It is a relatively simple method of which the most common materials are easily available; yet, it can be the means of preventing a lifetime of unwanted responsibility, fighting poverty and preserving fertility.
It is family planning, or contraception.
There is nothing more wonderful than a couple discovering they are pregnant when they have been wanting to start, or add to, their family.
However, the opposite can also be true, more so in our still-traditional Asian society if the two parties are not in a position, or willing to, get married and/or raise a child.
According to consultant gynaecologist and obstetrician Dr John Teo, the latest data published in 2014 shows that 40% of all pregnancies – a total of around 85 million worldwide – are unintended.
“That means four out of 10 pregnancies were unplanned. And what is very tragic is that 50% of them ended in abortion, and this is happening everywhere, including in this country,” he says.
While there is no official data on abortion rates in Malaysia, he notes that an estimate made in a 2011 study by Universiti Malaya researchers, published in the Asia-Pacific Journal of Public Health, put the percentage of pregnancies that end in abortion in this country at 14%.
He adds that this translates to about 90,000 abortions annually.
In Malaysia, abortions are illegal, except under three specific conditions: to save the life of the woman, to preserve her physical health, and to preserve her mental health.
Meanwhile, around 13% of unintended pregnancies ended in a miscarriage, while the rest went on to deliver an unplanned child.
“All these (three outcomes) have very high health consequences,” says the Federation of Reproductive Health Associations Malaysia (FRHAM) medical committee member.
“Because unplanned pregnancies are pregnancies that do not get enough check-ups, do not have proper preparation, do not see the doctor enough, etc.
“So the complications in women with unplanned pregnancies are much higher than in women who plan their pregnancies.”
According to the World Health Organization’s maternal mortality report, approximately 830 women are dying every day from preventable pregnancy- or childbirth-related causes, with 99% of those deaths occurring in developing nations.
With four out of 10 pregnancies being unintended, Dr Teo comments that 40% of these women need not actually die “because they did not want to get pregnant in the first place!”
He adds: “That’s how critical contraception is in trying to save women’s lives.”
In Malaysia, the 2016 maternal mortality ratio from the 2017 Health Facts by the Health Ministry is 29.1 per 100,000 live births.
This represents a rise in the ratio for the first time in two decades, according to Dr Teo.
“And this is only women dying, let’s not talk about women who suffer permanent health damage,” he says.
Sexually active without contraception
Unintended pregnancies are the consequence of unprotected sex, inadequate contraception or failure of contraception.
A study quoted by Dr Teo reports that 84% of the 89 million unintended pregnancies worldwide in 2017 were due to the lack of modern contraception.
Seventy-four percent were the result of no contraception at all, while the remaining 10% were due to the use of traditional methods of contraception, which are unreliable.
According to the latest Malaysian Population and Family Survey (MPFS), just over half (52.2%) of currently married women aged 15-49 years (i.e. of reproductive age) are currently on family planning.
This means that only one in two sexually-active married women capable of getting pregnant, are using any form of method to prevent getting pregnant.
“What is more worrying,” says Dr Teo, “is that only 34% are using modern methods. So, out of every 10 women, only three are using modern methods – the usage is very low.”
The 2014 survey, done once every 10 years, also found that among the nearly one-fifth (19.2%) of sexually-active singles aged 25 and above, 58.2% have used some form of contraception, with 56.7% of males and 64.8% of women having done so.
More worrying is that among the 4.8% of 13- to 24-year-olds who have had sex, only an average of 35.1% have used contraception, with around one in seven (14.9%) aged 13 to 17 and two in five (39.5%) of 18- to 24-year-olds having done so.
The more recent 2017 National Health and Morbidity Survey (NHMS), which spoke to secondary school students across Malaysia for its Adolescent Health section, reported that 7.3% of these students aged 13 to 17 have had sex, with 5.4% having had sex within the last 30 days.
