working to increase women's access to better contraceptives. And Ethiopia's experience could prove instructive in showing what works in reducing obstacles to birth control. Health workers there know the important role access to local health care providers plays in increasing knowledge around family planning while simultaneously removing barriers.
Why birth control implants became a dominant contraceptive in sub-Saharan Africa
Women in the United States have generally relied on birth control pills and condoms to prevent pregnancy. These methods tend to have high failure rates: Condoms can break, and women can forget to take the Pill at the exact same time each day.
The Centers for Disease Control and Prevention estimates that about nine of every 100 birth control pill users become pregnant annually.
Long-acting, reversible contraceptives (LARCs) like implants and intrauterine devices (IUDs) are way more effective at preventing pregnancy — they fail less than 1 percent of the time. But they can also be expensive, costing upward of $500 in the United States, and that's inhibited some women from using this type of contraceptive.
That's not, however, the story abroad. LARC adoption is actually increasing at a faster rate in some traditionally poorer countries than in more developed countries like the US.
About 12 percent of women who use contraception in the United States choose LARC methods — which is well below the percentage of women who use contraception in many developing countries.
(It's important to stress that we're not saying more women use birth control in these countries than women in the US. The US has a very high adoption rate of birth control — 99 percent of women who have ever had sexual intercourse used at least one contraceptive method, whereas large swaths of these countries' populations don't use any contraception at all.)
But in some countries like Guinea-Bissau and Burkina Faso, where many people live on less than $1 a day, large percentages of contraceptive users rely on longer-acting methods of contraception. These countries do not produce their own contraceptives, so most contraceptives are provided through donations from nonprofits and the international community, which is one reason why availability of methods varies so wildly from country to country, and inventory shortages are not uncommon.
For doctors on the ground, it's not hard to see why women would prefer longer-acting methods. Once placed, implants and IUDs last for at least three years without any action on the part of the patient.
"They don't have to go to the clinic every month or remember to take the Pill every day," said Asnake. "It's easier."
In addition, for women who must keep secret their use of contraceptives, implants provide a convenient way to conceal from their partners their use of birth control. In many cultures, large families are still considered an asset or source of wealth, which can lead to women having too many children without properly spacing pregnancies.
"Using contraception can be subversive for women," said Lester Coutinho, the family planning deputy director at the Bill & Melinda Gates Foundation. "Sex is not always happening within the context of volition and choice. Someone with an implant may have a partner that might not know."
Women health care workers are revolutionizing how women access birth control in sub-Saharan Africa
Ethiopia's radical effort to increase access to contraceptives starts with health extension workers.
These are women with a minimum of a 10th-grade education level who receive one-year training on issues such as hygiene and sanitation, disease prevention, and family health services and are then assigned to work in the community where they are from.
Since 2005, more than 34,000 women have been trained as health extension workers, and starting in 2009 health extension workers received training on how to insert implants in addition to providing pills, condoms, and injectables to community members.
"In the past, most women had to travel long distances to the nearest clinic, maybe walking three or four hours," said Asnake. "For a woman with lots of household responsibilities, it is difficult to travel so much." But by visiting community members' homes, health extension workers are able to bridge the service gap between clinics and communities.
Contraceptives and health care services are provided for free largely through the support of bilateral donors and nonprofits. Asnake told me there is a private health care sector in Ethiopia, which some women do use, particularly in some of the urban areas, but close to 95 percent of all family planning needs are provided for free by the public sector.
Ethiopia's health extension workers were the first nonprofessionals trained to insert implants in Africa. For a continent continually lambasted for its failure to empower women, this initiative is truly remarkable — women are trained and paid to provide contraception to other women.
Rumors, myths, and medical training: what stops birth control from spreading further in Africa
One of the biggest cultural hurdles health care providers face when increasing access to contraceptives is the taboo surrounding adolescent contraceptive use. Often we don't even know the percentage of youth that use contraception, because many countries only collect contraception data on married women.
"There is a lot of stigma against adolescents using contraceptives and about having sex," said Dr. Candace Lew, a senior technical adviser for contraception at Pathfinder International. "But like teens in the US they are going to have sex whether you give them something to protect them or not."
