“Reproductive health implies that people are able to have a responsible, satisfying and safe sex life, and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.
“Implicit in this are the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth, and provide couples with the best chance of having a healthy infant.” (World Health Organization)
The provision of information about sexuality and reproduction has been perceived by many that it encourages sexual activity.
However, this is not supported by evidence. Good quality reproductive health education does not lead to earlier or increased sexual activity.
When the young are well informed about sexual responsibility and contraception, evidence shows that it leads to decreased teenage pregnancies, abortions and sexually transmitted infections.
Sexual activity and pregnancy
Pregnancy can result if any sperm is deposited inside the vagina or spilled on the vulva.
A female can get pregnant if she has had her first period, even if she is aged 12 or less; it is the first time she has sexual intercourse; does not have intercourse often; has intercourse during her period; does not have an orgasm; is not fully breastfeeding; douches (washes the vagina with fluid or other materials) after intercourse; or the penis is withdrawn before ejaculation (coitus interruptus); and irrespective of the position during intercourse.
Young Malaysians have limited knowledge about sexual and reproductive health.
For example, one out of 10 and 42 out of 100 thought that douching and coitus interruptus respectively were effective contraceptive methods; 51 out of 100 did not know pregnancy could occur during the period; and one out of four thought contraception was “not required so long as there’s mutual trust between partners”.
“More than half of the sexually active said that their first sex was unexpected or unplanned.”
Unsurprisingly, Malaysia has a relatively low contraceptive prevalence rate of 55.6% in 2010 and 52.6% in 1990.
Malaysia’s unmet need for contraception was 17% in 2010 and 18.6% in 1990.
By comparison, the contraceptive prevalence rates for all developing countries were 62.0% in 2010 and 51.8% in 1990, and the unmet need 12.8% in 2010 and 16.5% in 1990.
Making the right choice
Choices are made throughout life.
A baby brings joy to parents who are prepared to provide the love and care needed.
However, an unintended or unwanted pregnancy brings problems and sorrow to the parents, particularly the young women.
There are about 18,000 teenage pregnancies annually in Malaysia, i.e. about 50 every day. Over a thousand newborns were reportedly dumped in the past decade, i.e. two every week with more than half found dead.
Advising adolescents and young people not to have sexual intercourse is obviously insufficient without concomitant information about contraception.
The provision of access to voluntary contraception is not only crucial to the improvement of reproductive health outcomes, but also has positive associations with improved health, schooling and economic outcomes.
There are various contraceptive methods available with different methods for individuals at different times in their lives.
To make a voluntary informed choice, the information provided should include the correct use of the method, how it works, its effectiveness, common side effects if any, health benefits and risks, return to fertility on discontinuation, signs and symptoms that will require medical attention, and information about sexually-transmitted infections (STIs).
Certain methods are usually not recommended for adolescents and young people, e.g. sterilisation, intra-uterine contraceptive device (IUCD), withdrawal and fertility awareness methods.
If there has been sexual contact without contraceptive use or the contraceptive method failed, there are emergency contraception methods that can be used.
There is no perfect contraceptive method. All methods have a failure rate.
There are two types of contraceptive failure, i.e. user failure and method failure.
User failure refers to pregnancy occurring because of incorrect use or non-use of a contraceptive method.
Method failure refers to pregnancy occurring despite the contraceptive method being used correctly and consistently, or fitted correctly.
The effectiveness of a contraceptive method depends on the individual’s age, the frequency of sexual intercourse and whether the instructions are followed.
If 100 sexually-active women do not use any contraception, about 85 will get pregnant in a year.
The contraceptive failure rates in daily life are higher than that reported from clinical trials because of user failure. As such, one cannot extrapolate the failure rates in clinical trials, in which usage is more likely to be correct and consistent, to that in common daily usage.
With the exception of male and/or female sterilisation, the various contraceptive methods do not result in irreversible changes in fertility. The return to fertility is immediate with all methods, except for progestogen injections.
Anyone is exposed to STIs, including HIV/AIDS, if he or she has more than one partner or their partner has other partners. In such circumstances, there is a need to prevent pregnancy and STI.
Whenever there is a possibility of STI, the advice is to have dual protection, either through the simultaneous use of condoms with other contraceptive methods, or the consistent and correct use of condoms alone for the prevention of pregnancy and transmission of STI.
