Frequently Asked Questions

What is contraceptive choice?
In simple terms, contraceptive choice is the ability of an individual to determine whether and when to practice contraception freely, with neither constraint nor pressure; and to select and obtain a safe and effective method that most suits her/his reproductive goals and intentions to delay, space, or limit a future birth. Contraceptive choice has been considered a “sine qua non” of international reproductive health and family planning programs for decades, yet in reality, few countries have achieved a balanced method mix, leaving millions of women and couples with few real options. The reemergence of family planning as a global health priority, as evidenced by the recent London Summit on Family Planning, makes this a good time to examine the meaning of contraceptive choice and how to make it a reality.

Why is contraceptive choice still out of reach for so many women? 
There are many reasons why contraceptive choice remains elusive. While there is no “ideal method mix” recognized by international experts, most agree that quality family planning programs must offer an array of methods that meet individuals’ different preferences and serve their changing needs throughout their reproductive life cycle. However, in many countries, only one or two methods predominate. This can be the result of such factors as government policy and promotion, program history, health system capacity, provider bias, women’s status, and community norms. Contraceptive security, defined as “the ability of people to choose, obtain, and use high-quality contraceptives and condoms whenever they want them,” remains one of the biggest challenges for family planning programs today. 

What options are available for women who want to limit future births?
All women should be able to adopt a method that suits their circumstances, preferences, and reproductive intentions and to switch methods when their circumstances and needs change. Women with a reproductive intent to limit future births can use any method of contraception. However, it is important that their options include effective, long-acting methods of contraception (i.e., the hormonal implant and the intrauterine device [IUD]), as well as permanent options (i.e., female sterilization and vasectomy). These methods are characterized by high levels of effectiveness and continued use, resulting in fewer unintended pregnancies and adverse health consequences. However, they also tend to be the most difficult to offer in low-resource settings, given the inadequacies of facilities and the lack of trained personnel. As a result, programs tend to rely on short-acting methods (such as the pill and injectables), since they are easier to provide.

What challenges do women who want to limit future births face?
Women who want to limit births face the same access barriers to contraception as women with other reproductive intentions. Moreover, these “limiters” have unique characteristics and needs that are often not adequately addressed by family planning programs and providers. Particularly in Africa, where family planning programs tend to be organized around the health benefits for mothers and children of the healthy timing and spacing of births, information and services are rarely geared toward women who have completed their childbearing. Enabling these women to end the fear of unwanted pregnancy and to be free of the side effects and return visits associated with short- and long-acting methods are not priorities in many programs. Current trends indicate that the numbers of women who intend to limit future births will only continue to grow.

What were the top three findings from the comprehensive literature review on female sterilization?
In 2012, RESPOND conducted a literature review on female sterilization in preparation for the Bellagio consultation, focusing on articles published since 2000. The top three major findings were: 

  1. Despite declarations made in the past two decades regarding the importance of individual reproductive rights, instances of sterilization abuse still exist. The legacy and stigma of forced sterilization continues to mar the image of family planning in many developed and developing countries. A common factor in both past and present cases of abuse is that victims tend to be from minority or other disadvantaged subsets of the population. Today, there are documented cases of coerced or involuntary sterilization among women from the Roma population in Eastern and Central Asia and among HIV-positive women in Eastern and Southern Africa. Vigilance to prevent and address sterilization abuse, once thought a thing of the past, remains an important issue in today’s world.
  2. Even in countries with a mature family planning program, significant access barriers to female sterilization remain. Legal constraints, providers’ attitudes, and societal pressures pose formidable obstacles above and beyond the general lack of availability of the method, especially in rural areas and in busy urban facilities. 
  3. Sterilization regret has been explored in numerous studies. The greatest concern is typically about postoperative regret. Overall rates of regret among women who have undergone sterilization are low. Reasons for regret are similar across studies, with risk factors including young age at sterilization (under age 30), decisions made under duress, changed family dynamics, and sterilization suggested by someone other than the client. One study in Zimbabwe (Verkuyl, 2002) showed that the percentage of sterilized women who regretted having the procedure (2.5%) was substantially lower than the level of regret among women who wanted sterilization but did not get it (40%). This finding prompted the researchers to argue that it is an ethical imperative to offer this method to women who request it.   

What common themes arose from key informant interviews on contraceptive choice and female sterilization?
In addition to the literature review, as part of the evidence base for the consultation in Bellagio, RESPOND  interviewed 18 key informants from international donor and technical assistance agencies working in reproductive health and family planning. Three important themes consistently emerged:

  1. The global image of sterilization among international and country leaders is one characterized by a lack of attention. Some believe this is because family planning was a neglected global issue during much of the last decade; others believe it is because other long-acting methods (notably hormonal implants and IUDs) supplanted the need to provide female sterilization, given their potential to provide effective and lasting contraceptive coverage. Still others suggest that stigma from past abuses is responsible for the overall lack of enthusiasm for the method. Regardless, most agreed that there has been an absence of dialogue and recommended renewed discourse.
  2. When considering rights and whether the greatest concern associated with sterilization is preventing coercion or preventing access barriers, informants felt that the program context was critical and that a choice between access and coercion is a false dichotomy—both are equally important. Most believed that access was a more pressing issue than abuse in today’s programs. However, some cautioned that renewed concern about global population growth and results-based financing of family planning programs might bring new pressures and instances of coercion.
  3. Most felt that female sterilization still has a role to play in family planning programs, although more is needed to address infrastructure and capacity constraints in low-resource settings. Informants recommended documenting success stories (such as in Kenya and Malawi), exploring how mobile units can both deliver services and build capacity, and developing an evidence base on cost and resource trade-offs to support advocacy to reposition this method.

What is the purpose of the Bellagio consultation?
EngenderHealth’s RESPOND Project is convening multidisciplinary experts at the Rockefeller Foundation’s Bellagio Conference Center in September 2012 to deliberate on what can be done to move from rhetoric to reality about matters of choice. We will be looking at these issues through the lens of female sterilization. The purpose of the Bellagio consultation is to explore what contraceptive choice means in programmatic and operational terms, why it is important, and how to advocate to policymakers and other leaders about the need to broaden method options in their programs. With specific regard to female sterilization, we expect to examine whether there is a rationale for continued attention and investment in ensuring that it remains a viable option in family planning programs.  

Why is there a particular focus on the role of female sterilization at the meeting?
Issues of choice are heightened with this method, since it the most widely contraceptive used among women worldwide, but its availability varies across regions and countries, and it is the method most often at the heart of reproductive rights abuses.  

What are the anticipated outcomes of the Bellagio consultation?
We expect to produce:

  1. An operational definition for contraceptive choice that can be used in dialogue with governments and institutions to help them assess and strengthen informed choice in their programs
  2. Clear messages for policymakers and communities about how to balance the various tensions that affect voluntary choice with respect to female sterilization
  3. Recommended actions that donors, policymakers, and program managers can take to ensure that programs protect clients’ right to equitable access to female sterilization as one contraceptive option, within the context of free and informed choice

Who is attending the Bellagio consultation?
The consultation will include 18 global and national experts from public-sector, nongovernmental, academic, donor, and rights organizations, representing nine countries.

What can I do to stay informed about this issue?
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U.S. Agency for International Development. [No date.] Contraceptive security ready lessons: Overview. Washington, DC: INFO Project/Johns Hopkins Bloomberg School of Public Health Center for Communication Programs.

Verkuyl DA. Sterilisation during unplanned caesarean sections for women likely to have a completed family--should they be offered? Experience in a country with limited health resources. BJOG. 2002 Aug; 109(8):900-4.