Preventing Sexually Transmitted Infections and Unintended Pregnancy, and Safeguarding Fertility: Triple Protection Needs of Young Women

Abstract

The problems and risks of unprotected sex, unintended pregnancy and sexually transmitted infections are inextricably linked. In this context, the critical yet overlooked problem of infertility also needs to be addressed. Dual protection means concurrent protection against unintended pregnancy and STI/HIV. This paper argues for a more comprehensive notion of “triple protection” to include the safeguarding of fertility. This is intended explicitly to draw out the connection between infertility and STIs—using the “visibility” of fertility and infertility and people's immediate connection with them—and in so doing to bolster STI prevention and control efforts. It could also serve to highlight the connections between infertility and unsafe abortion and delivery practices, which still exist in many developing countries. Understanding differences in perception and weighting of protection concerns by young women and men, whether they wish to start, postpone or avoid pregnancy, is essential for the creation of effective programmes. Building on efforts to promote dual protection, a strategic opportunity exists to include prevention of infertility into safer sex messages and to address the fragmentation of reproductive health and HIV/AIDS programmes.

Résumé

Les risques des relations sexuelles non protégées, des grossesses non désirées et des IST sont étroitement liés. Il faut aussi traiter le problème critique, et pourtant méconnu, de la stérilité. Une protection double évite les grossesses non désirées et les IST/VIH. Cet article préconise une notion plus globale de « triple protection » qui préserve la fécondité. L'objectif est de faire le lien entre stérilité et IST, et de stimuler ainsi les mesures de prévention et de lutte contre les IST, mais aussi de mettre en lumière les rapports entre la stérilité, et les avortements et accouchements non sûrs dans beaucoup de pays en développement. Les messages de « triple protection » peuvent se servir de la « visibilité » de la protection contre les IST et le VIH. Pour créer des programmes efficaces, il est essentiel de comprendre les différences de perception et de préoccupations en matière de protection des jeunes femmes et des hommes, qu'ils souhaitent commencer, retarder ou éviter une grossesse. En utilisant les mesures de promotion de la protection double, il est possible d'inclure la prévention de la stérilité dans des messages en faveur de relations sexuelles plus sûres et de corriger la fragmentation des programmes de santé génésique et de lutte contre le VIH/SIDA.

Resumen

Los problemas y los riesgos asociados con el sexo sin protección, el embarazo no planificado y las infecciones transmitidas sexualmente están inextricablemente vinculados. Habrı́a que abordar además el problema crı́tico pero no reconocido de la infecundidad. La doble protección significa protegerse en contra del embarazo no planificado y las ITS/VIH al mismo tiempo. En este artı́culo se postula la idea más inclusive de la “protección triple” que abarca también el salvaguardar la fecundidad. Pretende mostrar explı́citamente el vı́nculo entre la infecundidad y las ITS mientras fortalece la prevención y control de las ITS, y a la vez resaltar los nexos entre la infecundidad, el aborto practicado en condiciones de riesgo y las prácticas de atención al parto en muchos paı́ses en desarrollo. Los mensajes de la “triple protección” pueden usar la “visibilidad” de la fecundidad y la infecundidad para promover la protección en contra de las ITS y VIH. Para crear programas efectivos, es preciso comprender las diferencias en percepción y valoración de la protección por hombres y mujeres jóvenes según sus deseos de iniciar, posponer o evitar un embarazo. A partir de los esfuerzos por promover la doble protección, existe una oportunidad estratégica para incluir la prevención de la infecundidad en los mensajes de sexo seguro y abordar la fragmentación de los programas de salud reproductiva y VIH/SIDA.

