“Reproductive health implies that people are able to have a responsible, satisfying and safe sex life, and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.
“Implicit in this are the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth, and provide couples with the best chance of having a healthy infant.” (World Health Organization)
The provision of information about sexuality and reproduction has been perceived by many that it encourages sexual activity.
However, this is not supported by evidence. Good quality reproductive health education does not lead to earlier or increased sexual activity.
When the young are well informed about sexual responsibility and contraception, evidence shows that it leads to decreased teenage pregnancies, abortions and sexually transmitted infections.
Sexual activity and pregnancy
Pregnancy can result if any sperm is deposited inside the vagina or spilled on the vulva.
A female can get pregnant if she has had her first period, even if she is aged 12 or less; it is the first time she has sexual intercourse; does not have intercourse often; has intercourse during her period; does not have an orgasm; is not fully breastfeeding; douches (washes the vagina with fluid or other materials) after intercourse; or the penis is withdrawn before ejaculation (coitus interruptus); and irrespective of the position during intercourse.
Young Malaysians have limited knowledge about sexual and reproductive health.
For example, one out of 10 and 42 out of 100 thought that douching and coitus interruptus respectively were effective contraceptive methods; 51 out of 100 did not know pregnancy could occur during the period; and one out of four thought contraception was “not required so long as there’s mutual trust between partners”.
“More than half of the sexually active said that their first sex was unexpected or unplanned.”
Unsurprisingly, Malaysia has a relatively low contraceptive prevalence rate of 55.6% in 2010 and 52.6% in 1990.
Malaysia’s unmet need for contraception was 17% in 2010 and 18.6% in 1990.
By comparison, the contraceptive prevalence rates for all developing countries were 62.0% in 2010 and 51.8% in 1990, and the unmet need 12.8% in 2010 and 16.5% in 1990.
Making the right choice
Choices are made throughout life.
A baby brings joy to parents who are prepared to provide the love and care needed.
However, an unintended or unwanted pregnancy brings problems and sorrow to the parents, particularly the young women.
There are about 18,000 teenage pregnancies annually in Malaysia, i.e. about 50 every day. Over a thousand newborns were reportedly dumped in the past decade, i.e. two every week with more than half found dead.
Advising adolescents and young people not to have sexual intercourse is obviously insufficient without concomitant information about contraception.
The provision of access to voluntary contraception is not only crucial to the improvement of reproductive health outcomes, but also has positive associations with improved health, schooling and economic outcomes.
There are various contraceptive methods available with different methods for individuals at different times in their lives.
To make a voluntary informed choice, the information provided should include the correct use of the method, how it works, its effectiveness, common side effects if any, health benefits and risks, return to fertility on discontinuation, signs and symptoms that will require medical attention, and information about sexually-transmitted infections (STIs).
Certain methods are usually not recommended for adolescents and young people, e.g. sterilisation, intra-uterine contraceptive device (IUCD), withdrawal and fertility awareness methods.
If there has been sexual contact without contraceptive use or the contraceptive method failed, there are emergency contraception methods that can be used.
There is no perfect contraceptive method. All methods have a failure rate.
There are two types of contraceptive failure, i.e. user failure and method failure.
User failure refers to pregnancy occurring because of incorrect use or non-use of a contraceptive method.
Method failure refers to pregnancy occurring despite the contraceptive method being used correctly and consistently, or fitted correctly.
The effectiveness of a contraceptive method depends on the individual’s age, the frequency of sexual intercourse and whether the instructions are followed.
If 100 sexually-active women do not use any contraception, about 85 will get pregnant in a year.
The contraceptive failure rates in daily life are higher than that reported from clinical trials because of user failure. As such, one cannot extrapolate the failure rates in clinical trials, in which usage is more likely to be correct and consistent, to that in common daily usage.
With the exception of male and/or female sterilisation, the various contraceptive methods do not result in irreversible changes in fertility. The return to fertility is immediate with all methods, except for progestogen injections.
Anyone is exposed to STIs, including HIV/AIDS, if he or she has more than one partner or their partner has other partners. In such circumstances, there is a need to prevent pregnancy and STI.
Whenever there is a possibility of STI, the advice is to have dual protection, either through the simultaneous use of condoms with other contraceptive methods, or the consistent and correct use of condoms alone for the prevention of pregnancy and transmission of STI.
A healthy sexual relationship requires both partners to be responsible.
The questions each couple has to address include whether a pregnancy is wanted or unwanted, whether there is access to contraception if a pregnancy is unwanted and whether protection against STI is necessary.
Universal health coverage (UHC) is the core of the health-related targets of the Sustainable Development Goals which Malaysia has signed on.
Lack of coverage for sexual and reproductive health would cost women and girls their future with negative impacts on UHC and economic growth.
As health is a human right, access to quality sexual and reproductive health services, which includes contraception, should not depend on age, gender, race, financial standing or place of residence.
The contraceptive prevalence rate in Malaysia has stagnated since 1990 and is lower than the rate for all developing countries, with the unmet need for contraception higher than the rate for all developing countries.
The question is whether there are any policies and strategies to reduce the unmet need for contraception in Malaysia in the quest for UHC.
In short, it is always better to make a choice and not take a chance.