Ready When She Is, a CIFF-funded project creating a case for investing in on-demand contraception, sat with Gilda Sedgh, a Sexual and Reproductive Health Research Scientist, to explore the evidence – and where we go from here.

READY WHEN SHE IS (RWSI): WHAT DOES THE RESEARCH SAY ABOUT THE SEGMENTS OF WOMEN WHO CITED INFREQUENT OR NO SEX AS A REASON FOR NOT USING CONTRACEPTION?

Gilda Sedgh: We started our research simply examining why women across low- and- middle-income countries who want to avoid getting pregnant choose to not use contraception. We have information on sexually active, never-married women in 31 low- and middle-income countries. We found that, on average, 49 percent of women in this group who wanted to avoid pregnancy and weren’t using a contraceptive method said that they were not using a method because they had sex infrequently. Infrequent or no sex was the most common reason for not using a method cited by never-married women in 17 out of 31 countries for which we have data.

We have data on married women from 52 countries and, maybe surprisingly, many married women also said they weren’t using contraception because they have sex infrequently. About one in three married women who wanted to avoid getting pregnant and weren’t using a method in Asia, Latin America and the Caribbean, and one in five in Africa, cited infrequent or no sex as a reason for not using contraception. In 12 out of these 52 countries, infrequent or no sex is the most commonly cited reason for nonuse among married women.

We also found that the prevalence of this reason has been increasing: compared with studies on women’s reasons for not using contraception from the 1980s, more women cite infrequent sex as their reason for non-use in the most recent evidence, which is from the past decade.

RWSI: HOW DO YOU DEFINE INFREQUENT SEX?

GS: Women define it for themselves. But we did do some analyses to see how many of the women who cited infrequent or no sex as their reason for non-use had sex recently. Among the married women who cited infrequent or no sex as a reason for non-use, about half (47 percent) reported being sexually active in the prior three months. In some countries, closer to 80 percent had sex in the three months before the survey. These women are probably at risk of having an unplanned pregnancy. All of the unmarried women in these analyses had had sex in the three months before the survey. The question is, how can we support them to make the choices best for their bodies and their lives?

RWSI: WOMEN AND GIRLS WHO HAVE INFREQUENT SEX – OR NO SEX – SAY THEY WOULD CONSIDER USING CONTRACEPTION IN THE FUTURE. WHAT’S STOPPING THEM FROM USING CONTRACEPTION NOW?

GS: Of course, every woman is different. Some women might believe they have little or no risk of conceiving if they have sex infrequently, and some might be having infrequent sex in order to avoid an unplanned pregnancy. Others might feel that contraceptive methods available to them are too burdensome for the number of times they have sex.  No matter their situation, all women can benefit from access to contraceptive options and sexual health education from trust sources that align with their needs and preferences.

Unmarried women face additional challenges related to contraceptive use. Strong taboos against sexual activity outside of marriage make it harder for them to ask for contraceptive services. They are also more likely to require methods that they can use discreetly such as pericoital contraceptive methods, including condoms, which can be used at the time of sex in non-emergency situations.

RWSI: WHAT ADAPTATIONS ARE NEEDED TO SUPPORT WOMEN AND GIRLS WHO HAVE INFREQUENT SEX TO CHOOSE CONTRACEPTION, WHEN THEY ARE READY?

GS: Counseling supports women who have infrequent sex to understand their risk of getting pregnant and plan for the families they desire. This education should be incorporated into their primary care services to more easily reach women who are not visiting family planning clinics.

Counseling should emphasize choice. Based on a woman’s preferences, we can support women to choose tools, like contraception, so they can take their health into their hands. For example, for some who rarely have sex, the contraceptive pills that we typically refer to as emergency contraception (contraception used in the first few days after unprotected intercourse) would help them prevent an unintended pregnancy if they do have sex. But many women who have infrequent sex do still have sex – that is, sex is not a rare event nor an “emergency.” A wide range of contraceptive choices – including on-demand options – are key.

RWSI: WHAT OPPORTUNITIES DO WOMAN-CONTROLLED, ON-DEMAND CONTRACEPTIVE METHODS OFFER?