Key Words:

• sexually transmitted infections
• HIV/AIDS
• infertility
• contraception and unplanned pregnancy
• fertility awareness
• dual protection

As we enter the third decade of the HIV/AIDS epidemic, there are still limited options for preventing the sexual transmission of the virus. At the end of 2002, an estimated total of 38.6 million adults, of whom 11.8 million were aged 15–24, and 3.2 million children, were living with HIV/AIDS.¹ Although men and women have a roughly equal chance of becoming infected, women tend to become infected at younger ages.² In parts of Africa, due to sexual networking patterns, more young girls than young boys are infected. In some cities, the infection rate among adolescent girls aged 15–19 is two to eight times higher than among adolescent boys.³

The AIDS pandemic and the recognition that sexually transmitted infections (STIs) facilitate HIV transmission have fuelled a worldwide campaign to develop new programme strategies and prevention methods. The HIV and STI epidemics are closely linked and share the main transmission route of unprotected sex. They also share an underlying gender power imbalance between men and women in families, education, employment, and in civil society, which is at the heart of both epidemics. They are, however, different epidemics and geographically, due to differences in prevalence and incidence rates, not everyone is equally at risk of curable STIs and HIV. STIs are among the most common causes of illness in the world and have far-reaching health, social and economic consequences.⁴ Moreover, women are socially, economically and biologically more vulnerable to STIs than men. Women tend to be asymptomatic longer, seek treatment later, and, excluding HIV, suffer more serious consequences from certain STIs, including cervical cancer, ectopic pregnancy, sepsis and infertility.⁵

The problems and risks of unprotected sex, unintended pregnancy, and infection are inextricably linked. Discriminatory cultural practices such as early marriage and dowry, sexual violence and coercion, and women's economic dependence on men leave many women, particularly young women, vulnerable. The underlying task of changing the power balance between men and women is essential and must be given top priority.

Meanwhile, the global significance of both STI and HIV epidemics, and of unintended pregnancies, warrants a renewed commitment to meeting the more complex protection needs of young women, which require the support of family planning and other reproductive health programmes, in tandem with HIV/AIDS programmes. At the same time, there is the critical, yet overlooked, problem of infertility which also needs to be addressed. Prevention and treatment of infertility were explicitly acknowledged as basic elements of reproductive health care in the ICPD Programme of Action:

“Information and services should be made available to adolescents to help them understand their sexuality and protect them from unwanted pregnancies, sexually transmitted diseases and subsequent risk of infertility.” ⁶

Yet infertility has not been explicitly acknowledged or addressed by reproductive health programmes. This is due, in part, to the fragmentation of reproductive health services, and in part to the perception of policy makers and programme managers that infertility is a distal concern compared with the immediate, and more visible, threats of unintended pregnancy and STIs/HIV. However, given that fertility and infertility are central themes in the lives of many women, failure to address them head on is short-sighted. A review of the sociological and anthropological research on the subject reveals an impressive amount of grief and suffering among those affected by or fearing infertility, often resulting in prolonged, expensive and often ineffective care-seeking, primarily by women. Moreover, there is evidence that infertility treatment is playing an increasingly important role, and that assisted conception techniques have found a growing market in developing countries.⁷ Infertility deserves greater status as a public health problem—requiring proper investigation and treatment, appropriate prevention strategies and empathetic counselling and support.

The magnitude and significance of infertility for women

Infertility is a major reproductive health problem throughout the world. Male and female factors each account for approximately 40%, while the remaining 20% consists of either shared or unexplained factors.⁸ While reliable prevalence data on infertility are difficult to obtain due to problems in definition and reporting, estimates indicate that 8–12% of couples experiences some infertility problem during their reproductive lives.⁹ More recent data from sub-Saharan Africa, the region with the highest infertility rates, estimate prevalence at 15–30% in some countries.¹⁰ There is also evidence that the prevalence of infertility has been rising in many parts of the world, largely attributable to the increased incidence of infections, especially STIs, which can impair female fertility if untreated.

In much of the developing world, infertility in women is closely linked to certain STIs and to iatrogenic infections related to poorly performed medical procedures—unsafe abortion and delivery practices—all preventable conditions. Clearly, efforts to ensure access to safe abortion procedures and improve delivery practices and obstetric care would go a long way towards reducing infertility from these causes. Addressing the growing problem of STIs is also key, not least because of the relationship to HIV.

