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Why Are Unmarried Women Having Difficulty Accessing Contraceptives When MOH Has No Policy Against It?

A klinik kesihatan doctor says it is in their KPIs to increase the registration of unmarried women between the ages of 15 to 49 who are able to conceive to come to their pre-pregnancy clinic (PPC) to get contraceptives.

Deputy health minister, Lukanisman Awang Sani, on a working visit to Klinik Kesihatan Bako. Photo from Ministry of Health Facebook post dated January 16, 2023.

KUALA LUMPUR, March 21 – Stigma and prejudice remain for unmarried women as many are shunned from getting contraceptives at public health care facilities because of their marital status, despite the Ministry of Health’s (MOH’s) no-discrimination policy.

Malar (pseudonym), a media practitioner in her early forties, recounted her negative experience a few years ago at a public hospital in Petaling Jaya.

“I felt like I was being judged for taking care of my sexual health and engaging in premarital sex.”

– Malar

“I was not yet married at the time, so the gynaecologist, a woman, was not very happy about me asking about non-invasive birth control methods,” she told Ova, adding that the experience left an impact on her. “I felt like I was being judged for taking care of my sexual health and engaging in premarital sex.”

Malar now no longer goes to public health care facilities to seek contraceptives, saying: “I only go to private health care providers now, although they are more expensive. Their care, bedside manner and knowledge are far superior to public health care gynaecologists.”

Deterred From Seeking Subsidised Contraceptives

For some women, their ethnicity and religion, and even mental health, compound the problem even further.

Mia (pseudonym), a 32-year-old Malay pharmacist, was 24-years-old and unmarried when she contacted the nearest klinik nur sejahtera branch, to request for a copper IUD (intrauterine device).

The copper IUD is a long lasting, non-hormonal birth control placed into the uterus by a doctor. Experts say it has a 99 per cent chance of effectiveness so Mia wanted to explore using the IUD, having gone through several pregnancy scares due to relying solely on condoms.

According to the clinic’s website, the copper IUD was only RM80. In comparison to the RM200 or more it would cost at private health care facilities, this would be affordable for Mia as she had just started working at that time and was struggling financially.

But she got a shock when she called the clinic and the first question she was asked was whether she was married or not. The employee in charge said they did not provide contraceptives to unmarried women and when asked why, Mia was told it was just their policy.

Mia was taken aback as she had not heard of such a policy and could not find anything on the clinic’s official website regarding it. This made her abandon the plan to get an IUD inserted.

She continued using condoms, but not without suffering through a few more pregnancy scares. Mia has bipolar disorder, and the pregnancy scares worsened her mental health.

“The MO (medical officer) informed me that they only provided contraceptives for married people due to the way their registration system works as they needed to key in the sijil nikah.”

– Mia

Mia recalled the experience as “confusing”, saying it deterred her from seeking access to subsidised contraceptives, whether from the National Population and Family Development Board (LPPKN) or other government facilities because she was afraid of the scrutiny.

“What would happen if I – a tudung-clad Malay woman at that time – were to walk into the clinic, with no sijil nikah (marriage certificate) whatsoever, and straight up ask for an IUD?” she said. “Would it be scandalous? Would I get an earful from the staff about how premarital sex is forbidden?”

A few years later in 2020, Mia, now 29, encountered another negative experience when she called up LPPKN’s klinik nur sejahtera in Johor Bahru. She wanted to check whether she needed an appointment to get an IUCD or implant.

According to the LPPKN website, the IUCD would cost her only RM80, on top of a consultation fee of RM10, versus the RM300 that she was quoted from a private clinic at that time. And an implant would cost her RM500 from klinik nur sejahtera versus up to RM1000 from private establishments.

“The MO (medical officer) informed me that they only provided contraceptives for married people due to the way their registration system works as they needed to key in the sijil nikah,” Mia told Ova, saying she was told to get contraceptives from a private facility instead. 

“I was told they only offered contraception for unmarried people for health reasons, for example irregular or heavy periods, not for actual contraceptive purposes,” Mia said. “Someone whose pregnancy was contraindicated because of underlying illnesses, or while taking teratogenic medication, can also be considered, provided that they get a doctor’s letter.”

Teratogenic medicines are drugs that are able to disturb the growth and development of an embryo or foetus.

“In my case, I didn’t want to get pregnant as I have bipolar disorder, am currently on medication, so they required a memo from my psychiatrist,” Mia said.

