CHIGO: Hello and welcome. I'm Chigo Ahunanya, and this is the Humanitarian Lens, a podcast from Doctors Without Borders. Today we're talking about contraception, an issue that's become increasingly politicized. But beyond headlines and debates, contraception is first and foremost essential health care. It's also deeply personal and can be life-altering.
At MSF projects around the world, people seek contraception while living through conflict, displacement, insecurity, and limited access to health care services. These aren't abstract choices. They're decisions made in incredibly difficult circumstances, with real consequences for people's health, safety, and autonomy. In recent years, MSF has been placing greater care or greater emphasis on access, quality, and respect for patients’ choices. So, what does that look like in practice?
To help us explore that, I'm joined today by Dr. Julia McDonald, who's a family medicine physician who has worked with MSF in Ethiopia, the DRC (Democratic Republic of Congo), the Central African Republic, and most recently, Nigeria. Julia, thank you so much for joining us, especially since you've only been back for a few weeks.
JULIA: Thank you, Chigo, I'm so happy to be here to talk about contraception with you. I am passionate about this. So our teams work in conflict zones, displacement camps, and remote areas with a lot of humanitarian needs. And our patients face a lot of difficulties even before reaching our clinics. We can all agree with that.
CHIGO: Could you tell us a bit about some of those barriers, and about some of the misconceptions about contraception that you've heard from patients?
JULIA: Yeah, that's a great question. I think that many of our listeners would understand some of the most common barriers to accessing any kind of essential health care that MSF is faced with, including distance, access to working health care facilities. For example, I was working in western Ethiopia and many of our patients were crossing over from South Sudan. They had to walk for many hours to access their health care. And then they were also limited in how often they were able to travel. So sometimes we would see somebody who had walked for six hours to come in and receive contraception on a day. But I'd like to actually address the barrier of education and misconceptions. This is definitely something that we see both in staff members and in community members.
And so quite a bit of the education and outreach we do is to try and debunk some of these myths and barriers. We try and elicit from a community what some of those deeply held beliefs about contraception are.
For example, I was working in a project in DRC and there was a group of health care providers who had heard that the contraceptive implant that is placed in the arm often will migrate, especially if somebody is active and moving around, walking a lot or running a lot. And so they really avoided placing contraceptive implants. So it's not true. That is a myth. And if it is correctly placed, the huge majority of the time a contraceptive implant will stay right where it is placed and be easily removed.
Another misconception is about a very common injectable contraception. There is a side effect that can cause delayed fertility. So sometimes, somebody could get an injection that lasts 12 weeks, and then after 12 weeks, they'd like to try and get pregnant again. But they can have a delayed fertility sometimes for up to 9 or 10 months. And if they have not been told in advance that that is a potential side effect, then there becomes this myth that blooms in the society. So I think part of myth busting and breaking down these barriers to contraception is really providing excellent access to information and non-biased clinical information.
CHIGO: I love that you talked about that, the importance of information, because even us here, sometimes we're not necessarily informed. And we need the right information to be able to make the right decisions, which we'll talk a bit more about later. But, from your experience working with MSF, can you give us some specific examples of the benefits of having contraception from a personal as well as a community point of view?
JULIA: Absolutely. And I think this is a great example of why MSF's new contraceptive guidelines that really uplift patient autonomy are so awesome, because the personal benefit of contraception might be different for every single person. And this is one of the things that I love doing in community groups and with the staff that I work with in various projects, to brainstorm some of the many benefits — to women or people with uteruses, people using contraception — to children, to families, to community. And some of those things that people brainstorm might be the opportunity to have more education or to work and come up with savings to have a family. It might involve spacing pregnancy to allow a woman to breastfeed, or just feed a baby longer and decrease the risk of malnutrition and all the illnesses that go along with that.
The benefit to communities certainly is when a family is more secure, then the community is more secure, financially, emotionally, culturally. So I think that it's a difficult thing for me to say for each person what the benefit is. I think that there's also clinical benefits that, that we can counsel patients on. There are some forms of contraception that can cause periods to become very light or go away entirely. And for some people, especially displaced women, not having to worry about menstrual hygiene can be a real benefit.
CHIGO: There's so much that you said there and there are so many benefits that we don't even see. And beyond that, there's even like, the reduction of maternal mortality or complicated pregnancies.
JULIA: Yeah. Absolutely, Chigo. I mean, that should have been one of the first things that I said, that benefit to, to communities, families, women and the world is decreased maternal mortality. We know that the most common reasons that women die before, during and after pregnancy have to do with infection, bleeding, unsafe abortion. And so the ways that we can decrease maternal mortality is to decrease the incidence of unwanted or unintended pregnancy and decrease the risk of unsafe abortion. So full-spectrum contraception is an essential part of full-spectrum health care.
