L’essentiel sur la contraception en expatriation
Worldwide, all methods combined, (male and female) contraception is used by only 48% of women between the ages of 15 and 49, and this figure is in sharp decline since it was 63% in 2011 if we compare the United Nations reports of 2011 and 2019.
Of these 48%, female sterilization takes first place at 24%, followed by male contraceptives at 21% and then IUDs and the pill at 17% and 16%.
The gaps between the most and least-developed countries are enormous, with the overall contraceptive rate falling from 57% in the most-developed countries to only 30% in the least-developed countries. In these least-developed countries, contraception relies almost exclusively on women, in the form of hormonal contraceptives.
Africa: the contraceptive rate is only 29% and the top three most-used contraceptives are hormonal injections, the pill, and then implants and male condoms equally.
Asia: the contraceptive rate is 50% and the top three most-used contraceptives are female sterilization, male condoms, and IUDs. In China the rate is almost 70%, in third place worldwide behind Finland and the UK.
Europe: the contraceptive rate is 56% and the top three most-used contraceptives are the pill, male condoms and IUDs.
Latin America: the contraceptive rate is 58% and the top three most-used contraceptives are female sterilization, the pill and male condoms.
North America: the contraceptive rate is 62% and the top three most-used contraceptives are the pill, female sterilization and male condoms.
Oceania: the contraceptive rate is 49% and the top three most-used contraceptives are the pill, male condoms and male sterilization.
Some countries which are very close in terms of development, religion and culture may have very different contraceptive habits:
The United States vs. Canada: the pill is used twice as much in Canada as in the United States, male condoms are used three times as much in Canada than in the United States. In contrast, female sterilization and IUDs are used four times as much in the US.
These figures are not very surprising when you consider that Donald Trump decided to remove the contraceptive provision from the "Obamacare" law, which obliged employers to cover their employees' contraceptive methods in their insurance policies.
France vs. Italy: contraception is used less than in France at a rate of 56% vs. 64%, while Italy has a lower fertility rate than France. In Italy, male condom use is strictly equal to the pill, at 19% each, whereas in France, the pill is widely preferred and the male condom is only 8%.
United Kingdom, New Zealand and Australia vs. the rest of the world: these three countries use male sterilization the most. In New Zealand, more than one out of four married men have had a vasectomy. In these countries, contraception is not usually the sole responsibility of the woman and is shared by the couple. Strangely, this is not the case in Scandinavian countries, despite their often being noted for their strict principles of gender equality.
Access to a gynecologist or a midwife is free as part of the coordinated care pathway.
For adults, certain types of contraceptive pills, contraceptive implants, intrauterine devices (IUDs) and diaphragms are reimbursed by the Health Insurance. These contraceptives are reimbursed at 65%, with a medical prescription.
The following contraceptives aren't reimbursed: contraceptive patches, vaginal rings, cervical caps which are available in pharmacies with a medical prescription, spermicides and female condoms which are available in pharmacies without a medical prescription, and male condoms.
Minors can receive a free, confidential initial consultation, a follow-up consultation during the first year of contraception, and a consultation with a doctor or midwife once a year afterward, as well as certain biological tests. Contraceptives which are prescribed will also be provided free of charge in pharmacies, if they are reimbursable by the Health Insurance.
Planning and family education centers (CPEFs) also provide contraceptive consultations and prevention initiatives related to sexuality and education.
Each insurer can determine which contraceptives it chooses to reimburse, but it is possible to group these policies by origin:
French expatriate policies:
Expatriate insurance companies which are subject to French regulations generally reimburse contraceptives, according to the same rules as the French Social Security system. The advantage is that it is easy to know which methods are reimbursed. The disadvantage is that, in some cases, the policy isn't adapted to the habits of the host country. This is particularly the case for contraceptive pills, because each country has its own rules. Some policies therefore provide additional benefits to cover contraceptives that wouldn't be reimbursed in France.
International expatriate insurance:
All international expatriate policies that we have been able to review exclude coverage for all contraceptive methods. The principle behind these policies is to cover only the costs related to illnesses or accidents. Preventive measures aren't covered, unless they are expressly listed in specific coverages grouped under the term "well-being" and unfortunately, contraception doesn't seem to be part of the "well-being" concept.
