Department of Health, Pretoria, South Africa, December 2012
Foreword by the Minister of Health, Dr AP Motsoaledi, MP
The National Contraception and Fertility Planning Policy and Service Delivery Guidelines and National Contraception Clinical Guidelines are extremely important documents aimed at reprioritising contraception and fertility planning in South Africa, with an emphasis on dual protection.
Contraception is one of the most powerful public health tools for any country. Providing women with access to safe and effective contraception is a critical element of women’s health. Enabling women to make choices about their fertility is empowering and offers women better economic and social opportunities. Birth spacing also improves the opportunities for children to thrive physically and emotionally. Engaging men in sexual and reproductive health encourages shared responsibility in their roles as partners and parents.
The adoption of the revised Contraception Policy takes place within the context of renewed international focus — at the 2012 global Family Planning Summit held in London, the importance of contraception to human development, gender empowerment, HIV and sexual and reproductive health was once again emphasised.
Against this background I am delighted to release the revised policy on contraception and fertility planning. It is being launched during an exciting period in the history of health care in South Africa, with the re-engineering of primary health care, emphasis on health systems strengthening, implementation of the National Core Standards, and closely linked to this, the introduction of the National Health Insurance. In addition, the policy has been developed against the background of the HIV epidemic. About one-third of young South African women are HIV positive, and contraceptive provision and fertility advice must take this into account. Similarly, two-thirds of South Africa’s young women are HIV negative but are at risk of HIV infection, and their counselling and choices need to take issues related to risk and prevention into consideration.
Noting the above, much depends on the successful implementation of this policy. Contraception is one of the World Health Organization’s four strategic prongs for the prevention of mother-to-child transmission of HIV. Contraception and planning for conception contributes to the reduction of HIV transmission, thereby supporting the National Strategic Plan on HIV, STIs and TB (2012–2016). It has enormous potential to contribute to South Africa achieving its Millennium Development Goals, particularly MDGs 4 and 5. It is also an important part of the strategy to ensure the successful implementation of the African Union’s Campaign for the Accelerated Reduction of Maternal, Neonatal and Child Mortality in Africa (CARMMA), to which South Africa is a signatory. The revision of the contraception policy was deemed necessary to ensure up-to-date practice in South Africa, and reflects the changes over the last decade in the fields of HIV, contraceptive technology and related research. One of the most significant changes has been the expanded scope of the policy – to embrace both the prevention of pregnancy (contraception) and the planning for a healthy pregnancy (conception). The policy also reflects the Department of Health’s focus on human rights, quality and integration. Drawing on the expertise of scientists, clinicians, health workers and practitioners, the revised policy provides a framework for a broad, forward-looking contraception and fertility planning programme, with an emphasis on improved access as well as expanded contraceptive choice.
Now, more than ever, the successful implementation of this policy is of critical importance. We urgently need to deal more effectively with the challenges facing our country in terms of unacceptably high rates of HIV, teenage pregnancy, unintended pregnancies, infant and maternal mortality, and the elimination of mother-to-child transmission of HIV. Improved access to and use of contraception will result in a decreased demand for termination of pregnancies. Encouraging women to plan for healthy pregnancies, including timing and spacing, will improve health outcomes for both mothers and babies. However, the realisation of a sound, innovative policy can only be measured by its successful implementation. To ensure that this happens, I call upon all health workers to prioritise the following five key actions:
(i) The provision of quality contraceptive health services: We need to ensure that we have a robust health system so that we can provide the contraceptives and services we promise — this involves improved access, expanded choice, quality care, staff training and continuous and efficient commodity supply.
(ii) Stimulating community awareness and demand: We need to ensure that our communities understand the importance of contraception and planning for healthy pregnancies, the range of methods available and where they can be obtained — this requires advocacy and demand creation, underpinned by effective communication strategies which encourage informed decision-making and contraceptive use.
(iii) Putting integration into practice: We need to deal with the dual challenges of HIV and unwanted pregnancies, through the promotion of condom use and dual contraception as well as through the active promotion of integrated HIV and sexual and reproductive health services — we need commitment, creativity and flexibility to actively operationalise integration.