Infertility and perceived threats to fertility have serious implications for young women's lives. For example, in a review of adolescent sexual and reproductive behaviour in India, Jejeebhoy notes that infertility is deeply feared by young women,¹¹ and in Islamic society, it is said “heaven lies under the feet of mothers”. Infertility is thus often perceived as one of the worst problems a woman might face.¹²

Women's interest in safeguarding fertility may represent an important factor in decision-making concerning both contraception and abortion. Evidence from West Africa suggests that fertility and infertility are central themes for many women of reproductive age. For example, some young women believe, although erroneously, that infertility is a side effect of contraception, yet the impact on fertility of unsafe abortion, is perceived as remote.¹³ However, in other studies, adult women associate poorly performed abortion with subsequent infertility.¹⁴

Some researchers have postulated that high rates of infertility in many African communities have perpetuated the reluctance among women to initiate contraception for fear of jeopardising subsequent fertility.¹⁵ In research on contraceptive decision-making, concerns about infertility among the key reasons cited for discontinuation,¹⁶ have not been adequately probed. Asking women to provide only the main reason for discontinuing contraceptive use—a technique typically used in surveys—may give an oversimplified picture¹⁷ and mask other important underlying factors, including fear of infertility.

While infertility has a profound impact on the lives of both men and women in all parts of the world, the social consequences of infertility are arguably more severe for women than for men. Male infertility is often not acknowledged, and women are typically held responsible for a couple's childlessness.¹⁸ The repercussions of infertility have profound social, economic and health impacts for women, particularly in traditional settings where women's identity and status are inextricably bound to childbearing. Failure to produce children is known to have serious consequences and often leaves women vulnerable to physical and emotional abuse, psychological stress, ostracism and divorce.⁷¹⁸¹⁹

Men and infertility

The growing body of social science and biomedical evidence suggests that nearly 40% of infertility is attributed to problems suffered by men.⁸ Despite the significance of male infertility in the overall infertility equation, relatively little is known about how men think about their own fertility, or that of their partner. In many settings male fertility is assumed, not questioned. Despite considerable effort to involve men in reproductive health programmes in developing countries, relatively little attention—with some recent exceptions—has been paid to engaging men in discussion on and programmes to treat infertility.²⁰

The aetiology of infertility is strikingly different between men and women. The primary causes of male infertility are related to genetic and birth defects, immunologic and hormonal disorders, systemic diseases (e.g. tuberculosis), chronic illnesses, and environmental factors.²¹ STIs affect fertility in women primarily through infection of the upper genital tract and the sequelae of infection. Except for rare bilateral epididymitis, STIs produce infertility in men much less frequently.²² Studies hypothesising that STIs cause blockage to the vas deferens, thereby impairing fertility, have not been validated.²³

Men, like women, place a high value on fertility. In some societies, childless men are not treated as equal to fathers.⁷ Yet unlike women, men are better able to hide their infertility problem by claiming children elsewhere or allowing their partner secretly to have sex with another man, usually a relative, to get pregnant.²⁴ Reports from Zimbabwe, Tanzania, Cameroon and Uganda suggest that male infertility is handled with discretion in order to protect male dignity.⁷ This in turn may hamper men's involvement in infertility diagnosis, treatment and management. As a result women may undergo unnecessary and expensive treatment while the problem rests with their partners.

The degree to which women (and men) understand the links between sexually transmitted infection and infertility is not known, although given the dearth of educational and training materials on this topic, it seems likely that knowledge levels are low. A recent study in Mali aimed at understanding how adolescent boys and girls defined their sexual health needs found that the link between STIs and infertility was not understood.²⁵

Extending dual protection to include safeguarding fertility

The importance of protecting fertility, while not empirically tested, may have particular relevance wherever women's status is gauged by their fertility. Addressing the broad reproductive health needs of women, including infertility, not only exemplifies the Cairo principles but may provide useful programmatic synergies. One practical step is to build on and strengthen the momentum of dual protection initiatives.