A healthy sexual relationship requires both partners to be responsible.
The questions each couple has to address include whether a pregnancy is wanted or unwanted, whether there is access to contraception if a pregnancy is unwanted and whether protection against STI is necessary.
Universal health coverage (UHC) is the core of the health-related targets of the Sustainable Development Goals which Malaysia has signed on.
Lack of coverage for sexual and reproductive health would cost women and girls their future with negative impacts on UHC and economic growth.
As health is a human right, access to quality sexual and reproductive health services, which includes contraception, should not depend on age, gender, race, financial standing or place of residence.
The contraceptive prevalence rate in Malaysia has stagnated since 1990 and is lower than the rate for all developing countries, with the unmet need for contraception higher than the rate for all developing countries.
The question is whether there are any policies and strategies to reduce the unmet need for contraception in Malaysia in the quest for UHC.
In short, it is always better to make a choice and not take a chance.
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.
- Natural Cycles founders Elina Berglund Raoul Schewitzl
- Natural Cycles
- Birth-control app Natural Cycles has been approved by the US Food and Drug Administration – the first app to be approved for contraception in North America.
- The app uses an algorithm to tell women when they have the highest and lowest chances of getting pregnant, but it ultimately relies on men and women changing their behavior.
- The app recently came under fire in Sweden when 37 women reported getting pregnant while using it.
A birth-control app called Natural Cycles has been approved by the US Food and Drug Administration, marking the first time an app has been approved for contraception in North America.
Designed by physicist couple Elina Berglund and Raoul Scherwitzl, the app doesn’t involve a pill and contains no medication. It works by giving heterosexual couples recommendations about when to avoid sex or use protection, based on a woman’s daily temperature measurements and the regularity of her period.
“Consumers are increasingly using digital health technologies to inform their everyday health decisions, and this new app can provide an effective method of contraception if it’s used carefully and correctly,” Terri Cornelison, assistant director for women’s health at the FDA’s Center for Devices, said in a statement. “But women should know that no form of contraception works perfectly, so an unplanned pregnancy could still result from correct usage of this device.”
Natural Cycles only helps prevent pregnancy if people using it behave in the way it prescribes. The app also recently gained regulatory approval in Europe – the first app to do so there as well – but it came under fire in Sweden several months later when 37 women reported getting pregnant while using it.
Those pregnancies ignited a small controversy about how the app works and what it can – and can’t – do. But Scherwitzl told Business Insider in January that he was not surprised women had become pregnant.
“We give red and green days and clear recommendations on which days to abstain and which days we consider the risk of pregnancy to be negligible,” he said.
The problem with saying ‘as effective as the pill using only math’
- Unsplash/Brooke Lark
Natural Cycles was initially portrayed by multiple news outlets – including Business Insider – as being “as effective as the pill using only math.”
When is used properly, Natural Cycles may be comparable in effectiveness to the pill. But that doesn’t always happen, as the controversy in Sweden revealed.
So the problem with these types of statements is that the app relies on couples to change their behavior and either not have sex or use protection based on the app’s recommendations.
“Just like with the pill, you have scenarios where women take the pill everyday” and it’s as reliable as possible, Scherwitzl said, and then there are “scenarios where they don’t take it every day” and the reliability decreases.
How Natural Cycles compares with simply using a calendar
- Natural Cycles/Facebook
Natural Cycles’ approach puts it in a larger category of birth control known as fertility awareness, which is similar to the calendar-based approach people have used for decades.
The company’s founders published a study on the app’s effectiveness in the European Journal of Contraception and Reproductive Health Care in 2016. The research involved 4,000 women between the ages of 18 and 45, and the results showed that out of every 100 women who used the app in a “typical” way for a year (meaning certain common slip-ups were accounted for), seven of them got pregnant.
That rate is and significantly lower than the traditional calendar method, which has an average fail rate of 24%, according to the CDC.
The “typical use” scenario for the pill leads to about nine out of 100 women getting pregnant within a year, so the study suggests Natural Cycles is on par with an oral contraceptive. But the app still leads to more pregnancies than would be seen among people using injectable birth control or an IUD. The typical use fail rate for an IUD is 0.2-0.8%, or less than one out of 100 women getting pregnant each year.
