Academic journal article The Hastings Center Report

Long-Acting Contraceptives: Rationale, Current Development, and Ethical Implications

Academic journal article The Hastings Center Report

Long-Acting Contraceptives: Rationale, Current Development, and Ethical Implications

Article excerpt

Beginning in the 1950s, international anxiety about rapid population growth engendered great concern about reducing high fertility in developing countries. In many countries the demographic rationale for establishing family planning programs received greater emphasis than did concerns for the reproductive health of individuals. To achieve high levels of continuous contraceptive practice, priority was attached to modern contraceptives, especially long-acting methods and sterilization. Family planning program managers and international agency officials championed the "cafeteria approach," offering a wide range of methods to women and men. But modern, long-acting methods including sterilization were frequently emphasized, both in research and in service delivery. Methods requiring repeated actions by the user were given lower status in many countries, on the grounds that they were too difficult for women and men to use consistently.[1]

As a result of this enthusiasm for modern technologies, user-controlled barrier methods, despite their important historical role in industrialized countries, were relegated to second-class status. And while the oral contraceptive was quickly introduced and widely accepted by women in most industrialized countries, public health and family planning officials were skeptical about the ability of women in developing countries to use this technology effectively and continuously. The IUD, on the other hand, was greeted with great enthusiasm because it didn't require any motivation or action on the part of women after insertion, and it would remain in place for many years.[2]

Beginning in the 1960s research for improved contraceptives aimed for characteristics that seemed to have the greatest potential in developing countries with low levels of literacy. The "ideal" method would have the following characteristics:

* long-acting

* highly effective, as close to 100% as possible

* safe

* few or no side effects

* fully reversible

* application not coitus-related

* no need for continuing supplies

* little or no need for action on the part of the user, after initial acceptance

* low cost.[3]

Such a contraceptive would, in all likelihood, require the actions of a trained health provider to initiate and to stop. There was little examination of the relative value of provider-dependent methods and user-controlled ones, other than the requirements for training and sound medical technique that might be required for the former.

Ironically, another method, having virtually all the desired features save one, became increasingly widely used throughout the seventies and eighties. This method was sterilization. Despite its irreversibility, female sterilization became the most widely used method of contraception throughout the world.[4]

The search for new, long-acting, reversible contraceptives intensified. Ethical concerns about sterilization were greatly heightened by the coercive practices employed during the Indira Ghandi emergency period in India in the mid-seventies.[5] This experience, and the potential of coercive use of sterilization in other countries, further fueled the effort to find better long-acting methods that would be fully reversible.

With the strong support of U.S. foundations, and later of the United States and other Western governments and United Nations agencies, several public institutions initiated contraceptive research and development programs beginning in the early 1970s. Donor funding was primarily from international development assistance accounts (which were focused on the needs of developing country populations) and only secondarily on the developed world's needs.

An underlying assumption of the contraceptive development enterprise was that poor women in developing countries would have great difficulty using any method that required repeated application, that was coitus-related, or that required extensive education and training. …

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