Dual protection, as currently articulated, means concurrent protection against unintended pregnancy and STI/HIV. Only male and female condoms have been proven effective on their own against them both.²⁶ Dual protection can also be achieved through the use of male or female condoms plus another contraceptive method and/or abortion. “Dual method use” (using two methods at the same time) is a form of dual protection only if condoms are one of the two methods. Another way to achieve dual protection is through the use of a non-barrier contraceptive in the context of mutual monogamy between non-infected partners. Finally, dual protection can be achieved through non-penetrative sex. Although comparatively little attention has been paid to this last strategy in health promotion campaigns, it remains a potentially important area for future research and programmes, especially among young people.

A more comprehensive articulation of protection needs might be defined as “triple protection”, that is the prevention of three undesired outcomes: 1) STI/HIV, 2) unintended pregnancy and 3) infertility. This expansion of the dual protection construct is intended explicitly to draw out the connection between infertility and STIs, and in so doing to bolster STI prevention and control efforts, but also to highlight the connections between infertility, unsafe abortion and delivery practices in many developing countries. STIs and HIV are highly stigmatised and often not discussed, thereby making them poorly understood and often invisible. The connection between infertility and unsafe abortion and delivery techniques is often forgotten. “Triple protection” can use the “visibility” of fertility and infertility—and people's immediate connection with it—to simultaneously promote protection against STIs and HIV using. Indeed, the same methods that offer dual protection.

While other cervical and chemical barriers provide some protection against specific STIs, they have not been proven to be safe and effective against HIV. ²⁶ Cervical barriers such as diaphragms and caps could plausibly be effective in preventing or reducing the risk of some STIs, including HIV, but no prospective studies have assessed this to date. A study to test the diaphragm's effectiveness for this purpose has recently been launched. Vaginal microbicides hold promise for the future, but the lead microbicidal candidates have only recently begun advanced clinical testing.

New and improved products will help, but promotion of currently available methods of dual (triple) protection must continue with a renewed sense of urgency. The problem is that condoms are unpopular with many people, due in part to their perceived or experienced detrimental effect on sexual pleasure. In addition, family planning providers are biased against condoms because they are considered less effective contraceptives, even though with correct and consistent use they can be highly effective. The male condom is also, in many instances, associated with “casual sex” or sex outside of primary relationships. Yet this has not always been the case. Historically, male condoms became a legitimate part of pregnancy prevention strategies, first outside of marriage, and later within marriage. Condom use within marriage was acceptable and widespread, at least in developed countries, until other non-barrier contraceptive methods became more widely available. Whether STI prevention within marriage will undergo similar normative changes remains to be seen. Educating men, especially married men, about safeguarding fertility as a form of long-term self-interest might be a motivating force for changing individual and normative behaviour.

People need an expanded array of methods and means for enhancing their ability to protect themselves and their partners from HIV, STIs, infertility and unintended pregnancy, and new approaches to their introduction are also needed. The fact that dual/triple protection methods can aid in protecting fertility could be viewed, in health promotion terms, as a unique selling point. Experimentation with various promotional strategies is called for.

Meeting the protection needs of young women

The most dangerous assumption about programming for young people is that young people fit neatly into one category or another. It is critical to understand how they perceive their needs and their ability to practise protective behaviours. To date, however, much of the existing literature on adolescents has concentrated on levels and patterns of sexual activity, premarital childbearing, contraceptive and condom use, rather than on risk perception and reproductive health decision-making per se.²⁷

Power differentials between sexual partners strongly influence whether and what protective strategies are implemented, and young women are often more vulnerable than adult women to disparities in power based on age, low social bargaining power, lack of access to services and lack of economic options. In a review of age and economic asymmetries in the sexual relationships of adolescent girls in sub-Saharan Africa, Luke found that adolescent girls are not entirely victims, yet neither are they entirely in control of their sexual relationships.²⁸ Instead, girls seem to have considerable negotiating power over certain aspects of sexual relationships, yet little control over sexual practices within partnerships. Knowledge levels are often low and risk perception often does not match well with actual level of risk.²⁹³⁰

A first step is to distinguish between women desiring pregnancy and those wishing to avoid pregnancy, coupled with the extent of need for protection against STIs and HIV.

Women wishing to avoid pregnancy

For young women wishing to avoid pregnancy, the immediacy of risk of pregnancy often takes priority over concerns about infection, even though the consequences of STIs, particularly HIV, are serious. Evidence suggests that women are often able to use or negotiate use of condoms more consistently for pregnancy prevention than for disease prevention.