(iv) Strategic multi-sectoral collaboration: We need to expand access beyond traditional clinical settings and strengthen provision. To this end, we need vibrant, responsive partnerships — with civil society, the private sector, and development and implementing partners.
(v) Evidence-guided planning and provision: We need to ensure that the implementation of the policy is monitored, evaluated, and that international and local research informs decisions and planning.
from the Introduction
Guiding principles
These Policy and Guidelines for contraception and fertility planning are framed by the sexual and reproductive health and rights framework adopted by the Department of Health (DOH) in 2011 (Sexual and Reproductive Health and Rights: Fulfilling our commitments), the guiding principles for which are:
strong and visible stewardship for sexual and reproductive health and rights
integrated services at the district level
a human rights approach
a life cycle approach
meeting diverse needs
care for the caregivers
intersectoral collaboration.
The revision and updating process
The revision process involved the formation of an expert group and a broader consultative forum set up to make recommendations and review successive versions. There was also a wider call for submissions distributed through various electronic mailing lists. The deliberations and recommendations from these working groups, together with other submissions from individuals and organisations, form the main body of the revised policy.
What’s new in the revised policy?
The revised Policy and Guidelines include the following noteworthy changes:
Expanding the policy’s mandate
The new policy addresses both contraception and fertility planning. This is based on the view that, particularly in the era of HIV, fertility planning must be part of the approach to counselling women of childbearing age about their fertility intentions.
Key revisions
expansion of the scope of the policy to encompass both the prevention of pregnancy (contraception) and the planning for pregnancy (conception);
reformulation of principles, objectives and strategies;
inclusion of contraception and fertility planning within the context of HIV in South Africa — addressing the needs of women at risk of HIV, HIV-positive women either on or off antiretroviral treatment and their partners;
appropriate integration of contraceptive and fertility-planning services with HIV, tuberculosis, prevention of mother-to-child transmission of HIV, maternal health and adolescent services;
promotion of screening opportunities linked to contraceptive and fertility-planning services: HIV counselling and testing, HIV, sexually transmitted infections, tuberculosis, cervical and breast cancer;
special service delivery and access considerations for sex workers, lesbians, gay, bisexual, transgender and intersex persons, migrants, and men;
special service delivery and clinical considerations for adolescents;
special clinical considerations for women who are peri-menopausal, have a disability or a chronic condition;
strengthening the role of hospital-based referral services for training doctors and nurses, and management of complex clinical cases.
Expanded method mix
increased access to additional long-acting contraceptive methods, with specific consideration of:
increasing access to the copper intrauterine device (Cu IUD), with antibiotics at the time of insertion,
introduction of a single-rod progestogen implant,
introduction of the levonorgestrel intrauterine system (LNG-IUS) as a referral method,
introduction of combined oestrogen and progestogen injectables;
increased access to female condoms;
increased access to, and promotion of, emergency contraception pills;
increased access to contraception: the incremental expansion of non-clinical settings as outlets for the provision of contraception, for example, ward-based primary health care teams and community health workers to issue hormonal contraceptives.
In addition, noting the changes in the World Health Organization’s medical eligibility criteria, and possible increased risk of HIV acquisition with injectable progestogens, there is a shift in emphasis away from injectable progestogens towards alternative long-acting reversible contraceptives (Cu IUDs, intrauterine systems, subdermal implants); and, because of the possible increased risk of HIV acquisition, emphasis is given to the importance of condom use for women who choose to use injectable progestogens.
Summary of important data
Fertility has been declining gradually in South Africa in the past four decades.
Data from Statistics South Africa (Stats SA) indicate that fertility in South Africa is still on a downward trend (with an estimated total fertility rate of 2.35 in 2011, compared to 2.92 in 2001). This places the fertility level for South Africa among the lowest in the whole of sub-Saharan Africa.
Provision of contraception in public sector facilities
The 2003 South African Demographic and Household Survey indicates that 83% of women obtain their contraceptive methods from the public sector. The District Health and Information System records the distribution of each method of contraception in public sector clinics across all provinces.
