The World Health Organization (WHO) states, “Reproductive rights embrace certain human rights that are already recognised in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly on the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.
“It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence.”
The right to start or to have an addition to a family is a human right.
Contraception, commonly termed family planning or birth control, involves the deliberate use of method(s) to prevent an unwanted pregnancy.
Various factors influence what contraceptive method is to be used. They include whether the woman (or her spouse/partner) wants to become pregnant fairly soon, months and years away or not at all; whether the contraceptive method is to be used every day, every time there is sex or less often; whether there is any need for protection against sexually transmitted infection; whether the woman is breastfeeding; and how the contraceptive method would suit the lifestyle of the woman (or her spouse/partner).
The information provided to a patient seeking contraception for the first time includes the types; effectiveness, advantages and disadvantages of the various methods; and how the methods work.
There are two major types of contraceptive methods – one with no user failure i.e. it does not depend on the user remembering to take or use it – and the other, with user failure i.e. methods which the user practices in accordance to instructions, or something he/she has to think about each time there is sexual activity.
The former includes male or female sterilisation, which is intended to be permanent. The overall failure of vasectomy (male sterilisation) is one in 2,000. The overall failure rate of female tubal occlusion is about one in 200 to one in 500.
The failure rates of the latter:
- Depot contraception (Injection or implant) and intra-uterine contraceptive device (IUCD) is 1%.
- Oral contraceptive (combined and progestogen) in typical use is about 9%.
- Male and female condom are 18% and 21% respectively.
- “Natural family planning” is 24%.
The duration of action of the contraceptive injection and implant is 13 weeks and three years respectively, and the IUCD is three to five years, depending on the type. The duration of the other contraceptive methods is that of the duration that they are used.
The combined oral contraceptive is suitable for healthy non-smokers up to 50 years of age. The progestogen-only pill can be used by smokers and those above 35 years of age.
The disadvantages of the various contraceptive methods are:
- Contraceptive injection – irregular and/or prolonged periods and weight gain in some women. The periods and fertility may take time to return to normal after stopping the injection.
- Contraceptive implant – irregular and/or prolonged periods, periods which may stop, procedure for insertion and removal.
- IUCD – heavier, prolonged and/or irregular periods, and an increased risk of pelvic infection.
- Combined oral contraceptive (COC) – increased risk of blood clots, breast and cervical cancer, and temporary side-effects such as headaches, nausea, mood changes and breast tenderness. The COC is unsuitable in overweight individuals and smokers aged 35 years and above.
- Progestogen only pill – periods may stop, or be irregular, light or more frequent, and temporary-side effects e.g. acne, breast tenderness, weight change and headaches.
- Condom – the male condom can slip off or split if not used correctly or is not the right size or shape. The penis has to be withdrawn from the vagina immediately after ejaculation before the penis becomes soft, taking care not to spill any semen. In the case of the female condom, the penis has to be inserted into the condom and not between the vagina and the condom. The female condom is not as widely available as the male condom.
- “Natural family planning” – need to avoid sex or use a condom at fertile times of the cycle. It takes three to six menstrual cycles to learn effectively and daily records have to be kept.
If there had been sex without contraception, or it is thought that the method used might have failed, there are different types of emergency contraception available.
Apart from providing information, the doctor will take a history and carry out a physical examination, which usually includes a pelvic examination to assess the health status of the patient and determine her suitability or otherwise for the various contraceptive methods available.
The doctor then recommends a method to the patient who is the ultimate decision- maker.
Prior to any recommended treatment, including the prescription and administration of contraception, a doctor or other healthcare professional (HCP) has to obtain the patient’s consent.
Consent is a fundamental principle of medical practice and law. The reason is simple – every individual has a right to bodily integrity i.e. no one has the right to touch anyone else without lawful excuse and if doctors do so, it may well undermine the patient’s trust.
Such conduct may lead to a medical negligence claim, a complaint to the Malaysian Medical Council, in the case of a doctor, or even civil or criminal proceedings for assault.
There are three elements of consent i.e. the patient must have the capacity to decide, provision of information and it must be voluntary.
The provision of information is cardinal to obtaining valid consent. The Federal Court’s decision on the standard for provision of information is based on the Australian case, Rogers vs Whitaker i.e. – a doctor has a duty to warn a patient of any material risk involved in a proposed treatment.
A risk is considered material if a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.
It is the doctor or HCP’s duty to provide sufficient information for the patient to make an informed decision.
The patient’s decision has to be respected even if it is against a doctor’s advice i.e. force or threats cannot be used to obtain consent.
In short, consent is a process. The signing of a consent form just means that the patient can sign.
It is of evidential value only if the consent process has been undertaken.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.