New research on contraceptive method choice in Zambia and Malawi

ICRW recently released a new research study exploring the social and cultural context of gender dynamics, sexual relationships and contraceptive method choice in Zambia and Malawi.

The research was funded by USAID, and completed in partnership with WomanCare Global and PSI under the Expanding Effective Contraceptive Options (EECO) project, which aims to support the introduction of woman-initiated family planning methods in Zambia and Malawi.

Globally, an estimated 142 million women have an unmet need for family planning, with many sub-Saharan countries recording the highest levels of unmet need at 24 percent, double the world’s average in 2015. Effectively addressing unmet need for family planning requires implementing interventions to tackle constraints on both the supply and demand side of the equation, and recognizing the ways in which supply and demand issues affect each other.

As part of the global FP2020 effort to reach 120 million new women with access to family planning by 2020, the U.S. Agency for International Development’s Bureau for Global Health, Office of Population and Reproductive Health (USAID/GH/PRH) has prioritized the need to expand method choice as a key component of addressing unmet need for family planning.

One key requirement for expanding method choice is the increased availability of methods, including diversifying the method mix, as well as developing new methods that meet the dynamic and diverse needs of family planning clients. Expanding method choice also demands an in-depth understanding of how and why women and men choose among available contraceptive methods across their life course to best fit their needs, as well as an examination of the full spectrum of challenges that affect whether current family programs meet the needs of women and men globally.

The methods covered in this research study are the SILCS diaphragm and the Woman’s Condom, both developed by PATH. ICRW conducted studies in Malawi and Zambia to help inform the marketing of the Woman’s Condom and the potential introduction of the SILCS diaphragm in these countries. Both the Woman’s Condom and the SILCS diaphragm are woman-initiated non-hormonal barrier methods, though the condom has dual functionality as a family planning method as well as a form of protection against STIs, including HIV.

The study was designed to understand the social and cultural context of sexual relationships, explore how these contextual factors might influence the uptake of contraception in general, and these new methods specifically. ICRW also designed the study to understand provider-related attitudes and beliefs about potential users.

Findings

ICRW found that many study participants expressed views that reflected unequal gender norms. For example, men’s desires were often prioritized within sexual relationships, and gender stereotypes that subordinate women were prevalent in discussions about sexual relationships, pleasure and intimacy, and couple communication.

On the supply-side, when asked if they would recommend the Woman’s Condom or the

SILCS diaphragm to their clients, most providers responded in the affirmative, pointing to the non-hormonal aspect of the products and the fact that they were short-term, both qualities they believed best fit their younger clients. However, some providers stated that they would not recommend the SILCS diaphragm to commercial sex workers due to their heightened risk of exposure to HIV and STIs.

The study highlights the importance of ensuring that efforts to expand method choice incorporate a culturally appropriate and contextualized understanding of the reasons behind potential preferences for certain contraceptive methods over others, and how these preferences may change during different stages in an individual’s reproductive life and/or sexual relationships. The findings further suggest that the introduction of the Woman’s Condom and the SILCS diaphragm in Malawi and Zambia should be supplemented by strategies that address some of the gender norms and stereotypes that undermine women’s ability to make fully informed decisions about their reproductive intentions and needs.

“What is so important about these studies is that they demonstrate the intricacies of expanding methods choice and access to family planning,” said Lydia Murithi, co-author of this report. “These efforts must go beyond product design and supply chain management and take into account an individual’s motivations or impediments to use a given method at a particular time, even per sexual act, over the course of his or her life.”   

Recommendations

ICRW has used the findings to make concrete recommendations to improve marketing strategies that could help increase uptake of the new methods among women in Malawi and Zambia.

For the Woman’s Condom, marketing strategies should: portray use of the condom as desirable by both men and women in a variety of sexual relationships; bust myths around lubricating gel; and be guided by strong male engagement, including in challenging gender norms.

For the SILCS Diaphragm, marketing strategies should capitalize on the cost-effectiveness and non-hormonal nature of the method, as well as stress how the diaphragm prevents pregnancy but allows for the much-desired skin-to-skin contact. Additionally, education and awareness on proper use and hygiene of the diaphragm would be beneficial.

A full list of recommendations can be found here.