The modern world equips women with the technology to access information on sex and contraception, yet many women are not fully aware of the facts, contributing to a widening knowledge gap and low awareness about the most effective forms of birth control. Many myths especially regarding the pill are still circulating, un-demystified.

Therefore in conjunction with World Contraception Day 2016, Bayer Co. (Malaysia) invited Dr. Anita Nelson, professor and chair of the department of obstetrics & gynaecology at Western University of Health Science, Los Angeles and Dr. Tang Boon Nee, consultant obstetrician and gynaecologist at Subang Jaya Medical Centre, to share their expertise on addressing some of the problems patients face and provide advice for fellow OBGYN doctors on effective counselling.

Many Malaysian and Asian women not using contraceptives

A recent IMS report showed that there was a 38% increase in the use of the morning-after pill in Malaysia from April to June 2016, compared to the same time period last year. However, the method is not suitable for repeated use due to side effects and its ability to disrupt the natural menstrual cycle.

Meanwhile, the unmet need for contraception remains high. Only 22% of all women of reproductive age in Asia were using no or a less effective, traditional method of contraception, according to a Guttmacher Institute report. 77% of unplanned pregnancies stem from these women.

According to WHO, if every woman had access to a reliable form of contraception, unintended pregnancies would drop by 70% annually, maternal deaths would drop by 67%, infant deaths would drop by 77% and transmission of HIV from mothers to newborns would drop by 93%.

"One of the primary reasons why women are not using contraceptives is due to concerns on contraceptives' side effects or health risks and these are a result of the myths and misconceptions around sex and contraception. Many women fear that hormonal contraceptives could permanently affect their natural fertility but this is not true," said Dr. Nelson.

Dr. Tang agrees and said that it is important for physicians to inform their patients about the different types of contraceptive methods available.

"They need to be empowered to make educated decisions on what options fit best with their lifestyle and they should not be just relying on emergency means," she added.

Sexually active young women under the scrutiny of society

Many women especially those of the younger age group, are embarrassed or shy to talk about their sexuality or are more ignorant about the matter. Knowledge is readily available on the internet, but accessibility and acceptance is also as important.

The Malaysian government has made accessibility to contraceptives relatively easy. Condoms and pills are available most commonly at pharmacies, as well as convenience stores.

"But if you're an unmarried woman, walking into a clinic, you might be asked "What? Why are you doing this? When?", and that is a problem," Dr. Tang says.

She posed another scenario whereby a young teenager who wishes to protect herself seeks guidance from a pharmacist, teacher or physician.

"As a responsible, mature society, we cannot immediately say no and discourage them, but instead prompt a discussion to ask if the lady if she is actually ready physically and mentally, if she has actually thought about all the consequences that may come with being sexually active," Dr. Tang urges. "And if she is, ask what she is going to do, how she going to purchase contraceptives, whether she has thought about all the different options."

Information should never be withheld from women who wish to protect themselves when they become sexually active and it is the judgmental behaviour and lack of acceptance amongst the Asian community and healthcare professionals that makes it difficult for these women. A way has to be found as to how the government and society can facilitate young people who are not married and how to make it easier on them, she added.

The WHO guide 'Medical eligibility criteria for contraceptive use' provides an in-depth view on the eligibility of different contraceptions for women with different conditions. Similarly, the Centre of Disease Control and Prevention in the US have issued a similar guideline in July, which Dr. Nelson urges healthcare professionals to use as reference.

Pharmacists and doctors should be knowledgeable about these matters, but their attitudes should also be clinical and not salacious, helping people be informed as consumers, she added.

"I have posed as a young woman seeking advice from a pharmacist and it has appalled me as to how inappropriate and intimidating some of the questions are," Dr. Nelson said, ""How long have you known him?", "Why aren't you taking the pill?","Did he ejaculate inside you?" that is highly inappropriate." 

Reframing contraception to accommodate cultural and religious beliefs

For many religious women, it is believed that contraception is not allowed as it is against God's will and pregnancy should be received as a gift. However, it is also vital to persuade these women to be on contraceptives - for the sake of a healthy baby.

"If you persuade the woman to take a step back and look at the whole picture as controlling fertility until she's pregnant whereby her health is monitored for the optimal period to have the most healthy baby, then it's a means to an end,” Dr. Nelson said.

"It's just putting it into a context that it is planning and preparing to accept God's gift - a pro-family approach," she added.

Getting women to think about why they need to use contraception, to improve the quality of family planning as well as having healthier babies if pregnancy is times, is an important task.

Getting women to open up for frank discussions

As a physician, getting women to open up about their sexuality or about family planning is a seemingly intrusive task. But it is a vital step on determining the right type of contraceptive method for the patient.

"You're talking to a potentially young woman here and you're asking questions like "When do you want children, How many children? They can't know these things!," Dr. Nelson said, "It's a very daunting approach."

Instead, she urges physicians to ask indirectly with questions such as "How do you think you would feel if you get pregnant next year?"

"If the patient says "No way!" then you move on to talking about the possible contraceptives for her and if she says "I would be happy to" then it opens up a chance for you to talk about pre-pregnancy care," she added.

Dr. Tang advises that women need to understand and realise the free choice that they have to protect themselves from unwanted pregnancy and physicians should be there at every step when the patient needs help. They should be able to provide advice on the safety, convenience and reversibility of the different types of methods.

"Most women say "We'll see what happens." and that is not very wise," she added.

Moving male contraceptives beyond condoms and vasectomies

The biggest question of when male contraceptives will be made available is still unanswered.

"The thing about male contraceptives is that it is more elusive," said Dr. Nelson.

There have been many studies on producing hormonal contraceptives for men but they have not been going well as the shut-down on a man's production of sperm, "will make him a different type of man", Dr. Nelson added.

Many studies have been done such as placing plugs into the urethra tubes, pellets in the abdominal region, hormonal patches, ultrasounds on the testicles, and heating pads but there has not been a foolproof method.

"Men actually feel ostracised as their only two options are either condoms or a vasectomy," Dr. Nelson said, "And there must be something we can do and hopefully a breakthrough can happen soon."

"We also need different sizes of condoms! Have you walked into a shoe store with three different sizes to cater for all feet? No!" she laughed, "Better sized and better materials are needed for condoms."

Bayer Malaysia has introduced a new website, to promote the awareness o contraception and to help young people make informed decisions on their sexual and reproductive health. MIMS


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