Background to contraceptive services in Lesotho

The Kingdom of Lesotho has a fascinating history, only becoming independent from Britain in 1966.1 Today it is an extremely poor country, with most of the population relying on subsistence farming.2

In Lesotho HIV is like the mountains – the backdrop to every story; 23% of the adult population carry the virus.2 The epidemic contributes to a low life expectancy, which declined from 59 years in 1996 to 41 years in 2006.2 There are several reasons for the high prevalence of HIV, but local people believe the main problem is that most men of working age leave for months at a time to work in the mines of neighbouring South Africa. There many men contract the virus through paying for sex or having another partner, and then infect their wives when they return home. Antiretroviral drugs are available free of charge, but I saw many patients presenting with late-stage undiagnosed disease for whom such medication was of little use.

Women in Lesotho are generally better educated than men; in 2009, 97% of adult females were literate compared to 80% of men.2 In recent years the fertility rate has gradually declined and was 3.3 births per woman in 2008.2 However, childbearing remains risky. In the same year, the lifetime risk of maternal death was 1 in 62 compared with a global average of 1 in 140.3

Women who know they are HIV-positive are no less likely to wish to give birth, and in some cases are keen to have a child to conceal their status.4 Contraception services are an important part of global efforts to reduce mother-to-child transmission of HIV, but such services are poorly integrated with HIV care in Lesotho.4 ,5

Perhaps surprisingly, HIV-positive women report less unmet contraceptive needs than those who are HIV-negative, but in both groups over half say that services are inadequate.6 In a 2009 survey, 35% of all women aged 15–49 years used a ‘modern’ form of contraception, most commonly injectables (13% of women), the pill (8%) or the male condom (10%); 1.3% used intrauterine devices (IUDs).2 Young, sexually active, unmarried women tended to use condoms rather than more reliable methods. Of those aged 15–19 years in this group, about 37% used a condom but only 4% used injectables; none reported using the pill.2 Alarmingly, analysis of data from 2004 showed that only 6.3% of HIV-positive women used a condom.4

Health care in Lesotho is provided by a mix of Government facilities, private providers and non-governmental agencies; the largest of these is the Christian Health Association of Lesotho (CHAL), which operates 38% of primary health care centres.7 The CHAL hospital I worked for provided condoms, but some Roman Catholic institutions do not. Government and CHAL facilities charge standardised, subsidised fees for contraception services.

Challenges facing contraceptive services in Lesotho

Accessing a clinic is the first task facing women who wish to obtain contraception in Lesotho. The majority of people live in rural areas where travel involves long walks, donkey rides or expensive taxis. Because of the HIV epidemic, women are often responsible for the children of deceased or ill relatives as well as their own family. It can be hard to find childcare cover to make the trip.

The facilities may not be adequate once women make it to a clinic. The outreach facility I was at was a simple two-room shed with no running water or electricity. Providing privacy is very difficult in these cramped conditions. This was identified as a reason for stopping attending contraception services by women interviewed by Tuoane et al. One unmarried women in her 20s commented: “What separated me and other clients was just a counter … they could hear every word of the conversation”.6

Another problem is inadequate staff training. Tuoane et al. also interviewed staff providing contraceptive services.6 Three-quarters of those questioned had attended a refresher course in the last decade, but 6% had received no formal training at any time. This may account for some of the poor practices noted, such as teenagers being refused any contraception apart from condoms unless they were married, IUDs being fitted without first screening for sexually transmitted infections (STIs), and women being advised that sterilisation results in being unable to enjoy sex.

Generational differences make it harder for young people to access contraception. Sex is not undertaken before marriage in the traditional culture. However, premarital childbearing seems to be increasing and it is becoming acceptable for young people to kiss and hug in public places.8 Parents interviewed by Mturi in 2003 were often accepting of young people having sexual relationships, but it was rare for parents to discuss sex with their children and only a minority felt able to offer advice about contraception.8 Many parents were confused by the use of the term ‘family planning’ to describe contraception services and stated that adolescents should not access these services because they were too young to start a family.

Another barrier to healthy sexual relationships is the high rate of alcohol use among both men and women in Lesotho. In Lesotho, women retain their traditional role brewing the local alcoholic drink, joala. This is a sorgum-based liquid of variable colour, typically served in an old plastic pot with nondescript seeds floating on the top. I struggled to finish my serving, let alone drink enough to become inebriated.

Although I have been unable to find recent figures, anecdotally alcohol abuse is widespread and is reported to be a factor in many cases of unwanted sex.9 ,10 Heavy alcohol use is viewed disapprovingly, but women who drink are especially stigmatised as the local culture maintains that women should not drink alcohol at all; drinking would traditionally be grounds for a husband to end the marriage.11 It is difficult for both men and women to obtain professional help to manage substance misuse problems.

Lesotho has a high rate of sexual violence, which makes it harder for women to protect themselves from STIs and unwanted pregnancies. Brown et al. surveyed 939 sexually active women in the two biggest cities in 2006,9 where 25% reported one or more incidents of forced sex, 4% reported that sex had been demanded in return for continuing employment and 10% reported that they had engaged in unwanted sex in return for money or other gifts. Rape in marriage was not illegal until 2003; many are not familiar with the change of law and prosecutions are rare.9 Partners are the most common perpetrators of sexual violence.9

As with many developing countries, Lesotho struggles with both obesity and malnutrition. In 2009, about 17% of women aged 15–49 years were obese.2 Our understanding of the effect of obesity on contraception is limited despite the high prevalence of obesity in the Western world. One trial found that the failure rate while using the combined oral contraceptive (COC) pill is higher in obese women.12 In addition, correctly fitting IUDs and performing sterilisation procedures is more difficult in extremely overweight women.13 This is a particular concern in Lesotho given the low levels of staff training.

However, more than half of the children admitted to my hospital were malnourished. In 2009, about 30% of children aged less than 5 years in urban areas were moderately stunted (height-for-age between 2 and 3 standard deviations below the reference median, reflecting chronic malnutrition).2 This figure was about 40% for children from rural areas.2 Women in Lesotho often struggle to provide enough food for their children, which makes it imperative that they are able to control the size of their family.

Abortion is an important means by which women in many countries prevent unwanted births.14 In Lesotho abortion is illegal unless necessary to save the mother's life. However, prosecutions are rare and unsafe abortion is probably widely practised outside formal health care services. Complications of such abortions are reported to be a common cause of maternal death, but it is difficult to obtain accurate information.15 The lack of a safe, legal abortion service is another reason why ready access to effective contraception is essential.