She refused to obtain a memo. “I felt it’s not worth the hassle and I didn’t want to comply with this ridiculous policy. It was an unnecessary extra step that I needed to take to get contraception, all because of my status as an unmarried woman.” 

“I decided not to pursue the matter further and delayed getting an LARC (Long-Acting Reversible Contraception) and continued with my current contraceptive of choice that is the barrier method since it’s a method that does not require me to consult a medical professional who might chastise me for having premarital sex,” she said.

No Policy By MOH Barring Unmarried Women From Accessing Contraceptives

Despite the discrimination faced by women such as Mia, a check with a few doctors found there is no such policy by MOH to bar unmarried women from accessing contraceptives.

“No, there is no such policy,” said a family physician, who only wants to be known as Dr A and is based at a klinik kesihatan in the Klang Valley.

Most unmarried women, he said, prefer to go to private facilities or pharmacies for contraceptives not due to discrimination at public health care facilities, but because they do not want to be registered.

“In fact, my team and I actually want unmarried women to come to the clinic even more.”

– Dr A (family physician at klinik kesihatan)

“Very rarely do we capture them before pregnancy,” he told Ova. “We usually treat women when they are pregnant or during the post-delivery stage as this is part of our long-term care.”

Dr A said neither he nor his colleagues have rejected unmarried women, especially those at high risk of health issues such as those living with HIV, women who are sex workers, women living with diabetes and those living with chronic diseases, from accessing contraceptives and care at their clinic. 

Doctor A said it is in fact, in their KPIs to increase the registration of unmarried women between the ages of 15 to 49 who are able to conceive to come to their pre-pregnancy clinic (PPC) to get contraceptives.

He acknowledges that there are doctors who interpret MOH’s policy “according to their values and principles”, but said there was no such problem at the clinic he was based at.

“In fact, my team and I actually want unmarried women to come to the clinic even more,” he said, adding that the low turnout at his clinic could be because unmarried women are not aware of the services available and also because of the fear they might be judged.

Patients Should Be Offered The Complete Range Of Effective Contraceptives Available

Dr Subatra speaking at an online Women’s Health and Rights forum on April 2, 2022

Dr Subatra, primary care reproductive health specialist at Klinik Rakyat PJ, a private facility, in the Klang Valley, told Ova many public health care workers refuse to provide contraceptives to unmarried women because they simply interpret MOH’s policy “up to their whims and fancy.”

“The trend is because of discrimination and the judgemental attitudes of health providers. They have a  holier-than-thou approach, rather than a rights-based approach,” Dr Subatra said, adding that this trend is part of a complex ecosystem that many people in society — from the security guards to the receptionists, to the nurses and the doctors and pharmacists –- contribute to.

“KKM (Malay acronym for Ministry of Health) has reiterated to us that there is no such policy to refuse services based on marital status,” she said, adding that such dialogues happened in high-level meetings with the ministry.

“However, we continue to see that this happens on the ground, at klinik kesihatan, at LPPKN clinics and at hospitals, based on feedback from our clients. Even though KKM says there is no such policy to deny services based on marital status, in our experience from our clients’ feedback, non-married individuals have been denied pap smears, vaginal speculum checks, requests for contraception such as the pill, IUD insertions and Implanon insertions.”

“Many (medical doctors) are also not well versed with the latest guidelines, such as the recommendation for LARCs even for people who have never been pregnant or delivered before. For example, IUDs are recommended for 16-year-olds and above,” she added.

Dr Subatra said one aspect of reproductive rights is that a client should be offered the complete range of effective contraceptives available, but most of the time, a non-married person is offered only the oral contraceptive pill, but not offered the option for an IUD or implant.

Power Dynamics, Race, Religion Affect Access To Contraceptives

“The accessibility for services for non-married individuals seem to be random, with some clients having success, and some not. A client who is empowered, for example, can demand and stand up for herself in why she would need such services and then be able to access them,” Dr Subatra said.

“However, the power dynamic is large, and not many clients would do that after being refused access to a consultation.”

“Clients who have told me that they have been denied service usually are those who are privileged enough to know their rights, 20 to 30 years of age, based in the Klang Valley.
Yes, some do come because they were unable to seek services at government centres, most just don’t try because of the high assumption that they will be judged and denied.”

– Dr Subatra, primary care reproductive health specialist

“There is also the question of race and religion, with single, Malay, Muslim women having more issues in accessing services, than my clients who are non-Muslims.

“The randomness is what leads me to comment that the implementation depends on the ‘whims and fancies’ of the attending health care service provider.”