CHIGO: It's so important that we're having this conversation because many times it's very hard to see that perspective. And in some cases you need to actually see it and listen to the stories of our patients and hear what they're going through to really get this bigger, wider, holistic perspective. MSF has been working towards a person-centered approach to contraceptive counseling. Why the shift to person-centered then? What does this actually mean for day-to-day care?
JULIA: This is my favorite thing about the new MSF contraceptive guidelines that were released in 2021. And for me, as a physician who was trained in the United States, it really flipped on its head my understanding of how to take care of patients. When we are in medical school, we're taught about efficacy and, and the clinical trials that are done in a perfect setting. And then we're given that information to give to patients about efficacy and about the pharmacodynamics of various medications or procedures or practices. MSF has started to look at issues around patient autonomy and patient access in terms of contraception. That means that we need to provide access to excellent methods and to unbiased information, while upholding a patient's choice of what kind of method to use, or whether even to use contraception at all.
So it's this really beautiful idea of treating the patient in front of us because you could have a method that is 100 percent. There is no method that is 100 percent efficacious, but 99 percent efficacious in clinical studies. But if it doesn't work for a patient, then it's not efficacious for them at all. May I give you an example?
CHIGO: Please do.
JULIA: I recently was in Nigeria. Many women move in with their husband's family when they get married, and many mothers-in-law are in charge of doing the laundry. And one of the things that women are expected to do when they get married is to start producing children. In the project that I was working in, some mothers-in-law will examine the monthly menstrual cloths to see if she's bleeding or to see if it's possible that maybe there's a pregnancy. So if a couple comes into MSF and decides to delay pregnancy, for their own personal reasons, but they don't want to let the mother-in-law know, if I give them a method that's going to change her menstrual bleeding, then her confidentiality has been broken within that household. So for that couple, for that woman having a method that does not affect her menstrual bleeding, something more like pills or maybe a copper IUD, that is the most efficacious and most important method for her to use.
I wanted to also mention one story that I was thinking of with this question. When I was working in Ethiopia it was very hot and dry, and people would walk very far to receive contraception care. And when they arrived, they were often very dusty. So one of the ways that we ensured their confidentiality is when somebody wanted a contraceptive implant, which goes on the inside of one of their arms, we would have them wash both of their arms, because we realized that if we only washed and surgically prepared one arm, to walk out into the marketplace and everybody would see that one arm was dusty and one arm was not.
CHIGO: Wow, I did not even think about that.
JULIA: One other thing. It can be difficult and time-consuming to inform somebody, to provide that full, comprehensive sexuality education, and then go through all of the benefits and risks or side effects of various methods. But happily, MSF has a series of really awesome, patient-centered, low-literacy flip books that our staff use in projects around the world to help people understand what potential side effects are and what the benefits of one method over another are.
Another core tenet of the MSF guidelines is that they should be easy to change methods. So somebody might start, say, with an implantable contraceptive device in their arm, and if they have irregular bleeding or they have side effects that are not beneficial to them, they should be able to come in and switch methods. And so that's something that I work on training staff to do.
CHIGO: As you were speaking, I was thinking from my perspective of health care here, being a doctor is about efficacy, right? Especially if you're working in the project where you have so many patients coming in. So if you're providing access and autonomy, that takes more time. Something that could take 10 minutes now is about half an hour. And I was always wondering like, how do you go about that and manage your day? So I hear you have the material and are there other staff that support you in this?
JULIA: Absolutely. And I think in well-resourced countries in the global north, we tend to be very license- heavy and title-heavy. It's the physician who does this. It's the advanced practice clinician. But in projects around the world, I have incredible colleagues who maybe don't have so much official schooling, but they are incredibly knowledgeable about contraception. They provide patient-centered care and they have the time to sit and speak and listen to patients, in a way that can help uphold the patient's autonomy.
And those are SGBV focal points – that’s sexual and gender-based violence focal points, they're counselors, mental health counselors, health counselors. I work with health promoters who go out into the community with just very rudimentary education. At MSF we are a community of people who share values, and everybody is working to the top of their abilities.
CHIGO: It's so quintessential because I think, yeah, depending on the culture, there's a certain relationship with a doctor as the subject matter expert, where maybe people are a bit hesitant to share everything, but having these support staff that are there and are part of the community just adds to that person-centered care that we're always talking about. Sometimes those conversations about contraception are shaped by gender norms, stigma, or past experiences. How do teams make sure patients are informed and able to choose freely, especially when you have power dynamics or trauma as part of the picture? We talked about it a bit earlier, but could you share a bit more on that?