Apps can ‘provide encouragement,’ but still have key limitations
As far as the women who got pregnant while using the Natural Cycles app are concerned, the same European study found that more than half of them had unprotected sex with men on the days when the app advised against it. Those instances are evidence of a longstanding human reality: behavioral control is difficult, especially when it comes to sex, and not a guaranteed way to prevent pregnancy.
“While smartphone apps may provide encouragement, they can’t stop [men and women] from … sex altogether,” Susan Walker, a professor of sexual health at Anglia Ruskin University, wrote in an article for The Conversation.
A handful of other factors can also get in the way of the app working correctly, including having multiple sex partners and having a partner who is not equally committed to birth control.
So if you’re planning on using the app – or one of the dozens like it that have not been approved as medical devices – experts say you should have a predictable sex schedule, regular periods, be willing to check your temperature every day, and have the ability to abstain from sexual activity on consecutive days every month.
If you can do all that, the app could work for you.
“In the end, what we want to do is add a new method of contraception that women can choose from without side effects,” Scherwitzl said. “I think there are many women who this will be great for.”
Want to know your chances of getting pregnant this year?
There’s now an online test for that – and you can take it for free. The tool uses your age and 14 questions about your health to give you a snapshot of your chances of having a baby on your own or with a doctor’s help.
Created by a woman-run genetics and reproduction startup called Celmatix, the new tool relies on peer-reviewed scientific research about fertility. It also uses the same predictive models that inform the company’s data analytics platform, called Polaris, which has been used by thousands of physicians and more than 90,000 patients to track people’s reproduction journeys.
You need a doctor to use Polaris, but all you need to take the new test, called My Fertility Compass, is a computer.
“It’s an education tool; a companion,” Piraye Yurttas Beim, the founder and CEO of Celmatix, told Business Insider.
How to take the test
To use My Fertility Compass, go to Celmatix’s new site, enter your age, height, weight, and information about how long (and how frequently) you’ve been trying to conceive. You’ll also be prompted to answer several questions about lifestyle factors that affect your fertility, such as how often you drink or smoke.
Then you’ll get a percentage that shows your chances of getting pregnant by the end of one year of trying.
- Courtesy of Celmatix
Based on those numbers, the tool will either tell you to keep doing what you’re doing (meaning you’re on the right track with your current behavior) or it’ll suggest you see a doctor to get some extra help.
Dozens of factors can affect your fertility, from a family history of genetic conditions like polycystic ovary syndrome (PCOS) to lifestyle factors like smoking.
Women under 35 who’ve been trying to get pregnant for a year or longer and women over 35 who’ve been trying for at least 6 months will be advised to consult a physician.
That doesn’t necessarily mean there’s something wrong, it just means that it’s time to loop in an expert who can make sure everything is running as it should and provide guidance if it isn’t.
Making the black box of fertility clearer
- Piraye Yurttas Beim, the founder and CEO of biotech fertility startup Celmatix.
- Courtesy Celmatix
For Beim, Celmatix’s new tool is part of a broader goal. She wants to bring the advances we’ve seen in areas like cancer – such as precision medicine and other tools to better diagnose and treat the disease – to fertility.
“Fertility is still very much a black box,” Beim said. “The scientific playbook that’s being applied to cancer is not being applied here.”
We know, for example, that mutations on two genes play a role in the risk of developing breast cancer, but we’re just now learning how genetics and other factors influence the chances of getting pregnant.
As part of the effort to bring the latest cutting-edge science to fertility, Celmatix also offers the only spit-in-a-tube genetics testing kit for fertility.
While that kit is useful for women who are already thinking about family planning, it doesn’t help those who haven’t yet considered what they might do if they were to have trouble conceiving. Beim pointed out that by the time many women start thinking about ways to raise their chances of getting pregnant, they’re already beyond the ideal fertility window.
As Beim knows firsthand after struggling to to get pregnant herself, a big part of family planning is taking action early, when there’s plenty of time to get additional support. That support could include diagnostic testing or interventions like IVF. That’s why the new tool is free and easily accessible.
“This is an area where early interventions really matter,” Beim said.
The new test is designed to get more women thinking about fertility earlier, and have more options as a result.
“Having this as a companion – that’s the future,” Beim said.