My previous article touched on some of the pros and cons that Ugandan women balance when using the popular injectable contraceptive Depo-Provera. While severe side effects include heavy bleeding, cramps and aches, and excessive weight loss (among others) the shot is also an affordable, effective method of preventing pregnancy. It is also widely available in most communities – even some areas that are considered more remote.
This article was in response to a study recently published by the Guttmacher Institute on the controversial sale of Depo-Provera in drug shops in Uganda. According to national law, drug shops are not permitted to sell either prescription medication or injectable substances to customers. The reality is that most drug shops do, despite the fact that roughly 30 percent of drug shop attendants lack formal medical training or experience. On one hand, because drug shops are the most widely accessible sites for Ugandans to obtain medical treatment, it is tremendously positive that they sell this form of contraception. On the other hand, keeping in mind the horrifically adverse side effects many women experience while using the Depo shot, the ease with which women can receive this sometimes dangerous drug is disconcerting. Would less women experience negative side effects if the treatment was more closely monitored or provided at only health clinics? Perhaps. Would less women have access to any form of contraception if the treatment was only provided at health clinics? Probably.
In Uganda, drug shops are “considered the front line of health care for the poor,” especially in rural areas. They are not pharmacies, but must be owned by someone with at least a nursing degree. Other non-owner workers who responded to a research survey indicated that they had training in family planning (77 percent), injection safety (62 percent), or infection prevention and control (59 percent). Drug shops are supposed to be registered with the National Drug Authority (NDA), but many are not and still operate openly using a simple trading license or no license at all (56 percent). They offer medicine and medical supplies at low cost and often provide customers with advice or care, filling the absence of doctors or trained nurses in areas where health centers are too far to quickly reach. Many drug stores also offer “traditional” medicine or herbal remedies, allowing many Ugandans to feel more comfortable speaking with a drug store attendant than a doctor. However, in their research, John Stanback and his team report that more than one in 10 drug store employees admitted to reusing a disposable syringe due to lack of supplies. In a nation where the HIV/AIDS transmission rate is again on the rise, this is a terrifying statistic.
There are just under 5,000 drug stores registered with the NDA in Uganda. Stanback and his team found that drug store operators in three Ugandan cities outside of the capital “reported selling a mean of 3.5 doses of DMPA [depo provera] per week.” If you take into account the many additional unregistered drug stores and vendors, this means that quite a lot of the injectable contraceptive is being dispensed by potentially untrained attendants on a very regular basis. It also means that quite a lot of women are able to protect themselves against unwanted pregnancy. AND it means that the doses administered to these women are not tracked, recorded or regulated. (Basically, if a woman went to one drug store on Monday and asked for a Depo shot, she could get it and do the same thing again on Tuesday at a different drug shop.) See the controversy here?
It is crucial that women have access to birth control in Uganda not only because reproductive health is a right and a means for empowerment and community development, but also because it is an essential ingredient in a Ugandan woman’s struggle to survive past 50. Furthermore, it is crucial that women feel comfortable with their health care providers and can afford their services. In many rural areas, even if a health care center is nearby, women will choose to seek treatment from someone they trust – another community member who can identify with her daily needs and social environment rather than a stranger in a white coat. BUT it is also crucial that the allocation of contraception – especially the concentrated dose of hormones provided in the Depo shot – is carefully monitored! Too many women are deterred from continuing to use birth control methods due to the dangerous side effects they experience.
It is a Catch 22. What would you do?
Stanback, John et al. “Injected with Controversy: Sales and Administration of Injectable Contraceptives in Uganda.” International Perspectives on Sexual and Reproductive Health. Volume 37 Number 1. March 2011. http://www.guttmacher.org/pubs/journals/3702411.html