Contraception Family Planning Population Reproductive Health

Sometimes it is Best to Hide Contraceptive Use

            55 years ago a young patient and I were standing in the sun just outside the clinic doorway when a butterfly alighted on my left ear. “Yes, I would like to try an IUD” the patient said, amazed and apparently encouraged by the butterfly.

            It was the summer between my 3rd and 4th years of medical school. My new wife and I were having a wonderful adventure at the Moravian Hospital in Puerto Cabezas, Nicaragua.  The patient I had been persuading to try an IUD was also newly married and wanted something to keep from conceiving right away. She didn’t think her husband would approve of using birth control, however.

            “If you had an IUD, he wouldn’t know about it unless you told him,” I had encouraged her. Apparently, the butterfly landing on my ear was the deciding factor, and I was able to insert a Lippes loop.

            Hiding contraceptive use is a common strategy in many countries where patriarchy rules. Men in patriarchal societies usually desire large families, and don’t want their partners to make decisions about childbearing. Research has found that covert use of contraception is common in some African countries, especially for wives of polygamous marriages. As many as a third of women in some places conceal their use of birth control! Although I am certain that some women in the USA use contraception without their partner’s knowledge, I have not been able to find a study of its prevalence in this country.

Some birth control methods are easier to hide than others. A pack of pills would be easy to conceal, but it would be a dead giveaway if found. DepoProvera® shots are effective for 3 months and are easy to keep secret. A wife could go into town to shop, as usual, but also stop at the health clinic for her birth control shot. Indeed, some women have stated that is one of the reasons they chose thei method. 

            There is a new form of DepoProvera® that is packaged so that a woman can give it to herself at home. It is small enough that the pre-filled injection unit would be easy to conceal. Large studies in African countries have found women like this formulation, but unfortunately Sayana®Press is not available yet in the USA. There are other LARCs (Long-Acting Reversible Contraception): Nexplanon®, good for 3 years, and several IUDs, which last up to 10 years, are all easily concealed.

            I do not recommend covert use of contraception. However, in some cases it is the only way that women can avoid unwanted pregnancies. Since the majority of family planning methods are female-controlled, the wife should—and can (by hiding her birth control)—have the last word about childbearing.

It only seems right that women should decide about family planning since birthing and most of the responsibilities for childcare rest on women’s shoulders. However, it is best if husbands and wives talk about whether to use contraception, and together choose the method that would be best. This is supported by a statement of friend, Dr. Stan Becker, who has studied reproductive health decisions among couples: “…reproductive health interventions that target couples are found to be more effective than those directed to only one sex.” 

           However, we don’t live in a perfect world—unfortunately, there are many couples where power and decision-making are not shared. Since family planning is recognized as potential driver of women’s autonomy and health, covert use of family planning can be seen as a symbol of agency for the women in these relationships.

© Richard Grossman MD, 2024

Family Planning

Good News about Family Planning

            There is good news about human population. Access to voluntary family planning and to safe abortion services has not only helped women achieve their goals, but also helped slow our retreat from sustainability.

            Dr. George Denniston wrote that people in Mexico have experienced “…a real miracle! Women going from having 5 kids to just 2 kids in 20 years, thanks to soap operas.” His wife, Martha (now deceased) helped see the value of telenovelas (“soap operas”) to entertain and educate people about the advantages of small families. Thanks to the Population Media Center, millions of people in 50 countries are healthier, have less risk of HIV and have learned the importance of preventing unintended births.

            Mexico has established excellent programs to decrease adolescent pregnancies. Teens would be most hurt by having a child too early in their lives. One program almost halved the teen pregnancy rate in just 4 years!

            There is more good news: last month the Mexican supreme court decriminalized abortion. This decision stated: “… laws prohibiting the procedure are unconstitutional and violate women’s rights….” This is surprising since the majority of Mexicans are Roman Catholic. 

Mexico is following a trend throughout Latin America propelled by the “green wave” of abortion-rights activists. In the past many countries in this area have had strict antiabortion laws, but that is beginning to change. In 2021 Argentina started the trend to allow abortion on request, followed by Columbia and Mexico. Globally, 50 countries have liberalized their abortion laws since 1994, and only 4 have decreased access to safe abortion services—including the USA.

Fertility is decreasing all over the world. The replacement Total Fertility Rate, which will lead to a steady population eventually, is an average of 2.1 children born per woman. That’s one child to replace the woman and the second for the man, plus a fraction for children who don’t live to reproduce. However, due to “population momentum”, the population of a country will continue to grow for a few decades after its TFR has dropped to 2.1.

            50 years ago, the worldwide TFR was 4.4; now the global TFR is an amazingly low 2.3! We are getting closer to the goal of 2.1 replacement fertility. Already there are several countries that have shrinking populations, including Japan and the giant, China. In fact, the TFR is less than 2.1 in 124 countries out of the UN’s list of 240. One factor that has contributed to this fertility decline is that more than 100 million people around the world use long-acting reversible contraception—like intrauterine devices (IUDs). 

            Population growth is slowing down. The annual increase in global population is decreasing from a high of 92 million people in 1990 to 70 million or fewer during the past 3 years. In addition, we have reached “peak child”. We will probably never have as many children on the planet as we have now.

            What is amazing is that this decrease in fertility has been done without coercion. The major factors that have permitted this are: increasing the availability of effective contraception, women’s education, and decreasing patriarchy. There is one other wonderful factor which is seldom touted, but which is worth celebrating. The mortality rate of young children has been halved over the past 30 years. People choose to have smaller families when they know their children are likely to survive.

            Don’t get me wrong—we are still far from having a human population that fits sustainably on Earth! This is a progress report, not a final account of the effect of family planning on protecting the planet.

©Richard Grossman MD, 2023