This is an increase from the 2.3% of 13- to 17-year-olds in the MPFS done three years prior.
Of the 7.3% in the NHMS, nearly one-third (31.9%) had sex before they were 14 and 16.6% have had at least two sexual partners.
However, less than a quarter (23%) used contraception during their last sexual encounter, with 12.7% using condoms and the rest, other forms of birth control.
A result of this is that there were 12,492 pregnancies in girls aged 10 to 19 years old in 2016. This works out to an average of 34 teenage pregnancies in a day.
While the good news is that the numbers of such pregnancies have been decreasing annually since 2012 (18,856 pregnancies), a point to note is that these are only the girls that went to a public clinic; those who did not seek out medical care at a government clinic are not included in these numbers.
Says Dr Teo: “For the young, this is what we need to do – to actually institute comprehensive sexual education.
“Contrary to popular belief, comprehensive sexual education does not increase sexual activity. It does not encourage young people to have more sex. It does not increase risky behaviour.
“In fact, what comprehensive sexual education does is, it delays initiation of sexual intercourse.
“Because when you give more information, they know the danger, so that’s why they may not do it or wait until the right time – they delay.
“It also decreases risky sexual behaviour, so they do not get unintended pregnancy, they do not get HIV and all the other consequences.”
According to the 2014 MPFS, less than half of 18- to 24-year-olds (45%) are aware of contraceptive methods.
The two most well-known methods were the condom (81.7%) and the contraceptive pill (60.8%).
These are also the two most easily-available contraceptives.
Malaysian Pharmaceutical Society (MPS) Young Pharmacist Chapter (YPC) deputy chairperson Cedric Chua comments: “Across the board in all pharmacies, the two most common contraceptives would be the oral contraceptive pill and condoms.
“The pills can be readily acquired through consultation with the pharmacist, whereas the condoms are over-the-counter.”
He notes that pharmacists are often the first point of contact for those interested in family planning or contraception, as they are available in most retail pharmacies and are easier to get hold of than a doctor in a clinic.
He shares that some of the common questions they are asked include how to manage missing one day of the contraceptive pill, about emergency contraceptives, the benefits and side effects of oral contraceptives, and how to switch contraception brands.
“But then, we pharmacists do face a challenge – if you’ve been to a pharmacy before, you know how fast-paced things are, and oftentimes, pharmacists don’t have much time for you, so that’s a challenge,” he says.
This is where the Three-Minute Oral Contraceptive Counselling programme initiated by Bayer Malaysia, and run by MPS and FRHAM, can come in handy.
The programme, Chua says, can help pharmacists navigate two key challenges: the lack of time some of them have to counsel clients and the gap in knowledge of pharmacists on how best to communicate the necessary information to their clients.
Explains Dr Teo: “We developed this three-minute card to give them an instant reminder about common questions that women ask and common problems that women face, and also common management problems.
“So it is actually a professional tool; it is for pharmacists, rather than for the public.”
He adds that there are two parts to the programme, which are getting pharmacists acquainted with the information in the cards, and sharing counselling techniques with pharmacists to help them tackle this very personal issue.
Dr Teo and Chua were speaking at the launch of another initiative by Bayer Malaysia, a Messenger-based chatbot aimed at increasing access to family planning information for women.
Called Ask Maya, the chatbot was developed in collaboration with FRHAM and MPS YPC.
Bayer Malaysia senior product manager Shasila Nadarajan notes that young people tend to associate family planning with marriage.
She says: “We want young people – not only female, but also male – to understand that it’s not about you creating a family immediately, but it’s about you getting yourself educated.”
As family planning can be a sensitive, and even taboo, topic in our culture, Shasila explains that Ask Maya is a way to obtain accurate information in a private manner without feeling judged.
The chatbot is able to engage in a conversational manner on selected topics about the contraceptive pill chosen by the person engaging with it, including how to manage missing a pill and the long-term consequences of the pill on fertility.