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?
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.
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.
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
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
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
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:
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.
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.