Local policies:
Local policies generally exclude contraception, for the same reasons that international expatriate policies exclude it. Some local regulations may provide for coverage by the public system or may provide free coverage, while others require insurers to cover certain methods. In this case, you will need to ask a local doctor to find out which contraceptives are covered.
Temporary policies:
These policies can be taken out for a trip of four to twelve months, an internship or study abroad, or a temporary work permit. These policies are limited to emergency medical expenses and do reimburse contraceptives, prescription visits or related examinations.
Religion and culture often have different perspectives on the value of contraception. For example, various Christian churches have taken a stand against contraception for almost 2,000 years. But over time, attitudes have gradually changed in some branches of Christianity. Protestants place great importance on individual conscience, so couples are responsible for their own fertility and can use contraceptives. The Catholic Church, on the other hand, considers any form of artificial contraception in marriage to be immoral, but allows birth spacing by "natural" methods. However, the Catholic Church does not prohibit the use of the pill for medical reasons. Muslims forbid sex outside of marriage, however, all but the most conservative religious leaders accept the use of contraceptives for married couples. Judaism has a different view of contraception. The Talmud explicitly allows the use of contraceptives in certain circumstances. One of the principles influencing this issue is that the man cannot "waste his seed."
While religion may influence positions on contraception, other cultural factors also play a role. The decisions of the authorities in each country may partly determine individual opinions about contraceptive methods. For example, the pills used under the Soviet regime had a bad reputation because of their severe side effects. For this reason, women in these countries may consider other methods first if they lack the proper information.
Certain cultures give a specific place to menstruation in their cultural representations of the female body. Thus, in cultures where menstruation is seen as purification for the body, women may want to avoid contraceptives that suppress menstruation. Women from other cultures may prefer methods that produce the least amount of irregular bleeding so that bleeding does not occur during sex.
For long-term travel, the issue of contraception can be a real problem for many women. The different methods used in various countries are the result of traditions and policies, which may or may not be voluntary, and which favor or discourage particular contraceptive methods. Being aware of these variables will help you know what to expect during your expatriation.
In the United States, in order to obtain a month's treatment with the pill (approximately ), you must first have an appointment with a doctor, who will issue a prescription. This visit can cost at least 40 dollars and may cost as much as 250 dollars. Women of modest financial means can turn to Planned Parenthood.
Other countries, such as Australia (15?), Canada (17?), Hong Kong, South Korea (7?), Japan (18?), Mexico, Uruguay, provide the pill only with a medical prescription.
On the other hand, no prescription is needed in Argentina or Brazil. In Argentina, you can even get the pill for free in public hospitals.
Emergency contraception:
Before you leave, you can always buy morning-after pills in case you need them in an emergency. If you a temporary work permit trip in a country where the morning-after pill is not allowed or readily available, this may be a good idea. In France, the morning-after pill is reimbursed at 65% with a prescription and costs between 7 and 10 euros without a prescription and it is free and available without a prescription for minors. In Belgium, the morning-after pill is reimbursed at 100% until the age of 21 and costs about 8 euros without a prescription.
Condoms:
In some countries, it can be more difficult to find condoms (the right brand, the right size, without latex, etc.). You can of course take a small supply of condoms with you, but remember that condoms should not be kept for too long under high temperatures, as this could damage them. Female condoms are even more difficult to find in some countries.
Abortion abroad can be considered in the case of an unwanted pregnancy. However, before making this decision, it is important to know the legislation in force in different countries, and the conditions for performing an abortion. Abortion can be legally performed in most European countries. In general, the legal time limit for abortion is 12 weeks, but can be up to 24 weeks in some countries and is prohibited in others.
The legislation and the steps to be taken vary greatly from one country to another, so it is best to contact the family planning office closest to your home.
Apart from what is provided for by the law, you must also consider what is actually possible due to cultural or religious pressures:
Will you be able to find a doctor who will validate the request if it is necessary?
Can you find a clinic that will perform the procedure? Can the deadlines be met?
In many countries, the notion of therapeutic abortion does not exist or has nothing to do with our understanding of it, and as a result, testing for fetal anomalies is not even performed during ultrasound. This practice is one of the reasons why the consequences of Zika in Brazil in 2016 were so dramatic.
This is something to consider when a pregnancy occurs in another country.