Dr Subatra said she knows of many Malay women who were affected by such practices. For example, a 23-year-old sexually active Malay administrative assistant was refused combined oral contraceptives because she was unmarried. 

In another case, a 25-year-old sexually active, non-married Malay woman was denied pap smears at a public health facility (while pap smears are not a contraceptive they are also part of sexual and reproductive rights).

As a result, many women choose to come to her practice at Klinik Rakyat PJ, a low to middle-income reproductive health clinic in the Klang Valley.

Dr Subatra’s clinic has a confidential no-ask policy in terms of marital status, so specific data cannot be given. “I am unable to give you accurate statistics, except for what is implied and relayed by our non-married clients regarding their experiences in being denied services elsewhere.

“Clients who have told me that they have been denied service usually are those who are privileged enough to know their rights, 20 to 30 years of age, based in the Klang Valley.

“Yes, some do come because they were unable to seek services at government centres, most just don’t try because of the high assumption that they will be judged and denied,” she said, affirming Dr A’s opinion.

“If they really want to, most will seek services in private health care,” Dr Subatra said. “Condoms are available widely as an option. Oral contraceptives and emergency contraception are available in pharmacies.

“It can be assumed that most women also fall back on fertility awareness based methods,” she said, adding that taboo and stigma also exist in private health care spheres too, though to a lesser extent.

Health Care Should Be Gold-Standard, Evidence-Based, Non-Judgemental, Rights-Based 

“The guidelines and policy needs to be clearly spelt out to all frontline health care providers,” Dr Subatra said when asked what she proposed as solutions. 

“There needs to be leadership from the top that health care provision should be gold-standard, evidence-based, non-judgemental, rights-based health care. Yes, more awareness and workshops are needed.”

“Health providers also should stop assuming and falsely equating the question ‘are you married?’ with ‘are you sexually active?’” Dr Subatra continued. “Every individual, men included, should also have access to high quality comprehensive sexuality education and information on where to access contraceptive services if needed.“

It has been highlighted that Malaysia’s contraceptive prevalence rate (CPR) stands at only 50 per cent, a figure based on a 2014 study, and a small estimate considering that it only gathered data among married women since sex outside marriage remains taboo in this conservative country.

The importance of access to effective contraceptives is also underscored by the country’s high maternal morbidity rate. In 2021, Malaysia’s maternal mortality ratio (MMR) was 68.2 maternal deaths per one hundred thousand live births, more than double compared to the previous year.

Recently, Alpro Pharmacy, ran a survey and found that despite unplanned pregnancies being among the top five worries of the 1,300 Malaysian women they surveyed, a quarter do not use contraceptives, with nearly 50 per cent relying on traditional methods, also known as the pull-out method.

Society Feels Entitled To Comment And Belittle Women’s Bodies

Rozana Isa, executive director of Sisters in Islam speaking at the “Tackling Unintended Pregnancies In Malaysia” conference organised by the Galen Centre for Health and Social Policy on May 20, 2022, in Kuala Lumpur. Picture by Saw Siow Feng for the Galen Centre.

Executive director of women’s rights NGO, Sisters in Islam, Rozana Isa said that the trend of denying women’s access to contraceptives is not surprising as our society feels entitled to comment and belittle women’s bodies in the first place. 

“It is most condescending and humiliating when persons in the position to provide health care or service take that extra time to ask questions to quickly assess in their heads whether a woman deserves to be given that service or procedure on the basis of their marital status or sexuality choices.”

– Rozana Isa, executive director, SIS

In an email response to Ova, she said: “It’s terribly fascinating how some, if not most of us, think that we are totally entitled to comment on other women’s bodies, especially on their sizes, what they are wearing and on their sexual and reproductive choices.

“We certainly don’t think that way when it comes to men. We are not as critical when it comes to men’s body sizes, nor what they wear and we certainly would not openly pass judgement on their sexual and reproductive choices even if they are openly sexually promiscuous.

“It is most condescending and humiliating when persons in the position to provide health care or service take that extra time to ask questions to quickly assess in their heads whether a woman deserves to be given that service or procedure on the basis of their marital status or sexuality choices,” Rozana said.

“Persons involved in the provision of medical and health care services or procedures should be guided by the ethics of their medical and health care professions and to apply them at all times.

“It becomes an issue of power and control because the medical or health care provider is essentially deciding whether the patient meets the standards of our moral values, and if she doesn’t, then she doesn’t deserve to be treated with just, equal respect, dignity and humanity as a human being.”

This article, written by Mohani Niza, was produced in collaboration with the Canada Fund for Local Initiatives.

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