GS: Woman-controlled, on-demand methods of contraception can be of value for women who have sex infrequently and want to prevent a pregnancy. But these methods might help other groups of women, too. Some women do not use contraception because they do not like the side effects of the methods available to them, and others do not use a method because their partners don’t want them to. If these women had access to a method free from undesirable the side effects typical of hormonal methods, and can be used discreetly, we could better support women to make the best choices for them.

RWSI: HOW CAN ON-DEMAND CONTRACEPTIVES SUPPORT US – DONORS, PARTNERS, HEALTH SYSTEMS AND CONSUMERS TOGETHER – TO BE #READYWHENSHEIS? WHAT WILL IT TAKE TO GET THERE?

GS: When it comes to contraceptive options today, our research shows that we’re missing the needs of a large segment of women and girls who have infrequent sex. When we invest in bringing woman-controlled, on-demand options closer to consumers, we’re support consumers to make the choices best for their lives. That’s what it means to be #ReadyWhenSheIs: to go where she needs us to go so she has the tools and support to be the driver of her own life.

By Ashley Jackson, Former Deputy Project Director, Expanding Effective Contraceptive Options, and Léonce Dossou, Mass Media Communications, Sales, and Distribution Manager, L’Association Béninoise pour le Marketing Social et la Communication pour la Santé

Péniel, age 23, and Valérie, age 42, both use contraception – but only when they have sex.

“I am not living with my man at the moment, but he comes over from time to time,” Péniel shares.

Péniel didn’t feel like oral contraceptive pills and condoms were right for her. She worried she would forget her pills, or that her partner would use a condom incorrectly.

For Valérie too, sex happens intermittently. “When my husband comes back from his travels,” she explains. “Not every day.”

“I was hesitant about other methods,” Valérie adds. She wants her contraception to be discreet, easy to use, non-hormonal, and without side effects.

These women – like the 1.1 billion sexually active women globally who do not want to get pregnant – need options to prevent pregnancy on their own terms.

When a new on-demand, self-care contraceptive product first arrived in Benin, Péniel and Valérie were among the first in their community to line up for the Caya® diaphragm.

THE CASE FOR ON-DEMAND CONTRACEPTION

Consumers need a range of effective contraceptive options that meet their varied preferences, including the preference for on-demand contraception—especially among those who have infrequent sex.

Globally, the two most common reasons women give for not using contraception while in need are:

1. “Health concerns,” including health risks, fears of side effects, and unwanted menstrual changes.
2. “Infrequent sex.” Women who are unmarried and those who do not have children are more likely than others to say infrequent sex is why they do not use contraception.

Across a wide range of countries, studies have found an interest in on-demand options among women who have infrequent sex, many of whom desire convenience, ease of remembering, the ability to conceal use and the avoidance of continuous exposure to contraceptive hormones and/or side effects.

But for consumers who want contraception only at or around the time of sex, what on-demand options really exist?

THE NARROW RANGE OF CURRENT ON-DEMAND OPTIONS

The range of on-demand options on the market is limited. Only three options are widely available:

• Withdrawal is one of the most common traditional methods of family planning. No product is needed. However, this approach is less effective than modern contraceptive methods.
• Male and female condoms are the preferred modern methods for many. These non-hormonal barrier methods provide protection against HIV and other sexually transmitted infections in addition to contraception. But condoms do not satisfy the entire universe of consumers with a desire for on-demand contraception. Many consumers report they do not use condoms due to dislike of the physical sensation of use, social stigma, lack of male partner support, and other reasons.
• Emergency contraceptive pills (ECPs) can be taken up to 5 days after sex. (The sooner they are taken, the more likely they are to be effective.) Unlike other modern methods, ECPs do not need to be accessed before sex—making this method particularly valuable when sex is unplanned. Yet some consumers, like Valérie, desire a non-hormonal option. In addition, regular use of ECPs is not yet authorized by national regulatory authorities.

MIGHT NEW ON-DEMAND CONTRACEPTIVE METHODS FILL A MARKET GAP? OPTIONS ON THE HORIZON

Research shows that on-demand options have enormous potential to respond to consumer preferences. Yet of the USD $64 million spent globally on contraceptive technology development in 2018, just $3.7 million (5.7 percent) went to on-demand methods, according to the 2020 G-FINDER Report.

