The advent of hormonal family planning impacted society in the United States in a manner not seen since woman's suffrage. The FDA approved the first oral contraceptive pill, or "the pill", in 1960; three years later there were already 2.3 million women using it. This altered the makeup of families, drastically decreasing unwanted or unplanned pregnancies and reduced overall fertility levels. Smaller families and improved planning mechanisms helped move women out of their traditional housekeeping roles of the first half of the 1900s and into the economy. For young women this meant higher wages and more extensive work experience. Since then, hormonal family planning methods have exploded in popularity and option, running the gambit from the pill to a hormonal intrauterine device. Though still not close to universal access, the scope and availability of hormonal contraceptive methods have made planning a family possible for most women in the United States.
Globally, the availability and use of hormonal contraceptive methods have a different story. In developing countries there are approximately 215 million women of reproductive age who are categorized as having an unmet need for modern contraception. Of that number, about 140 million are not using any method of contraception, and the other 75 million are using traditional methods, which have been proven to be less effective. Within this total are some extreme outliers, with one of the highest percentages found in Uganda. According to the 2012 Uganda Demographic and Health Survey, 45 percent of women in Uganda have an unmet need for a modern contraceptive method. That is almost double the global average of 26 percent and many times higher than the 8 percent found in the United States in 2010. In real numbers, that means that almost half of the approximate 10 million women of reproductive age lack any form of effective and safe family planning. For a country whose population is expected to increase 160 percent to 104 million by 2050 that number is worrisome, impacting not only physical space but also Uganda's continued economic growth and poverty reduction.
Providing family planning in Uganda isn't as easy as it sounds, despite the relatively small size of the country and distribution of the population. Where I work with the Uganda Village Project in Eastern Uganda the population density is one of the highest outside of the capital city of Kampala. Despite this, reaching women in the rural communities is often impossible because of poorly maintained or non-existence infrastructure. With hormonal methods of family planning, as many know, it is imperative that the woman continues the doses in even intervals. When a road is washed out or a family living in the deep countryside during planting and harvesting seasons, it can be almost impossible to provide family planning services on a consistent basis, especially when a nurse or medical officer needs to journey from Iganga, the district seat, to these areas. Beyond inaccessibility, the social stigma of birth control is still very much present in the rural communities of the Iganga District where Uganda Village Project focuses their programs. Women who do come to our family planning outreaches sometimes do so against their husband's wishes, and the location is often tucked out of sight to prevent discovery and gossip. We are still able to reach between 30 to 70 women in each village, but the number with an unmet need for family planning is undoubtedly higher.
Sayana® Press is a new and improved version of Depo-Provera that has great potential to increase access to contraceptives in rural settings like the Iganga District. It has some similarities to Depo-Provera (the three month duration and injection delivery) but the changes are breakthrough. Instead of the current method of delivery available in Uganda that necessitates a nurse or medical professional and reusable syringes, Sayana Press uses a prefilled, auto-disable devise that can be administered with little training and safely disposed of afterwards. In addition, trained local women in each community would be able to distribute this method, making the dosing much less obvious. The injection has been reformatted to allow subcutaneous injection, instead of the more painful intramuscular administration injection for Depo-Provera. The popularity of Sayana Press may in fact extend beyond the rural populations, with a recent observational study in central Uganda finding that 80% of the participants preferred Sayana Press to traditional intramuscular injection.
The government has yet to start a large-scale rollout of Sayana Press and it is currently only available in health facilities. However, it seems to only be a matter of time before scale-up, and when that happens it will change the face of family planning in Uganda for good. Rural communities will no longer rely on overworked nurses and medical staff for their family planning needs, their very presence broadcasting contractive use. Instead, women will be able to access contraceptive services through a local contact in a local context, bringing consistent and discreet access to a planned and healthy family into their lives for the first time.