Stuck Between a LARC and a Hard Place

How contraceptives—especially long-acting reversible contraceptives (LARCs)—can improve the health and wellbeing of young women is a topic that presents tough questions. With USAID’s support, Population Services International (PSI), FHI360, Pathfinder’s Evidence2Action Project and Marie Stopes International held a symposium to tackle those questions head on, and chart a course to improve the sexual and reproductive health of young people. Addressing the third of five tough questions, this post discusses how parents and other key influencers are crucial players in determining whether young women and girls have voluntary and comprehensive access to contraception, particularly LARCs.

When Sylvia Msokera took the stage at the recent “For Youth, A Healthy Option with LARCs” symposium, she bypassed the podium, sat in an armchair, crossed her legs and opened a newspaper: “Here I was sitting,” she bellowed,  “having my morning tea, when Mary walked into my clinic.” Sylvia, who owns and runs her own Tunza health clinic in Lilongwe – one of the 65+ clinics within PSI’s social franchise in Malawi – went onto to tell a dramatic story, a story that begins with great promise, but ends with deep questions about values, ethics and one’s own moral compass.

Mary was becoming sexually active with her boyfriend and wished to use contraception so that she wouldn’t become pregnant before she finished school. She was 15 and seemed to have her priorities in order, said Sylvia. For her part, Sylvia had been trained by PSI in youth-friendly health services and had become a champion provider, having arranged a youth-only entrance and waiting room in her clinic, hosting youth events on the weekends and working with young community educators to promote her services. She counseled Mary on her different contraceptive options, discussing each of their benefits and side effects. Mary chose a contraceptive implant — a long-acting and reversible method that lasts up to five years. She had it inserted that very day and, according to Sylvia, went home happy.

The next morning, Mary returned to the clinic. Only this time, she was with her mother. Her mother was livid, berating Sylvia for giving her daughter contraception and therefore encouraging her to have sex. She demanded that Sylvia remove the implant.

Sylvia asked to speak with Mary privately. Mary, who was in tears, explained that her two sisters saw the implant in her arm and told their mother about it. All three spent the rest of the day shaming and insulting her. “Please just take it out,” she cried, “I would rather risk pregnancy, than face this every day.”

Sylvia was at a total loss. She thought of herself as a provider of honor and integrity; upholding her oath to do no harm, respect client autonomy and act with justice. Yet, wasn’t enabling her client to risk unintended pregnancy, and all of the risks that come with it at such a young age, potentially doing Mary harm? Wasn’t providing a service (in this case, a removal) for the client, because her mother demanded it rather than the client herself, disrespecting her autonomy? Who was her client then? Who was Sylvia accountable to?

In the end, she removed the implant.

“I felt so bad,” Sylvia said, wincing from the memory. “What was I supposed to do? What was I supposed to do?”

Sylvia’s story is a stark reminder that all the work we have done to train health providers to be youth-friendly and provide equitable access to contraception for young people; all the investments we have made to build demand for those services and change young people’s behavior so they indeed access them; all that work is still not enough. We must also create opportunities to engage and inform those people that play influential roles in young people’s lives — their parents, families and partners, among others.

On November 10, at the International Conference on Family Planning, the symposium report entitled “For Youth, A Healthy Option with LARCs” will be released. In it, there are no fewer than six recommendations for providers to use to educate parents, as well as their young clients. They include micro and macro level solutions from empowering young clients with the tools to explain the decision themselves to their parents to using mass media to engage and inform parents how to communicate with their children about sex and voluntary contraceptive options.

We must help parents and their children have open and healthy discussions about sex. We can use community-level data to demonstrate to parents that sex education does not promote sex and that the benefits of supporting their sexually active children in using contraception far outweigh the costs. We must do this so that when young people try to access the contraceptive services of their choosing, providers like Sylvia will not get stuck.

Check out the full symposium report, as well as a global consensus statement on expanding contraceptive access to LARCs for young people.