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 Introduction of Emergency Contraception in India
  Dr Suneeta Mittal
  Chief Co-ordinator, Consortium on National Consensus for Emergency Contraception
  Officer-in-Charge, WHO-CCR on Human Reproduction

World over, there are millions of unintended and unwanted pregnancies each year. Many of them end in unsafe abortions, while others are carried on till term and contribute to the ever-increasing population burden on the Earth. This is specially felt in developing countries like India, which is also projected to be the most populous nation in the world by 2040 A.D.

India with its population crossing one billion is in urgent need of population control measures. Despite a National Family Welfare Programme and widespread efforts by the Government of India, the contraceptive coverage continues to be poor (46% couple-protection rate, National Census, 1991). This results in almost 78% unplanned and 25% unwanted pregnancies (National Family Health Survey, 1995). All these pregnancies either add to the population burden or the women resort to pregnancy termination. Annually, 11 million abortions occur in India, killing almost 20,000 women.

The search for an ideal contraceptive which does not interfere with spontaneity or pleasure of the sexual act, yet effectively controls the fertility, is still continuing. Numerous contraceptive techniques are available, yet contraceptive coverage continues to be poor in India, as most people are either ignorant or shy, do not want to use a contraceptive continuously regardless of sexual activity for fear of side-effects (pill or intra-uterine device), or do not like to use methods linked with coitus (barriers like condom or diaphragm). Thus even when not planning for a pregnancy, exposure to unprotected sex takes place often, necessitating the use of Emergency Contraception, to avoid the potential hazards of pregnancy termination. This need may also arise due to failure of contraceptive method being used (condom rupture, diaphragm slippage, forgotten oral pills) or following sexual assault. The risk of pregnancy following a single act of coitus varies from 4-25% depending on the time when intercourse takes place during the menstrual cycle. Risk is more when sexual exposure occurs close to ovulation.
Surveys have shown three major reasons for unplanned pregnancies viz women's failure to use a contraceptive method, failure to use a method correctly and their unawareness about Emergency Contraception. By timely and judicious use of Emergency Contraception (EC), 75-99% of these unplanned pregnancies, and thereby unsafe abortions, can be prevented (Emergency Contraception Consensus Conference, Bellagio, 1998). Prevention of these unplanned pregnancies will go a long way in improving the reproductive health of women in India.

Emergency Contraception is really not a new concept. In the literature written 2000 years ago, we find evidence of various herbs to be used for the 'morning after'. A number of ineffective folklore methods which are rather unscientific, like use of vaginal douching using different agents, blowing nose or jumping backwards have been used to prevent conception following unprotected coitus. Several opportunities are offered during the reproductive process to interrupt the process of conception, rather than resorting to abortion. But, usually when couples fail to take precautions, they only keep hoping and praying that pregnancy would not take place and wait anxiously for luck and nature to decide their fate.

Emergency contraceptives act as interceptive agents i.e. ovulation, fertilization or implantation is prevented depending on the phase of menstrual cycle. If used before ovulation, follicular maturation as well as ovulation is disrupted. Following ovulation implantation of blastocyst is interfered with by causing asynchronous endometrial maturation. Function of corpus luteum is also affected and progesterone surge does not take place. There is a fall in the level of endometrial carbonic anhydrase which is important for stickiness of blastocyst. Progesterone also acts by increasing intra-uterine pH. Copper IUD prevents implantation by a direct embryotoxic effect. Danazol acts as a luteolytic as well as prevents nidation and hampers decidualization. The GnRH analogues act by inhibiting LH secretion.

Failure rate of Emergency Contraception is varying from 0-2.4% depending on the method used, interval between coitus and method use and relationship of coitus to ovulation. But all methods are ineffective once implantation has already occurred, thus these are not abortifacients.

A woman faced with the prospect of an unplanned and unwanted pregnancy can, in many cases, avoid the pregnancy by using Emergency Contraception. Several scientific methods are available for Emergency Contraception now and most of these are safe and effective to prevent pregnancy occurring after unprotected intercourse or contraceptive failure. Emergency Contraception should be regarded not only as a 'second chance' of family planning but also as a means to emphasize the need for a regular contraception method and reduce maternal morbidity and mortality arising out of unsafe abortions and unwanted pregnancies.

In India both women and providers are uniformed about these methods. As awareness is limited, women as well as healthcare providers are unable to gain any benefit. Currently, no product is being marketed as Emergency Contraception in India. The time has now come to have a National Policy regarding these methods, and to make them available, train the doctors and paramedics for its proper use and disseminate this information to the masses.

Today, India has the right policy environment to improve the quality of reproductive healthcare and expand the contraceptive options for individuals and couples. The National Population Policy, 2000 has just been formulated and introduced in the country. Increasing access to Emergency Contraception is well within such a programme. A national consensus regarding initiatives to provide the required information, knowledge, availability and distribution of appropriate EC was urgently required, thus it was decided to have a Consortium on National Consensus for Emergency Contraception.
The purpose of calling a consensus meeting is to get together national and international experts and opinion leaders to deliberate on issues related to introduction of Emergency Contraception and its impact on reproductive health and quality of life of Indian women. A multi-disciplinary approach, involving technical experts, experts from countries with experience of EC introduction, policy-makers and planners, Drug Controller of India, NGOs, social scientists, service-providers, pharmaceutical companies, women's groups, media, legal and ethics experts has been adopted to reach a consensus.

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Dr C P Thakur
Minister of Health & family Welfare, GOI
Dr Wang Yifei
Area Manager, Asia and the Pacific, Dept. of Reproductive Healt & Research, WHO
Dr Helena von Hertzen
Medical Officer, Post Ovulatory Methods of Contraception, RHR, WHO
Shri A R Nanda
Secretary Family Welfare, Ministry of Health & Family Welfare, GOI

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