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Emergency Contraception : Indian Perspective

Constraints in introduction of EC in the National Family Welfare Program
– Dr Chander Puri, IRR, Mumbai

Inspite of our 49 year old NFWP, even today, the couple protection rate remains at 48% with an unmet need of 16%1. One in every four women has an unmet need and over 50% of adolescents are married by 18 years of age, with only 5% using contraception, unplanned pregnancy becomes a concern. Inconsistent use of contraception and relative inexperience often renders them in need for EC. Among the different family planning methods available, 2% of users accepted IUDs whereas 3% used condoms, 4% preferred traditional methods and 2% used COC1. The couples resorting to condoms, COCs and traditional methods are at risk and a woman may need an EC back-up in case of failure, incorrect use or an occasional non-use. Women who are victims of sexual violence and coercion can opt for EC to prevent pregnancy. Thus, though no studies have been conducted for evidence-based requirement of Emergency Contraception, the above facts are an indirect evidence of the felt need for Emergency Contraception among Indian women.

Introducing EC and promoting it in the NFWP needs careful planning, strong infrastructure and a joint effort by the Government, NGOs, medical associations, women’s organizations, religious and communal leaders. Several bottlenecks/constraints need to be overcome prior to introducing EC in the NFWP. Key issues that need to be tackled before introducing Emergency Contraception are detailed below:

l Misconceptions

Misconceptions about EC use exist, mainly among the providers and, to some extent, among the users, religious leaders and women activists. Often, EC is considered as an abortifacient. Since use of mifepristone along with prostaglandin induces abortion, Emergency Contraception is considered to have a similar mechanism of action. A study conducted among post-partum women in San Francisco revealed that though two-thirds of the total 371 women showed willingness to use EC, the remaining had either moral or religious objections to the use of EC, as they perceived it as an abortifacient or believed it to be unsafe2. Hence, the service- providers should aptly inform that EC methods act prior to implantation and frequently before ovulation, thus preventing pregnancy and the need for abortion.

The most sensitive issue of concern about promotion of promiscuous behaviour due to Emergency Contraception is illogical and till date, no data suggest or prove it. Rather, in cases of promiscuity, pregnancy can still occur due to contraceptive failure and in such conditions use of Emergency Contraception can help prevent pregnancy. Further, majority of the adolescents and unmarried women not using any contraception face the risk of pregnancy as do the victims of sexual assault or rape. Information on EC provides an opportunity to provide information on prevention of STI/HIV and help not only adolescents but women of all ages who need Emergency Contraception. It is high time we broaden our frame of mind and appreciate that risk of pregnancy and induced abortion is greater than the risk of using emergency contraception.

Family planning care providers fear that women may stop using regular contraception if EC is easily available. It should be clearly emphasized that EC is meant for only an emergency situation and cannot replace regular contraception. In addition, EC is associated with unpleasant side-effects like nausea and vomiting and repeated use of EC in a month may expose women to higher doses of steroids than those recommended in a cycle. Hence, EC should be used only as a back-up method. Use of condoms helps in preventing pregnancy and the transmission of STI/HIV whereas, EC will not protect against STI, hence the argument that men will be less willing to use condoms since their partners have EC protection remains largely invalid in the HIV era.

l Provider-related reasons

Quality-care service is only possible if the providers and healthcare personnel are themselves convinced of the utility of EC in the FP service bracket for which studies on the knowledge, attitude and practices should be undertaken. In India, awareness about EC among providers is low as reflected by a random survey among gynaecologists, which revealed that only 30% were aware about EC. Studies from UK and USA found that a vast majority of providers do offer EC. Studies reveal judgemental attitude of providers against delivering EC to non- users of FP methods and unmarried adolescents other than rape victims. A few providers do not counsel couples who face risk of pregnancy like barrier-users and adolescents, whereas some are reluctant to give EC in advance. Moral and religious attitudes prevent providers from giving EC3. All providers should have knowledge about the methods, indications for use, management, special counselling needs, follow-up procedure, and should emphatically put forth that EC does not protect against STI or subsequent unprotected intercourse.