JULIA: Absolutely. I think again, this goes back to patient autonomy, access to unbiased clinical information, and meeting patients where patients are at, without bias or preconceived notions. I want to talk about gender norms for a minute because so often we focus on women or people with uteruses and girls around contraception. And it's really important to bring boys and men into this as well. And that's why I love working with health promoters, because we have teams of people who go into barber shops or into, tea restaurants or into soccer games and talk with boys and men about contraception. So often a couple is making a decision together. And so it's really important to meet men where they're at, and also to point out that it doesn't always have to weigh only on the women to prevent future pregnancies.
CHIGO: Yes. As a man, I approve of that message. I think there's definitely a responsibility that we have as men to be informed and to be able to support women and people with uteruses.
JULIA: And I will say, Chigo, I think that this can be a challenging aspect of the care that we provide when we're balancing patient autonomy with cultural sensitivity. And to ensure that our patients have autonomy, sometimes has to be a two-way conversation. We love involving families or husbands in decisions when that's possible and when that's safe for the woman. That's not always safe. So we have to also educate the community that we take care of the patient who's in front of us, even if that might be a married woman without her husband.
CHIGO: So everything I've heard now, my question is what are some of the challenges we face in implementing this approach? And how are our teams addressing those challenges?
JULIA: I think certainly myths and misconceptions remain a big and ongoing challenge, and we're starting to see more and more of that in the United States as well. Social media certainly propagates myths and misconceptions. And so we are also trying to use some of the same avenues to share factual, scientific, evidence-based information. I've worked in projects where we've had radio spots or we've had people with cars and speaker phones go out and do sensitization within the community. Another thing that we do is we involve groups of people, maybe teenagers, in doing plays or skits or coming up with songs.
There are a number of activities that we do with storytelling to help people understand the individual experience of people around contraception, or maybe safe abortion care or safe obstetrical care. So there are a number of ways that we're trying to decrease the barriers to contraception. We're also training and providing education. So one of the big things that I do is I go into low-resourced areas and I gather up soda bottles and gloves and cotton, and I create models like model uteruses and vaginas and make cardboard pelvises and have health care professionals practice what it's like to place an IUD. If we don't have trained health care providers who can offer every single method, then patients don't have full and free access to every method.
CHIGO: I love that side of adding some creativity. Sometimes you have to just figure out how to work with what you have, and that's something I've heard from so many of our physicians — that you're in this situation and you just have to make it work with what you have. And as we talk, I keep realizing that a lot of what we're talking about goes back to misinformation, and it's not something that just happens in our projects. I know for me, if I have an issue before I even call the doctor, I usually Google it. And maybe that's not the best way to go about everything. So access to information for people to be able to make the right choices is so important. Not every patient searching for contraception care has the same needs or personal experiences. How do MSF teams adapt counseling and care for different groups? For example, adolescents, first-time users, survivors of sexual violence, or gender-diverse people?
JULIA: Well, I think one of the core tenets of MSF is our principle of nondiscrimination. So any individual who comes to us seeking medical care will receive medical care. I also think that question goes back to this idea of patient autonomy and being able to tailor our education and our counseling and our provision of care to the needs of the patient who's sitting in front of us. And you're exactly right. There are some special populations. We might counsel adolescents differently than maybe, an older woman who's used many different kinds of contraception. So again, we have some wonderful counseling guides and flip books that we're able to use.
CHIGO: I love that every single answer you've given so far, it keeps going back to that person-centered care person.
JULIA: Absolutely, and I'll just put in a plug for trauma-informed care in addition to patient-centered care. And this is a core tenant of what I teach and how I provide care. Trauma-informed care is a universal precaution that we use for all people with the assumption that they may have experienced trauma at some point in their life. So it's easy to talk about populations who have experienced sexual violence and to compartmentalize them, but to forget that sexual violence and many other kinds of violence and trauma are incredibly widespread. So one of the things that I think MSF staff are increasingly very competent at doing is understanding that every patient that comes to us has their own individual needs, which might involve trauma. And so all of the counseling and medical care that we provide is given through that lens.
CHIGO: That's a very important addition to this conversation. So before we wrap up, Dr. Julia, if there's one thing you want listeners to understand about contraception in humanitarian settings, what would it be?
JULIA: That contraception is essential health care and that it is vital that we do this. This isn't a political issue. This isn't a legal issue. This is a critical, lifesaving medical issue. And I'm so proud of MSF for providing it across all settings.
CHIGO: Thank you so much, Dr. Julia. I thank you for your insights and your experiences. Thank you for joining us. We truly appreciate having you with us.
JULIA: Thank you. so much, Chigo.
CHIGO: Thanks, audience for tuning in. To learn more about MSF's work on women's health, including contraception, visit doctorswithoutborders.org. And remember to subscribe and leave a review anywhere you listen to this podcast. This will help the conversation reach further.
This is the Humanitarian Lens from Doctors Without Borders. I'm Chigo Anhunanya and until next time.
