Clinics and hospitals are experiencing fewer medication stockouts than in previous years but contraception shortages remain the most reported medical shortage in the country, according to a new report from the Stop Stockouts Project.
Injectables, the most widely used method in South Africa, accounted for three-quarters of contraception stockouts reported.
In Spotlight, Aisha Abdool Karim breaks down what this means for women’s sexual and reproductive health.
The report notes that 6.9% of patients said at least one medication was out of stock when they were at one of the 380 facilities surveyed during a three-month period. Four out of 10 shortages were of a contraceptive, with injectable contraceptives being the least available option.
“It’s likely we are under-accounting for stockouts,” says Sasha Stevenson, head of SECTION27’s Health Rights Programme. “The people at the facilities and answering the questions in the survey have not given up on the healthcare system – they are going back. But there will be others who haven’t been able to get what they need for several months and may not have returned.”
Even with stockouts remaining a problem in the public healthcare system, more than two-thirds of patients are still leaving with a medication – with healthcare workers offering alternative options in the event of stockouts, the report says.
Overall, there have been fewer shortages reported compared with previous years when the survey was conducted, notes Stevenson. But the one area that remains unimproved is contraceptives.
Providing women with options
There are more than 162m women globally who have an unmet need for contraception, meaning they do not wish to become pregnant but are unable to access some form of birth control, according to a July study in The Lancet.
The study, the largest of its kind, found that around half of the women in South Africa aged between 15 and 49 were using some form of birth control. One in 10 had an unmet need for contraception.
Theoretically, they should have their choice of contraception, regardless of whether they use a private or public healthcare facility. The options available include hormonal methods like pills, injectables, an implant, patch, or vaginal ring as well as non-hormonal choices like an intrauterine device (IUD), condoms, or female and male sterilisation.
“In reality, it’s quite different depending on what women want and what is pushed by healthcare providers,” says Diane Cooper, a professor of public health at the University of the Western Cape. “Healthcare providers tend to recommend the injectable, often not trusting that women will remember to take a pill daily.”
The IUD and implant require training for healthcare workers to both insert and remove the devices, which is why some may be more reluctant to offer these options to women, says Cooper.
Both methods were the least requested options by those surveyed in the SSP report, with around 8% trying to get an implant and one in 20 women seeking an IUD.
“Not knowing how to provide a method also plays a part in stock orders – low demand from the client can also be the result for the low promotion or request of these methods,” said Lucy O’Connell, Key Populations Advisor in Doctors Without Borders (Médecins Sans Frontières) Southern Africa’s Medical Unit.
In South Africa, there are two injectable contraceptives on offer – Noristerat (a two-monthly regimen) and Depo-Provera (given every three months). These are the most widely used birth control methods in the country.
“Some women are in situations where they’re hiding (the) use of contraception and then the pill is difficult,” says Cooper. “Others prefer the injectable because they don’t want to come back as often, or they don’t want to remember to take something all the time.”
A 2017 study in the South African Medical Journal found that around 46% of women had used an injectable contraceptive at some point and a quarter of those surveyed were currently using the method.
The problem is that while injectables are the most widely used contraceptive in SA, they are also the most commonly out of stock, making up 76% of the reports received by the SSP.
“While it is reassuring to see that 95.6% of patients requesting contraception in this survey were able to get what they wanted, it is concerning that contraception – specifically injectable contraception – is the most reported medicine shortage across the country,” the SSP report notes.
The trouble with switching methods
Two-thirds of healthcare workers said they offered an alternative medication to people at their clinics, says the SSP report. Regarding contraception, around 58% suggested patients switch methods when the contraceptive of choice was unavailable.
This solution isn’t ideal, however, as it can have negative consequences for women forced to abruptly change medications. When medications aren’t available, it places the burden on the person seeking them to find an alternative way to access them or return to the clinic, which comes at a cost, explains Cooper.
“They must take time off work or even if they’re not working, they’re still losing time. If they have to go to a private clinic or pharmacy, it costs money,” she says. “If their particular method isn’t available, they don’t necessarily want to try another option. So, women may stop taking contraception or there will be a gap when they could fall pregnant. Stockouts or periods of time when there aren’t services or methods available are a real problem.”
Contraception shortages mean women have fewer options available and remove some of the control they have over their sexual/reproductive health. If the onus of family planning falls on her, it may become difficult to get a man to wear a condom if her method of choice is unavailable.
Most women in South Africa are not able to negotiate condom use with their partners, particularly if there is a power imbalance or financial dependence component to the relationship, according to a 2021 study in the African Journal of AIDS Research.