Three on-demand methods have the potential to become more widely available by 2025:

• Pericoital oral contraception could address a need for women who want the option to use a contraceptive pill before or after sex, as needed. A review of 19 studies in 16 countries found substantial interest among women in a pericoital pill that could be taken repeatedly. Research by the World Health Organization supports the safety and efficacy of this use of LNG 1.5 mg pills, the same formulation of many current ECPs, multiple times within a menstrual cycle. Furthermore, recent (pre-published) research in Ghana and Kenya showed demand and high satisfaction with this method. Discussions are underway with regulatory bodies about the possibility of authorization of this method.
• Vaginal contraceptive gels, such as spermicidal gels, can be self-inserted in the vagina before sex to stop fertilization. A new type of gel may enter more markets soon: Phexxi®, which prevents pregnancy by maintaining vaginal pH, received U.S. Food & Drug Administration (FDA) approval in 2020.
• Diaphragms are a barrier method placed over the cervix during sex. Caya® departs from past diaphragms primarily because it comes in a single size, meaning it requires no fitting by a provider. With approvals by Stringent Regulatory Authorities and several dozen other countries, including three in sub-Saharan Africa (Benin, Niger, and Nigeria), Caya access may soon increase—including in countries that have never had widespread diaphragm access.

EECO and Knowledge SUCCESS curated a collection of 20 Essential Resources for Contraceptive Product Introduction. The selected resources can support efforts by program planners and implementers to bring to market the new contraceptive products that consumers want, including on-demand options. 

PENIEL AND VALERIE’S CHOICE: A SINGLE-SIZE DIAPHRAGM

“When he comes over and I’m ovulating, I use Caya to prevent pregnancy for now,” Péniel says.

In Benin and Niger, EECO project monitoring and user research have found that infrequent sex and a preference for on-demand contraception motivated many women like Péniel and Valérie to choose the Caya diaphragm.

Péniel and Valérie accessed the Caya diaphragm through USAID’s Expanding Effective Contraceptive Options (EECO) project, which leads pilot introductions of promising contraceptive methods. Through EECO, PSI’s network member in Benin, the Association Béninoise pour le Marketing Social et la Communication pour la Santé (ABMS), supports providers to offer Caya alongside a wide range of contraceptive options.

ABMS communicates with women and men about the possibility of pairing Caya with the fertility awareness-based Standard Days Method, which is available in the same clinics that offer Caya. On fertile days, some clients choose to use Caya rather than abstaining or using condoms.

To address unmet need among consumers who have infrequent sex and are dissatisfied with current contraception options, there’s more work to do. When pharmaceutical companies and donors invest in developing novel on-demand methods and when we collectively increase consumer access to available products, we put the power of choice into the hands of consumers like Péniel and Valérie.

“[Caya] is a very easy method to use,” Valérie explains. “It’s discreet… practical, and without side effects and hormones.”

Simply, it’s contraception on her terms.

For more information, please contact Abigail Winskell ([email protected]). 

Traditionally in international development, community-based and grassroots organizations are used solely as implementers: they’re given a small, specific scope of work that they’re asked to achieve, after a thorough due diligence process led by the “prime” awardee—typically a big INGO that serves as a pseudo-donor to the local partner.  

It’s time for local partners to lead  

When we shift power and co-create, co-implement and co-evaluate programming alongside local partners, we can advance people powered health solutions and get us all closer to Universal Health Coverage (UHC). 

Locally-led models for feminist funding can get us there. Maverick Collective by PSI and Fòs Feminista are collaborating on a new feminist fund – Maverick Portfolio.  

FEMINIST FUNDING CALLS ON US TO PROVIDE INCREASED AND BETTER-QUALITY FUNDING 

Fadekemi Akinfaderin, Chief Advocacy Officer, Fós Feminista  

Institutions with resources tend to hold the power and dictate how much funding is provided; to whom those resources go; and what priorities are resourced. Feminist funding aims to: 

• Challenge this power by calling on institutions, especially those in the Global North, to question how this power is being used 

• Call on us to provide increased and better-quality funding to activists, organizations and movements in ways that provide the greatest flexibilities on a long-term basis to bring about systematic change 
• Center the leadership and experiences of those most affected by systematic oppression and aims to resource them to change the status quo.    

