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.
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
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.
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.
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.
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.