Tracey Koehlmoos: Whatever happened to the diaphragm?

Tracey Koehlmoos

The recent debate in Washington about birth control being mandated for coverage by employers or by health insurance as well as the 101st celebration of International Women’s Day makes me feel empowered to write about a women’s health related issue that I am experiencing now as part of life in the widow-hood.

When the Colonel died in August, I was surprised by how many friends were quick to mention that I would have sex again but with other people. Protocol-wise, there is little written about what to say to the recently widowed but this seems to fall outside of Oretha B. Schwartz’s “Service Etiquette” 4th edition, which suggests the rather limited conversation: “I am so sorry for your loss,” to which the response is, “Thank you.”

In September a senior global demographer visited me in Indonesia. With a background in reproductive health and a guru of understanding populations, he said, “You need to think about family planning.” Of course, he was right, the programme that I lead in Bangladesh is a health systems AND family planning programme, but it is true that I generally pay more attention to health systems research, systematic reviews, and chronic disease. He clarified, “You need to think about contraception. For yourself.”

Since the Colonel’s death, whenever I need to make a decision I have tried to look at everything through a five year lens. However, because I was, and am still, so missing my husband, I had simply not thought about that aspect of my new reality. Given the assignment, I did come up with a plan of sorts.

The demographic adviser came back in February and after talking about fertility declines in Bangladesh, he asked how I was progressing on making a contraceptive plan. He noted that my five-year plan to only date smart men in their 50s who liked to work out and had vasectomies had inherent flaws. I think the “smart, 50s, work out” part was fairly straight forward, but agreed that the “vasectomies” parts was a limiting and unrealistic factor.

Again, there does not seem to be a protocol for this. I will forever be too polite to ask and I am not sure when or how such a discussion would take place. After the appetizer? During the fourth date? Although there is nothing urgent right now, I have been reminded repeatedly that the vow was “til death” so that the obligation is fulfilled whether or not I would like it to be so. Also, I can assure you that my husband’s pre-deployment wishes should he die were always that I would 1) bury him at Arlington and 2) move on and marry again. So, perhaps I am not meant to live a life of chastity forever, although the idea of sex with anyone is unthinkable to me now.

Given the lack of urgency, I do not feel the need to do something permanently to my body. Also, I do not think I should have to fill myself with hormones, take a pill every day, or have a shot every three months for something that I may never need or might only require sporadically. After taking the Planned Parenthood “My Method” quiz and discussing it with my two best girlfriends, I decided on a diaphragm. It could sit in the drawer until required but I would have the added benefit of being prepared.

When I went to my American nurse practitioner in Jakarta, she laughed at me for wanting the birth control of the last Millennium and then notified me that she does not even have the tools to measure for one and order it. She referred me to the Indonesian provider.

I booked an appointment with the Indonesian gynaecologist and was clear about wanting to be measured for and purchase a diaphragm while booking the appointment. At the time of my appointment, the provider asked me where my diaphragm was so she could fit me for it. She quickly stated that “The diaphragm does not exist as a form of birth control in Indonesia.” It does not exist as a form of birth control in Bangladesh, either.

What has happened to the women’s movement that means that now every advocated form of birth control in family planning programmes has become body altering and long lasting? Is it easier for providers to administer and control family planning amid populations using longer lasting, hormonal methods? In general, family planning programmes concentrate on a specific demographic: married women in peak childbearing years, and cater very poorly to the increasing numbers of women who fall outside of that group.

Is it that in global health we are so busy getting people to use condoms to prevent HIV that we have allowed it to become the sole barrier method available? The condom empowers men and requires negotiation for the woman to achieve this level of protection. Also, it is less than comfortable for all involved. (My knowledge of the female condom is limited to a friend’s critical appraisal that “It is like a plastic bag, only inside of you. Very awkward.”) The diaphragm used with spermicide is fantastic in that it can be popped in and popped out as needed. It is re-useable, inexpensive, and protects against pregnancy and some sexually transmitted infections. Why is the diaphragm not available to women in developing countries?

I did read that PATH has developed and is testing a new type of diaphragm in South Africa, the US, the Dominican Republic, and Thailand. It is a one-size fits all, silicon-based product. I will watch for the results of these studies and the subsequent roll out of this product.

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh.

  • Shafieka

    Awesome job, again.

  • Gareth

    A very valid point. However, at least you have more options than us boys. At the moment I can get “the bag” or the knife; which frankly makes it sound like I’m negotiating my own assassination. 
    And in reality I’m too young to the knife anyway: I don’t want it and I think I would be very hard pressed to find a doctor willing to give me one if I could.
    Bag it is.

  • Tracey

     Dear Gareth;
    You are right, and I apologize for not thinking about this from the perspective of the other half of the population. The truth is that men are rather the left behind group when we talk about reproductive health–again, with the exception of HIV prevention.
     Thank you for raising this valid point. Your options are limited too.

  • Tracey

     Thank you so much Shafieka. You read my blog. As you  know, it is challenging to write about contraception so personally so thank you for your support.
     I omitted the link to the information pamphlet from PATH. In case you are curious, you can read more here:
    It is purple. I would like to see some effectiveness results and see more details of the acceptability studies.They don’t seem to be available through the PATH website or in PubMed.
    Thank you again, –Tracey

  • Terri P

    Exactly right on for all of us who find ourselves single after long marriages.

  • Elizabeth

    I’ve used the Billings Method for many years with no surprises, yet doctors often dismiss this method and want to put you on the Pill. It took a while to feel confident with the Method and we have never cut corners. I can read my body and the method is now second nature. I’ve said to puzzled doctors and women that I’d never trust the Pill because I wouldn’t know what was happening in my body…with this method the signs are clear after you’ve used it for awhile. It’s a shame it isn’t considered by more women…so many women end up on the Pill for many years. It’s best in a monogamous relationship – if STIs are a concern, you’d have to use condoms as well….at least until he gets the all-clear. I have always
    liked being in control of my body and fertility.

  • GM

    In developing a product for the 3rd world, and specifically for an under-educated population, is it not right to factor in hygiene and complexity?  A daily pill is simple.  The process of placing the diaphragm, applying the spermicide (fully admitting I have no idea if this is a before or after part of the process), and later removing and cleaning and storing the diaphragm, plus keeping up with the supply of the spermicide; it just seems so much more complicated, and as such less likely to be carried out efficiently.  Of course cost must factor in and I have no idea of that either. 

    Of course for the educated implementers of the programs it is a very different story with a different set of drivers.