Common misconceptions about feminist funding include perceptions that grassroots organizations are not able to manage large and flexible funding that are not tied to prescribed project activities; that it is difficult to measure results and change with feminist funding; and that feminist funding has no due diligence processes, and it is greater risk. These misconceptions are false and center around the notion of power and control. We now have examples that have demonstrated otherwise.    

We recognize that many organizations, especially those led by excluded communities, do not have the luxury to engage in co-creation processes due to resourcing constraints. PSI and Fós Feminista are committed to eliminating this barrier by providing flexible funding to grassroots partners to not just engage, but take leadership in the entire process. Through this partnership we are demonstrating how we can shift power and work with partners horizontally in program co-creation, implementation and evaluation. 

To integrate feminist approaches into program implementation, we recognize the power we hold in our relationships with national partners; we commit to co-create the project and resulting scope of work for each partner; jointly own work products produced through this partnership and make it open source; and engage in a process of mutual learning, exchanges and capacity building, where every partner shares its strengths and capacities for the benefit of all.  We will also include as part of our theory of change and results framework systems to check on how we have been able to live into the partnership values we have set and not just the “outcomes” related to sexual and reproductive health and rights (SRHR).  

Finally, we are very intrigued and excited about working through Maverick Portfolio on “engaging men and boys” for delivering SRHR interventions.  This is the funding theme the pilot countries have selected, with local input, to focus on, and we see this as a unique opportunity to reflect, dream and co-create a feminist model to engaging men and boys. Most of the national partners are feminist organizations who have strong analysis that will be brought together in the design of this new initiative ensuring that we continue to center women, girls, and gender diverse people, while working with men and boys to transform harmful social norms around masculinities. 

WE CAN’T CATALYZE SYSTEMIC CHANGE ALONE 

Natalie Fellows, Senior Manager for Impact, Experiential Philanthropy, PSI DC 

We know that local partners, and their deep ties to the community, as well as their experiences and expertise, bring so much to the table, especially in terms of strategy, setting priorities and determining metrics for success. We want to work with incredible local organizations and grassroots movements as true partners – this means mutual accountability, transparency, respect and decision making. 

We are doing this through Maverick Portfolio, a new giving program from Maverick Collective by PSI implemented in partnership with Fòs Feminista. 

The Portfolio started with a question: how is traditional philanthropy and international development actually standing in the way of achieving the most impact possible? With this question, we launched a co-design process—with seed funding from our existing members—to create a philanthropic fund that eliminates these barriers and puts impact front-and-center. The resulting model shifts power from the donors to the doers, the people in the countries where our programs operate, who are closest to the impact. We hypothesized that by moving decision making power to those closest to the work; providing flexible funding to allow for adaptive programing; engaging with local partners who bring their full value to the table; and co-creating solutions, we can create more impact, at-scale for the communities we aim to serve.  

But we know we can’t catalyze systemic change alone. Our partnership with Fòs Feminista and local actors is fundamental to us accomplishing long-term change; this partnership will be our guidepost to make sure we’re walking the walk and not just talking the talk.    

CENTERING CONSUMERS AND ENSURING LOCAL PRIORITIES AND SOLUTIONS ARE UPLIFTED 

Metsehate Ayenekulu, Adolescent Sexual and Reproductive Health Director, PSI Ethiopia 

The Maverick Portfolio model is all about centering consumers and ensuring local priorities and solutions are uplifted. We know that local partners often have some of the deepest connections to the communities we are aiming to serve, and by working with them it can help further support the goal of consumer powered healthcare.  

Through Maverick Portfolio’s development, we’ve thought a lot about the due diligence process, reporting requirements, credit due and donor access. We see these as elements of a partnership in need of change. Why should INGOs get to see all the financial, operational and programmatic details of a local partner during the due diligence process, when they themselves are sharing no information? How can we co-create reporting requirements that fit both organizations’ needs? And how do we ensure that local partners have access to donors as well, and are also given proper credit for the success of initiatives they contribute to and lead? These are all things we’re working to shift through Maverick Portfolio.  