l Product-related reasons

Till date, there is no product registered and marketed as EC in India. Though high dose estrogen and progestrone pills (COC) and IUD are available as FP methods, their use as EC has not been propagated and promoted in the Indian context. Levonorgestrel (LNG) and Mifepristone are unavailable in the Indian market. IUD as an EC is better than LNG (98.6% vs 85.4%) which is better than Yuzpe regimen (85.4% vs 56.4%)4. Hence efforts to promote IUD as EC and introduce LNG as alternative should be boosted. Further, IUD can be used even up to 5-7 days of unprotected sexual intercourse, and is a one-time long-term method. True effectiveness of Yuzpe regimen is likely to be more than 74% because treatment failures also included women who were pregnant prior to EC treatment5. In a country like India, where cost is an important factor, COC can be utilised as EC and extra tablets to take care of vomiting can be supplied. Prescription requirement over a period of time should be discouraged since it becomes a major obstacle for young women, poor women and those who lack access to FP methods.

l Service delivery system

EC is not available in the National Family Welfare Programme. The needs of the target population and service capability should be carefully screened and planned within the contraceptive method mix before initiating the service delivery of EC in the NFWP. The greatest hurdles in service delivery of EC is logistics of distribution and availability of EC within 72 hours to those needing it. This can be overcome by increasing avenues like FP clinics, NGO, general practitioners, vending machines and pharmacies with information brochures for use. Freely available EC services and advance provision of EC pills to all at risk subjects like those who use condoms, pills, coitus interruptus may benefit, especially those who find it difficult to take time out of their daily chores to collect EC.

Efforts to provide scientific information to NGOs, women activists, government and community with answers to their concerns cannot be undermined. The participatory approach of NGOs, medical associations, women activists, with the Government of India will help in the introductory services and setbacks if any, can be promptly attended to without allowing myths to prevail in the community. It is the responsibility of the provider and the Government to ensure quality-care services along with good counselling. Utmost care should be taken to give detailed information to women regarding the need for EC and when and how to take it. Failure rate of EC should be appropriately explained and need for follow-up stressed. Though doctors, nurses, midwives and other paramedical workers having complete knowledge about EC can provide efficient EC services, easy accessibility through pharmacies should also be considered in due course. Germany, Netherlands and other European countries have 24 hour telephone referral services for EC users. EC services can be initiated in a phased manner in order to identify the lacunae and take prompt action before the programme faces strong criticism. Hence, there is a need to identify service delivery appropriate for Indian settings.

l Client-related reasons

Indian women have negligible awareness about EC. A survey of 1125 urban and 575 rural women in reproductive age group showed that only 8% and 3% of the women in the two groups, respectively, knew about EC. Even in countries like UK and USA where EC is widely propagated, a substantial number of women were not aware of the 72 hour limit and had incomplete knowledge and fear about health risks2. In a USA study of knowledge about EC among 2000 men and women, 55% had heard of EC, 9% knew proper timing for use and 1% had used it6. Considering the level of literacy and knowledge of FP methods among Indian women, it is a high priority that the service delivery system should strategically lay down a well-designed, intensive information, education and counselling campaign for effective use of EC to those needing it. Another major constraint is that women who have infrequent sex, no stock of condoms or COCs, usually take a chance and hence do not use EC. Emphasis on strengthening counselling, and motivation to prevent the chance factor should be considered. Since many of the women who need EC may not be FP clients, strategies to address and appraise them about EC should be innovatively planned.

l Streamlining EC in the NFWP

Introducing EC methods in NFWP demands sincere commitment from the public and private sector, decision-makers and potential users. Support of community leaders and government officials make the introductory services more successful. Understanding client’s perspectives and identifying factors which may influence patterns of choice and potential use of EC and the magnitude of the felt need can help to channelise and streamline the service delivery approach with necessary adaptations to local needs. Selection of drugs approved legally by the drug regulatory authorities which are cheap and are easily and widely accessible, can be distributed in a phased manner in the initial stages either through FP clinics, hospitals and general practitioners. Once the awareness and knowledge about EC increases, with telephone information and referral services developed, EC can be promoted over the counter too.

Success of EC lies mainly on correct and prompt use by the beneficiaries and continuous supply by the programme manager. Through trained providers, the service should be rendered to the client’s satisfaction. The EC programme should be stringently monitored along with evaluating the method provision, user-perspectives, provider-perceptions with their experience with the EC pills. Whether the service delivery channels are accommodating and addressing majority of the women who need EC, when the EC pills are used appropriately and they bridge the gap so that clients use regular contraception, should also be assessed. The results of monitoring and evaluation of the EC programme should be studied and information disseminated with subsequent development of strategies for a more acceptable, appropriate quality EC programme.

Finally, EC methods not only prevent pregnancy but also save time and the agony of induced abortion with associated health risk, and work out to be more economical by saving over 100 to 400 US$.

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