An analysis for the period 2008–2010, based on data from the District Health and Information System, identified these broad trends:
Relative to other methods, provision of copper intrauterine devices (Cu IUDs) is extremely low. However, there are suggestions that provision is increasing in most provinces, with provision in the Western Cape being the highest.
In all provinces more injectable progestogen contraceptives are used than oral contraceptives.
Progestogen injectable contraceptives account for 49% of current contraceptive use nationally and up to 90% in some areas. Of the two available injectable progestogens, depot medroxyprogesterone acetate (DMPA) is more commonly used than norethisterone enanthate (NET-EN). The latter is often favoured for use amongst younger women.
Availability of services
The Negotiated Service Delivery Agreement aims to improve access to contraceptive services with a target of 90% of all public health care facilities providing contraceptive services by 2013. Information on the current availability of contraceptive services is limited and outdated. The last audit of primary health care facilities was undertaken in 2003 and indicated that, nationally, 88% of primary health care facilities offered contraceptive services five days a week.
The 2009 DOH annual report states that 1,053 (30.3%) of facilities provide an acceptable contraceptive mix to clients, defined as dual protection – condom and a contraceptive method.Footnote*
Rates of contraceptive use
Data indicate that contraceptive use is relatively high, with an estimated 65% of sexually active women between the ages of 15–49 using a modern contraceptive method. (Modern methods of contraception include female and male sterilisation, oral hormonal pills, the Cu IUD, the male condom, injectables, the implant (including Norplant), vaginal barrier methods, the female condom and emergency contraception.)
Adolescent contraceptive use… fertility and pregnancy
According to the second national youth risk behaviour survey in 2008 (South African Medical Research Council), a survey of learners in Grades 8 to 11 in public sector schools across the nine provinces found that 37.5% of learners had already had sex, of which 17.9% indicated that they used no contraception. Overall, 45.1% of learners who had already had sex indicated that the method of contraception that they most commonly used was a condom. Only 7% used injectable contraceptives and 4.2% used oral contraceptives.
Reporting on teenage pregnancy rates is complicated and very little recent nationally representative data are available. Data on the number of teenagers who get pregnant come from a number of different sources and suggest that teenage fertility rates are decreasing. Teenage fertility has declined by 16% between 1996 (78 per 1,000) and 2001 (65 per 1,000). A further decline in teenage fertility (54 per 1,000) was reported in the 2007 community survey. Older adolescents, 17–19 year olds, account for the bulk of teenage fertility in South Africa…. A report on teenage pregnancy in school learners indicates a steady increase in pregnant learners.
Termination of pregnancy
Data on the availability of counselling and termination of pregnancy services are limited. Both the national and provincial Departments of Health report that service provision is suboptimal and that not all accredited facilities are actually providing termination of pregnancy services. A number of districts across the country are unable to provide such services at all. Reasons given for suboptimal service provision were inadequate numbers of trained staff, long waiting times and conscientious objection by health care workers. As a result of suboptimal service provision, the number of terminations performed decreased from 77,207 in 2009 to 68,736 in 2010.
HIV and contraception in South Africa
The overall HIV prevalence in South Africa is estimated to be 17.9%, with an estimated 5.575 million people living with HIV. The National Antenatal Sentinel HIV and Syphilis Survey (2010) indicates that the overall HIV prevalence among pregnant women is 30.2%. While the overall prevalence has changed little in the past three years, the persistently high HIV prevalence among young women remains a major concern, with 15–25 year-old women being the highest incidence group in the general population. While the number of girls aged 10–14 years in the antenatal survey was only 0.4% (n = 121), the HIV prevalence of 9.1% in this group was significant and is of great concern. Young teenagers represent a high risk and vulnerable age group and warrant special attention.
South Africa’s response to HIV is shaped by the National Strategic Plan on HIV, Sexually Transmitted Infections and Tuberculosis: 2012–2016 (NSP). The NSP makes explicit reference to sexual and reproductive health and rights, and the necessity of including contraception and fertility planning in its HIV strategic objectives
Notes
* The District Health Barometer 2008/2009 reports that there are 3,470 clinics and community health centres in South Africa. This number of facilities was used to calculate the percentage of facilities providing an acceptable mix of services. Note that mobile clinics and hospitals were excluded from this denominator.