We can see that, on an operational level, PSI is shifting in a similar way – looking at its subaward processes to simplify and streamline for our partners, and making a concerted effort to continue shifting power to local-led entities. We hope that this pilot will deepen the evidence base for how INGOs can shift power dynamics on resource allocation and decision-making processes; how we define success and on how we thoughtfully and effectively engage local partners.  

Visit Fòs Feminista and Maverick Portfolio to learn more.  

By Faustina Fynn-Nyame​​, Executive Director, Africa, Children’s Investment Fund Foundation  

The year was 1995, the location, Beijing, China.   

Back then, many of us did not quite comprehend how the deliberations and commitments made at the United Nations Fourth World Conference on Women would impact the future of the girl-child and women across the globe.  

Adopted by 189 countries, the Beijing Declaration and Platform for Action presented a significant turning point for the global agenda for gender equality, identifying 12 strategic areas and actions aimed at removing all the obstacles to women’s active participation in all spheres of public and private life through a full and equal share in economic, social, cultural and political decision-making.  

26 years after these commitments were made, there has been significant progress, but we are still a long way from removing all obstacles to gender equality and the advancement and empowerment of women and girls.  

A 2020 analytical review of achievements and challenges in the 12 areas of the Beijing Platform for Action conducted by UN Women for the East and Southern Africa Region cited persistent gender gaps in education and training, negative cultural and entrenched patriarchal social norms, dwindling political will to adopt sustained campaigns for the transformation of these negative social norms, and inadequate resources to implement them as some of the present-day obstacles to delivering on these commitments.  

Across Kenya, Ethiopia, Nigeria, and Burkina Faso, nearly half of the adolescent girls are married before 18, two-thirds do not attain secondary education, one quarter have a child by 18, and young working women continue to earn less than men. These outcomes are worsened by a resistance to include comprehensive sexuality education in school curricula, denying both boys and girls the information and skills to safely manage their sexuality to avoid early sex debut and unwanted pregnancies.  

This is happening against a backdrop of inadequate investment in the health sector, with many countries heavily relying on foreign assistance and donor grants further limiting quality and equitable access to (reproductive) health and related social services.  

We will continue to fail women and girls if we fail to eliminate these obstacles and barriers.  

The Children’s Investment Fund Foundation (CIFF) is committed to transforming the life of the African girl. Informed by CIFF’s Africa Strategy, our aim is to ensure that girls achieve their aspirations and rights. Our work is not done until African girls have the health, economic opportunity, and the agency to contribute to a thriving and self-determined Africa.  

This complex challenge calls for bold, catalytic, transformative, and locally driven sustainable solutions, with an explicit equity focus that leaves no girl behind. This will involve tailoring interventions to reach and improve outcomes for girls in marginalized communities and doing things differently. Business as usual will not suffice, but rather a radical change in how we view the problem and its solutions.   

Our promise to the African girl is to build her capabilities by addressing norms and barriers to staying in school and learning, and building life skills and agency, to prepare her for the future by supporting secondary education and vocational pathways, universal access to sexual reproductive health (SRH), and economic empowerment by addressing gender gaps in key sectors.  

For this to happen, we have made a commitment to put the adolescent girl at the center of our design process starting with her needs and aspirations, and address this holistically to maximize impact. We realize that we can only do this sustainably by working through local organizations and leaders, building capacity, strengthening networks and empowering the voices of our partners while leveraging existing platforms, partnering with government to scale our investments, and putting sustainability at the front and center of our strategic approach.   

To deliver on this promise and commitment calls for transformational opportunities to scale what we and our partners know works, testing new models where evidence is lacking, and providing catalytic funding to transform large scale programs and initiatives.   

26 years on, the African Girl still needs all our support to become the woman of her dreams. To live in a world where she can actively participate in all spheres of public and private life through a full and equal share in economic, social, cultural, and political decision-making. And to live in the world we promised her in September of 1995 in Beijing.  

“Only when girls, including those most-at-risk, have equal rights, opportunities and agency to achieve their full potential can we have resilient, prosperous and just societies.’’