 AIIMS
was involved in the multi-centre WHO trials on Emergency Contraception in India.
The trials conducted at AIIMS included :
• a
prospective, randomized, multicentre study to compare the Yuzpe regimen with levonorgestrel
in emergency contraception. (published in The Lancet, 1998:352;428-483).
• a randomized, double blind, multinational study to compare
mifepristone and two regimens of levonorgestrel in emergency contraception. This
has been conducted from 1998 to 2000. The interim analysis of results has been
carried out. The final results are going to be available soon.
All of us are aware that EC is a little-known concept in India and is not included
in the National Family Welfare Programme. There is no dedicated product available
so far. All concerned with women’s healthcare feel that EC should be included
in the ‘basket’ of services provided for contraception, not as a substitute but
as a ‘back-up’ method. In fact, since the need for EC can arise at any time,
there is a need for ‘Emergency Unit’ in Family Welfare Department to look after
such needs. In this paper, instead of results
of studies, I will be focusing on the profile of women who availed themselves
of Emergency Contraception from our centre. A total of 247 women were recruited
in these two studies. Their socio-demographic profile is depicted in Table 1.
Most women were between 20-30 years of age, married, belonging to middle class,
with some education and having one or more children.
Table-1 : Profile of Emergency Contraceptive users
Age Distribution ¨20
- 6% 21-25 - 35%
26-30 - 33% 30-35 - 17% >35
- 9% Parity
0 - 22% 1 - 25%
2 - 37% 3 - 12%
4+ - 4% Marital status
Married - 95.5% Single - 4.5%
Previous
MTP One - 20.6%
More than one - 6.9% Place of residence
Urban - 89.8% Rural - 10.2%
Religion Hindu -
93% Christian - 4%
Muslim - 3% Level of education
illiterate - 8.4% primary - 19.6%
secondary - 32.8% college - 39.2%
Socio-economic status
Low - 24% Middle - 72%
High - 4%
Observations and problems encountered during studies
Women were mostly unaware of EC; only a few had inadequate knowledge. there was
a total lack of guidance by the Family Welfare Department, as the staff there
was also not familiar with Emergency Contraception. Initially, most of the requests
came from women who were overdue for their periods, as they thought the pill would
prevent pregnancy after missing a period. As the message slowly spread by `word
of mouth’, the concept of Emergency Contraception became familiar to women. Still,
a great deal of effort was required on the part of project staff to educate the
women and resolve their misconceptions. Non-availability of required drug from
elsewhere also made them suspicious. A shyness to discuss the problems with their
partner and fear of complications were other concerns. Most also expressed that
if there is such an easy method of contraception, it is surely going to be misused
or repeatedly used. We also initially thought so, and counselled all the women
about use of regular contraception at the time of follow-up visit. Subsequently,
all women in the first study were questioned six months later about their current
contraceptive use. Women were not told initially that this would be evaluated.
During this period, only one woman requested for EC again. Pre and post EC contraceptive
use is depicted in table 2. Table
2 : Contraceptive use before and after EC
(n=100)
before EC after EC P value Regular use 13%
70% <0.0001 Condom 10% 18% <0.01
OCP 3% 44% <0.0001 CuT - 3%
Sterilization - 5% Occasional users 44% 23%
<0.01 Non users 43% 7% <0.001
Repeat users 2% 1% As evident from the
table, almost 70% became regular users of contraception. Most significant increase
was noted in the acceptance of oral pills, as non-users and occasional users showed
a significant decline. The probable reason for increase in contraceptive use could
be that the use of Emergency Contraception by these women provided an opportunity
to have a close contact with the providers.
Throughout the studies, it was felt that awareness of women and healthcare providers
about Emergency Contraception was uniformly poor. It was, therefore, decided to
evaluate their knowledge and perceptions about EC. The structured questionnaire
surveys were conducted in three groups. Group
I : Contraceptive knowledge and use in New Delhi women
Group II : Contraceptive knowledge and use in rural women
Group III : Knowledge and attitudes of healthcare providers about EC
The results of these studies are depicted in Tables 3-5.
Table 3 : Contraceptive knowledge and use
in New Delhi women (n=2000)
Method Awareness Ever used
Rhythm 38% 17% Condom 81% 66%
IUD 70% 3% OCP 82% 20%
Sterilization 62% 9% Injectables 33% –
EC 6% – Though overall awareness about
EC was only 6%, 98% women expressed that they themselves or someone close to them
had desired or needed EC at some time during their reproductive life.
Table 4 : Contraceptive
knowledge and use
in rural women (n=122)
Method
awareness ever used
Sterilization 95% 7.2% IUD 87.6% 12.1%
OCP 88.5% 8.2% Condom 86.8% 5.3%
Rhythm 17.2 – Injection/implants 7.8% –
EC 1.6% – In the rural set-up, though
awareness about sterilization, IUD, OCP and condom was present, but use was very
limited mainly due to non-availability of services. Awareness about EC was a meagre
1.6 %.
Table 5 : Knowledge and attitudes of
healthcare providers about EC (n=102)
Awareness of Concept •
General practitioners – 40% • OBG specialist
– 100% Healthcare providers were divided
in two groups. Those who had a postgraduate degree in obstetrics and Gynaecology
(OBG) and those who were internists doing general practice (GP). Awareness of
even the concept that such a possibility exists for contraception was lacking
in 60% of general practitioners. Those who knew about the concept were evaluated
about the accuracy of their knowledge regarding the composition of various methods,
their dosage schedule and time-frame of EC methods. (Table 6).
The study revealed that correct knowledge was lacking in both general practitioners
as well as OBG specialists. None of them had ever prescribed emergency contraception.
Table 6 : Knowledge about composition,
dosage schedule and timeframe of EC
methods (n=102)
Method GP OBG Familiar Correct Familiar
Correct Yuzpe
85% 35% 75% 42% LNG 10% 0 67% 12%
MFP 65% 15% 78% 13% High dose
estrogen 95% 5% 80% 6% IUD 65% 45% 86% 48%
The providers were also questioned about the mechanism
of action of emergency contraceptives and their safety profile. Most described
the action by blocking fertilization or implantation, yet 15% GP and 2% OBG specialists
felt that it acts by causing early abortion. Equally deficient was the knowledge
about safety. Very few perceived EC as a safe method (15% GP & 13% OBG specialists).
As evident from these studies, a lot needs to be done in India to increase the
user and provider awareness and the providers need to be methodically trained
for safe and effective provision of EC to our women.
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