So as a result, Lew said, many of the women impacted are young teenage women, who have some of the highest rates of birth complications and maternal deaths.
Dr. Aben Ngay, the country representative for Pathfinder International in the Democratic Republic of Congo (DRC), echoed Lew's concern. He says that often a young woman will ask a health provider about contraceptives but will instead get a lecture.
Ngay said the provider will say, "I won’t give you the method. You are so young, why do you need this method? If I give you this method, I’m promoting a loose life. I don’t want young people to become loose."
Many misconceptions persist around IUDs, particularly within sub-Saharan Africa, presenting another hurdle for health workers. "Once you insert something like an IUD, rumors exist that you will get cancer or never bear a child again, or that it reduces sexual pleasure," Ngay said. As of the 2011-'12 national health survey, zero percent of women reported using an IUD in the DRC.
But there are some signs that information around IUDs is improving. A study commissioned by Pathfinder International found that the prevalence rate of IUDs in Ethiopia increased from less than 1 percent in 2011 to 6 percent in 2014.
For countries that don't have Ethiopia's many health workers, technical challenges can also impede long-acting birth controls from spreading further. This is why in sub-Saharan Africa, for example, condoms, pills, and injectables remain the most prevalent contraceptives.
"The minute you are inserting [birth control] devices, you are dealing with a different skill level," said Lester Coutinho of the Gates Foundation. "You need facility-based care." And in the case of countries like the DRC, where family planning initiatives are not as established, this severely limits options available to women.
When I spoke with Dr. Claudine Monganza, EngenderHealth's program officer in the DRC, I learned that the health extension worker program there is still in its infancy. Many of the health extension workers just provide counseling and distribute information on available methods instead of providing implants or injectables like in Ethiopia.
Additionally, because modern contraceptives are not completely subsidized by the government, most women only seek contraception when it's offered for free by NGOs like EngenderHealth. Dr. Monganza told me the price of contraceptives vary from clinic to clinic and implants can cost as much as $20, which is unattainable for most, as the majority of incomes in the DRC are less than $1 a day.
Prevalence of contraceptive methods is regional, influenced by culture and a country's history with family planning
Jason Bremner manages data and performance for FP2020, a family planning initiative led by the United Nations Foundation. He's constantly looking at data about how to improve contraceptive use across the world and what obstacles still remain.
He told me the prevalence of contraceptive methods in an individual country varies widely and is shaped by a whole host of factors, including what's readily available and the historical timeline of a country's family planning initiatives.
For instance, Bremner told me that even neighboring countries like India and Bangladesh can have wildly different method mixes that don't resemble each other despite geographic proximity.
In India, for instance more than 75 percent of female contraceptive users opt for sterilization or a hysterectomy, which is a surgery that removes a woman's uterus. Meanwhile, in Bangladesh, only 8.5 percent of female contraceptive users choose sterilization while 23 percent choose birth control injections, one-time hormonal shots that are usually effective for at least three months. In India, women didn't have birth control injections as a choice until very recently.
Studies have shown that increasing the types of modern contraceptive methods a country offers matters. Generally, countries that offer more types of modern contraceptives have higher overall percentages of contraceptive use.
Bremner stressed that one of the main goals of FP2020 is to increase the number of modern contraceptives offered to all women. "We aim to offer a range of options — whether a woman is married or unmarried — that gives them the protection they want," he said.
But in addition to increased method choice, as we have seen in Ethiopia, one of the most fundamental ways to increase women's access to contraception is to invest in knowledgeable health care practitioners.
Ethiopia is not the first country to employ community health workers at scale, but its program is proven to work, and there are signs that other countries are interested in implementing something similar. Dr. Asnake has spoken with officials in other African countries like Mozambique and Angola about Ethiopia's approach, but he's also been able to share Ethiopia's approach with non-African countries like Pakistan.
"When we started our community-based program, we learned from Nigeria and invited experts from Tanzania and Kenya," Asnake told me. "But when you learn you have to payback, and so we've shared our lessons with several countries about what makes family planning unique in Ethiopia."