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Emergency Contraception : Indian Perspective

Looking ahead : Role of Professional Associations
– Dr Farah Usmani, UNFPA, New Delhi

It is indeed my privilege to be here this afternoon and share with you some thoughts on initiatives professional associations could take to move forward in the area of helping women achieve their reproductive intentions by avoiding unwanted pregnancy, specifically through additional informed choice of emergency contraception. UNFPA is pleased to be associated with this consortium.

a) Informed choice: There was agreement in Cairo on provision of expanded informed choice and the ICPD Programme of Action states that `the aim of family planning programmes must be to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choices (para 7.12)’. Yet, as we are aware, a gap exists between the rhetoric of informed choice and reality. If a woman is not thoroughly counselled about the actual contraceptive failure rates and the options available in case of failure, is her choice truly informed?

b) Barriers and issues: The need for Emergency Contraception is clearly demonstrated by the occurrence of unwanted pregnancies and induced abortions, and by the high rates of unwanted pregnancies among adolescents in many places. Some barriers to expanding informed choice with Emergency Contraception in programmes include i) cultural : perceived as abortifacient, may pose serious health risk with repeated use; ii) client-related : lack of knowledge, myths, short period of time to access the service; iii) provider-related : lack of clear understanding and reluctance to provide because of insufficient training; iv) product-related : pills specially packed for EC are available in other countries and are relatively expensive; v) policy/regulatory issues : EC would encourage people to continue using the method as on-going contraceptive.

From here, I will move to address the topic I have been asked to speak on, and suggest some areas that can be considered for an expanded and meaningful role for professional associations in India.

Guidelines, Standards, Service Delivery Protocols

As we are aware, several agencies including the partners in the global Consortium for EC, have developed protocols and guidelines. Among these are : IPPF; International Medical Advisory Panel guidelines; Royal College of Obstetricians and Gynaecologists guidelines; Population Council’s booklet ‘Know your Options’ which also includes service delivery guidelines; PATH and Pathfinder International are others. An important area for contribution would be in facilitating adaptation/development of standards/guidelines feasible for the Indian context and, perhaps, regional too. To give an example, one of the service delivery guidelines mentions doing a vaginal examination and blood pressure measurement prior to offering EC. Also, in the Indian context, our guidelines would need to comply with national requirements and our programme-content. clear guidelines to minimise abuse and misuse, protocols and norms for counselling and confidentiality are also needed.

Research and Documentation

Research and documentation is an area in EC where there are lacunae, and information would help us in designing and implementation of better programmes. Some areas of special importance for EC in the Indian context could be:

Studies on providers’ and clients’ perceptions of EC: Experience with EC in India is limited. Globally too, only a handful of studies have assessed providers’ and clients’ perceptions and knowledge on EC. There is need for information on attitudes of the health workers to EC, inclinations and hesitations. A small multi-centric Population Council study in Andhra Pradesh, Orissa and Delhi brings out regional differences in attitudes and policy towards EC. More research would be useful, and this would be an area of contribution for professional organisations.

Action Research : Documentation of action research on EC is another area which will help in designing and implementation of programmes, specifically those focussed on meeting the needs of special populations, including adolescents, victims of sexual violence, male involvement in EC.

Gender Issues: The gender dynamics of the method needs to be explored. Gender issues as seen by the client, need careful consideration as they affect attitudes towards EC. For example, women interviewed said that they did not go to the pharmacy to buy the product or were reluctant to ask a stranger or male for the product. A gender perspective also helps providers recognise and respond to crucial differences among clients. Two kinds of gender differentiation has been identified

i) Qualitative differences in the life-style and experiences of groups distinguished by sexual identities: wife, mother, single professional, male homosexual.

ii) Sexual discrimination in legal, political, religious, educational institutions where policies and practices tend to transform gender differences into inequalities.

Research prior to introduction that could be useful to industry as well as government agencies in provision of commodities. This would include baseline survey to measure general awareness, ascertain acceptability, potential users, possible channels for the product, user and provider attitudes and cost issues.

Integrated Interventions

Incorporate focussed and integrated interventions in existing programmes and projects supported by professional organisations for better success. An aspect I want to flag here is that a careful situational analysis needs to be done to develop specific interventions to integrate information and services for EC in the on-going programmes. It is essential to understand the local situation. Examples of innovative projects could include needs of abused/battered women as well as the issue of social marketing:

Abused/battered women: Abused women clearly have special needs, including medical, psychological and legal support. To be effective, solutions must acknowledge the whole problem. Emergency Contraception also is a pressing need for many battered women. To address this need, a project in Vietnam is surveying call from abused women to a crisis hotline to find out what reproductive health problems they report. Based on the survey, a curriculum will be developed for hotline workers which would probably include information on EC. UNFPA has prepared a guidance note on its role in addressing gender-based violence and its effects on reproductive health topics which includes adding EC to the method-mix.

Social marketing: Where a dedicated EC product is available, social marketing may be a useful distribution mechanism. Incorporating EC pills into social marketing programmes would involve defining the target audience, market research, develop marketing strategies, promoting and distributing the product and evaluating the results.

Policy/ Advocacy

Another initiative would be in the area of advocacy in addressing policy-barriers. A focussed media campaign on EC may, perhaps, upset the other policy /programmes like contraception and HIV/AIDS control. There is need to develop careful media messages. Other areas of advocacy could be for professional agencies to participate proactively in national technical meetings, network to involve various partners/stakeholders (NGOs, women’s groups) for increasing awareness on this intervention and facilitate development of regulatory mechanisms.

To conclude, Emergency Contraception has an important role to play in helping women achieve their reproductive intentions. Partnerships need to be formed to move forward in providing women with this contraceptive choice.

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