“When women come for the first time, for anything, there’s a gap of about a month before it’s properly effective – and the same applies if you switch,” explains Cooper. “That’s when providers encourage condom use because you could become pregnant during the month before the contraceptive is effective but not all women are able to use condoms.”
The fallout of unintended pregnancy
The other issue is that each form of contraception has its own set of side effects and not all women react to the intervention the same way.
“The more you switch methods, the more your body must adapt to that method,” says Melanie Pleaner, a senior technical adviser at the Wits Reproductive Health and HIV Institute. “For someone with a preferred method that they’re settled well with, they’re more likely to stick with that. Whereas if they start something new, they might decide not to continue until they can get their preferred contraceptive.”
Pleaner said changing contraceptives also requires “reorientation” around (its) use. For instance, someone used to being on an injectable requiring a clinic visit three-monthly may struggle with taking a daily pill. This could interrupt how people take their contraception and lead women to abandoning using a birth control method altogether, she cautions.
“It’s quite confusing for women and it leaves them a lot more vulnerable,” says Pleaner. “Particularly in that first year, if you’re switching between contraceptives, it leads to discontinuation and to increased pregnancy.”
Around one in five births in South Africa were “unwanted”, where the woman was not planning to have anymore children, according to a 2020 report by StatsSA. This rate is even higher among women living with HIV, with about half reporting an unplanned pregnancy in a 2021 Nature paper.
These types of pregnancies come with health risks to mother and child as well as socio-economic consequences, such as preventing the mother from pursuing higher education or affecting their job prospects. A 2019 study by the World Health Organisation found that half of the women who had aborted an unintended pregnancy ended up not using a contraceptive method afterward, either due to health concerns or inconvenience.
“When women and girls cannot access a contraceptive, or the contraceptive of their choice, there can be really serious fallout and unwanted pregnancy,” says Claire Waterhouse, Regional Advocacy Coordinator for Doctors Without Borders. “An unwanted pregnancy impacts literally every aspect of a woman’s life – emotionally, mentally, and financially, professionally, educationally. There is no area of her life that will not be affected by a pregnancy they would have preferred to prevent.”
This rise in unintended pregnancy also creates a cycle of reliance, says Baone Twala, a legal researcher at SECTION27. “It forces women to re-engage with a system that failed them in providing them with contraception to seek abortion from that same system and have it fail them once again.”
‘A system that fails women’
Waiting in long lines at healthcare facilities and then having rushed consultations with staff where you aren’t given enough information about switching contraceptives only increases the barriers women face when trying to access sexual and reproductive health services, says Pleaner.
“Barriers will prevent effective use of contraception and stockouts are adding to the barriers,” she says.
To help healthcare workers present the options available, the National Department of Health introduced contraception clinical guidelines in 2012, with the most recent revision released in 2019.
Pleaner, who was involved in the development of these guidelines, says the department also included training on the implementation of the new guidelines, part of which focused specifically on counselling.
“In reality, the kind of counselling a woman needs to make an informed decision – from understanding how a method works to managing possible side effects – takes more than health providers might have time for.”
The SSP report noted that a “lack of clinical guidance on how to manage hormonal contraceptive stockouts put staff and particularly patients in a difficult position”. The report notes conflicting responses from healthcare workers about whether or not they have sufficient guidance on how to handle these shortages.
“The health system is under-resourced and understaffed,” says O’Connell. “As a nurse, I can sense and speak about the absence of support to the frontline healthcare workers who are more than aware of the contraceptive needs of their communities, yet they have limited agency to demand adequate supplies and services.”
It’s not just about contraceptives but also about the tools women need for their sexual and reproductive health. Apart from contraception shortages, one in 10 stockouts were of pregnancy tests.
“Depriving women of contraceptives and then not offering other services they may need afterward is all interlinked,” Waterhouse tells Spotlight. “It’s all interlinked in the sense that somewhere along the line, their health is not being seen as a priority in the system and it needs to be.”
Ultimately, Waterhouse and Stevenson argue there needs to be better support put in place to help women and girls make informed decisions about their sexual and reproductive health. That doesn’t just come down to making contraception available but starts with providing information at school and carries through to other family planning services they might require.
“The different ways we fail women, it’s completely heartbreaking,” says Stevenson. “We’re not providing sufficient comprehensive sexuality education at school. We’re not ensuring women can access contraceptives and we’re then not providing abortion services to the extent that they are required and where they are required. The contraceptives issue shouldn’t just be seen by itself as a medical problem but it’s a link in this chain of failing women in our health system.”
NOTE: Representatives of SECTION27 are quoted in this article. Spotlight is published by SECTION27 and the Treatment Action Campaign, but is editorially independent.
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Stop Stockouts introduces online report facility for whistleblowers