Married women represent the majority of sexually active young women in developing countries. Those wishing to postpone or avoid pregnancy are usually offered non-barrier contraception, which gives no protection against STIs/HIV. Research indicates that the consistent use of a highly effective contraceptive method is negatively correlated with consistent condom use.³¹ Young married women have been largely ignored in STI and HIV prevention programmes due to the underlying assumption that marriage is the gateway to safe sex. Getting their partners to use male condoms within the marriage (even for pregnancy prevention) has proven difficult for many women, while encouraging their partners to do so outside of the marriage may or may not be possible.³² However, a strategy that explicitly promotes condoms to prevent pregnancy while safeguarding fertility may prove more acceptable, even in settings with high STI and HIV prevalence. Female condoms have been promoted in Zimbabwe on just these grounds, for example.³³

Women wishing to become pregnant

Both married and unmarried girls may wish to become pregnant. Evidence suggests that some unmarried girls use pregnancy as a strategy to solidify relationships and/or marriage, though not always successfully. With respect to married women, evidence suggests that a new bride is often expected (and she herself often expects) to produce a child early in the marriage—often within the first year.³⁴ Not to do so raises suspicion about her fertility. STIs are likely to be a much more remote concern, yet the risk of STIs from sexual relationships prior to and outside marriage might exist.

The dilemma is how to reconcile the different, sometimes conflicting, needs of young women. Currently, the only options for HIV-negative women wishing to become pregnant with an HIV-positive partner are donor insemination with the semen of an uninfected, fertile man, or washing of the husband's sperm to eliminate HIV, followed by insemination.³⁵ These are not well known or accepted methods, and the latter is not yet available in most countries. Thus, there is an urgent need for an effective, non-contraceptive microbicide that would permit pregnancy while protecting, at least partially, against STI/HIV transmission.

Triple protection: moving forward

Young women need accurate information and access to services. Equally important, they need social support to protect themselves effectively.

A first step is to acknowledge the sexual and reproductive health rights of young women, including the right to safe, pleasurable, and consensual sexual relationships and the right to a safe and freely chosen marriage. At policy and programme level cross-sectoral collaboration to address the broad health and development needs of young people should also be fostered.

Educating men and women (of all ages) about healthy sexual behaviour and safer sex, basic reproductive anatomy and functioning, the risks of unprotected sex and the various means of prevention of pregnancy and STIs, what does and does not cause infertility, and what can and cannot be done about it, is needed. Such efforts could take many forms: strengthening school-based life skills education programmes, incorporating these messages into family planning, primary care, STI and AIDS prevention and control programmes, antenatal and delivery care, abortion or post-abortion care and adolescent health programmes, as well as through broader public education efforts.

Part of the challenge in addressing these needs has to do with the fragmentation of reproductive health services. Thus, STIs are most often dealt with at primary care facilities or specialist STI clinics. Problems related to infertility, if addressed at all, are more typically handled by alternative or traditional healers, particularly for poorer women, and infertility specialists for wealthier women. Contraceptives are still provided mainly by vertical family planning services, commercial marketing and or private practitioners and may or may not be linked to antenatal care. AIDS control programmes are also mainly vertical. Overcoming this fragmentation philosophically, technically and logistically will require experimentation with different service models tailored to specific settings. For example, family planning programmes could play a critical role in preventing and in some cases treating some aspects of infertility, thereby helping those with fertility problems, involving men in reproductive health care, reducing STI rates and winning greater trust from the community.³⁶ Broadening the scope of services may in fact help reduce the stigma of STIs and HIV, and make service integration more feasible and ultimately more successful.

In terms of research, there is a need for explanatory and predictive research on adolescent understanding of and use of dual/triple protection and how young people understand the causes and consequences of infertility.

Finally, the unequal status of girls and women in many societies is central to any serious discussion of protection strategies. Perhaps a combination of empowering women and enlightening men is the best way forward

HIV educator distributes contraceptives and condoms, Ethiopia, 2001