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Controversial Issues in EC Introduction : A Debate

Should Emergency Contraception be widely publicized?

– Dr A Sundaravalli, KMC Hospital, ChennaiDr Kamal Hazari, IRR, Mumbai

Emergency Contraception has a history of over 40 years with 20 years of availability. The need to emphasize this under-utilized method as a part of Family Planning can be estimated by the fact that

12% of maternal deaths are attributed to unsafe abortions.

17% of total fertility is attributed to teenage mothers and their problems.

Total abortion rate is 2 abortions per woman during her reproductive years.

Among the total terminations of pregnancy performed at our hospital, 18.5% were due to unwanted pregnancies and 7.8% were due to failure of contraception. Emergency Contraception, if properly implemented, goes a long way in changing these statistics for the better. Lack of awareness of this two-decade-old concept contributes to its lack of implementation. Very few studies have been conducted in the developing countries to assess awareness of Emergency Contraception among providers and beneficiaries.

We assessed the knowledge, attitudes and practices of both providers and beneficiaries in Chennai and found that 100% of our beneficiaries were ignorant about EC. Our study sample of health providers include 74 doctors and 60 paramedicals belonging to different healthcare systems. (KMC Teaching Hospital, District Hospital, Vellore and Primary Health Centres).

Awareness about EC among providers was 29.84%, (among the doctors : 47.3% and among paramedicals only 8.3%). When we split the data of awareness among the different healthcare institutes we found 100% awareness in doctors at teaching hospitals, 45% awareness in medical officers at PHCs and only 16% awareness in doctors in the district hospitals. Paramedical staff at the teaching and district hospitals were unaware of EC, while 10% of the paramedicals were aware about EC at the PHCs. This awareness about EC at PHC level is due to the CME programmes given to them.

Those who were aware about EC had a good knowledge about dosage, timing, route of administration, types of EC and their success rates, but 70% of our providers felt that if EC failed it caused birth defects, which is a misconception. Most providers felt that there would be increase in promiscuity if Emergency Contraceptives were sold over the counter. Still, 80% of providers felt that EC should be publicized among the general public and 67.5% felt that adolescents should be educated about EC. Television and counselling were felt to be the best modes to advertise about EC by 82.5% of providers. The preferred route of administration was oral.

There is a need for education and wide publicity due to several misperceptions which include over-emphasis on side-effects and birth defects, feeling that EC can cause abortions, detailed examination is a must before EC administration, a medical disorder is a hindrance for EC and easy availability will increase promiscuity.

In reality, EC is a back-up for all current contraception methods which can fail, and provides a critical second chance to prevent unwanted pregnancy and reduces the need for abortion. In our set-up where abortions are a major drain on scarce medical resources i.e. hospital staff, beds, blood and medicine supply, EC is cost effective. There is need for training and publicity for Emergency Contraception.

Respected chairpersons, colleagues and friends in the audience, I state that Emergency Contraception should not be widely publicized for the following reasons:

The wide publicity could lead to too wide a use, misuse, frequent use and even forced use. This would be harmful for society and women. In our cultural context, it would create an imbalance in maintaining responsible sexual behaviour.

In situations where girls/females want regular contraception or refuse sex, the male partners would pressurize them, saying that EC is an easily available method. A proper balance in male-female partnership will be disturbed and men will hold EC as a green signal to have sex, especially in this male-dominated society. What about discordant couples as far as STI / HIV is concerned? Women will be at a greater risk of both pregnancies and STI. Many HIV positive persons have desperate behaviour and attitudes and may not care. These aspects of STI and HIV must be kept in mind when deciding about how widely to publicize.

Wide media publicity may not convey the correct information or may be interpreted incorrectly by all persons of different understanding capacity. All pros and cons have to be explained - the risks and benefits. Counselling is essential before proper and correct EC use, as well as after use.

But awareness among responsible potential users, spacing contraception users, healthcare providers at various levels where eC methods can be given is absolutely necessary. Until a dedicated pill package is available, it is early to publicize EC pills widely. The potential users and providers may not give the correct dosages from the regular OC packs which is again harmful.

Also, women will feel it is their right to have EC pills and feel deprived or frustrated if they do not get it, but they will not understand the full implications of the service delivery mechanism.

So, I conclude by stating that Emergency Contraception should not be widely publicized.


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