The updated national contraception clinical guidelines and the national contraception and fertility planning policy and service delivery guidelines from the health department are a welcome political commitment to women's health, including sexual and reproductive health and rights.
Apartheid was associated with an effort to control the fertility levels of the black population. With the coming of democracy, the new population policy and the contraception policy actively shifted to promote contraception as part of the right of women and men to decide for themselves if and when to have children and how many they would like to have.
Promoting choices and personal decision-making is an ethos that should never be compromised. However, contraceptive services have, to date, not received the attention they deserve. This is despite the strategy to prevent the transmission of HIV from mother to child. This strategy is intended to strengthen a woman's ability to decide whether or not to have a child, as well as to prevent the transmission of HIV to babies, but in reality it is often solely focused on the baby.
The national contraception clinical guidelines are accompanied by service delivery guidelines – a companion implementation guide. This is to be commended because it addresses the services that need to be provided in the context of HIV and, in particular, it addresses the concern that certain types of hormonal contraception (progestogen-only injectable contraception for instance) may either increase a woman's vulnerability to contracting HIV or, if she is HIV-positive, increase the transmission of HIV to her HIV-negative partner. While there is not yet adequate evidence on this, the reintroduction of the "loop" (intra-uterine device) is the correct direction in which to head as a loop is not contraindicated for HIV-positive women.
Given the high rates of HIV infection in South Africa, recognition of the need for greater supplies of condoms and in particular, female condoms, is to be welcomed. The tender is out for the female condom and we look forward to a range of female condoms becoming widely available. With the woman's condom receiving SABS certification in May 2013, it is hoped that it will be supplied in state facilities soon.
The policy is also to be commended for clear sections that address the provision of services to those who are often marginalised in healthcare settings. Clear guidance is provided to health workers for making qua-lity health services available to adolescents, sex workers, transgender women and migrants.
All too often these marginalised people are turned away by the judgmental attitudes of health workers. Sex workers need to be provided with services and condoms without fear that they will be confiscated as proof of criminal behaviour. Migrants need contraception irrespective of citizenship. Adolescents – including those born and living with HIV – need to be provided with contraception and their emerging sexual and reproductive health needs should be embraced as opposed to shamed and neglected. We need to welcome the opportunity to provide comprehensive education to our children to guide their future sexual and reproductive health. Children with information and a safe space to talk about sexual issues tend to delay sexual debut, have fewer sexual partners, fewer unintended pregnancies, and experience lower rates of coerced sex and sexually transmitted infections.
The contraceptive policy is also a first step towards addressing the needs of transgender people for hormones, although we look forward to a substantive policy on this issue in its own right. Transwomen have used self-administered contraceptives to obtain optimal hormonal effects, but have done so without the appropriate blood, liver function and cholesterol testing, which has put them at risk. For HIV-positive transgender women, issues such as the interaction with antiretroviral drugs and other hormones needs to be carefully considered.
To ensure the policy is effectively implemented the department needs to collaborate with others to develop and accredit the comprehensive training of health workers in sexual and reproductive health and associated rights to address the continuum of care and address stigma in relation to fertility planning issues. Beyond the policy is the need for mulisectoral collaboration to obtain adequate implementation and good quality care.
Monitoring contraception rates
It is important to measure our contraception rates, which has not been done since 2003. With this data, we could plan better services and assign clear budget lines. Similarly, it is important to trace contraception services and ensure that no woman, whether in the public or private sector, is having to pay for these services.
In line with the department of health's quality of care initiatives it would also be important to monitor the implementation and quality of care of contraception and fertility planning services.
Implementation of this policy provides a welcome opportunity for training and partnerships with the private sector and nongovernmental organisations to increase capacity and resilience in the provision of health services to women.
The policy refers to an overarching framework produced by the department but not yet published – "Sexual and Reproductive Health and Rights: Fulfilling our Commitments". Its publication would help the department of health as well as corporate, civil society and donor stakeholders to understand how to address people's sexual and reproductive rights and needs in a more integrated manner. More importantly, it would encourage all sectors to take on the issues that underlie unintended pregnancy – the resort of young women to have sex with older men as a means of accessing resources, coercive sex and a culture that continues to make pregnancy the sole responsibility of women.
The dangers inherent in this contraception policy are that unless the department also promotes women's rights, health workers will continue to decide for women what contraceptive they need and when. The convention of giving black women contraceptive injections immediately after childbirth, for example, will not be changed without concerted efforts to build a culture that respects women's autonomy; and the introduction of long-term implants will only increase the likelihood of abuse. What is needed is for the department, with the social development department, to lead a multisector, multistakeholder initiative to promote dialogue about sexuality and a culture that respects the dignity and autonomy of all people.
In doing so, these groups would be acting as stewards to facilitate the constitutional provisions of the right to reproductive choice and reproductive healthcare.
The contributors to this article are The African Gender Institute, University of Cape Town (UCT); Alex Muller, health and human rights division, UCT; Gender DynamiX; Ipas; PATH; Barbara Klugman, School of Public Health, Wits; SHE; Sisonke; SWEAT; WISH Associates; and the Women's Global Network for Reproductive Rights