family planning programme has percolated in India down to the grassroot level.
Already, there exists a full-fledged distribution and monitoring system. Emergency
Contraception can, therefore, be made available to the masses through the same
It has been widely accepted
that judicious use of EC is safe for women even in self–administered cases. Nonetheless,
counselling by medical personnel plays an important role in helping women decide
about the future mode of contraception and prevention of sexually transmitted
to be answered
Is there a need for monitoring?
B. Who should
be monitored and how?
C. What should be the
framework for monitoring including the need for a National Monitoring Cell?
Need for monitoring was also felt for defining the eligibility criteria, efficacy,
side-effects, failures and need to have a follow-up form for each client.
Views of the Group
A. Need for monitoring
The National programme for EC distribution in India
needs monitoring in its initial phase because of the following special reasons:
I It is a new concept in India where there is a lack of public awareness about
EC, which makes it mandatory for the distribution staff to be discreet and cautious,
as well as to ensure that the client has understood the correct dosage schedule
II Injudicious and repeated
use needs to be monitored.
III The negative
impact on society as well as spread of STI/AIDS is to be monitored.
The Group suggested the following :
and assessing base-line information through documented information, such as, registries
and other materials that give insight into the characteristics of the target population
and its surrounding environment.
to set the priorities. This is based on assessment of the needs and of what is
feasible and what is acceptable to the client.
Monitoring the factors which facilitate or inhibit the programme success through
feed- back from all levels of the pyramid and through local community leaders.
• Direct co-ordination of all the centres from subcentre level
to district level in collecting data and computation under proper competent supervision.
B. Who is to be monitored
It was decided by the Group that monitoring would
be required at all levels. There is need to monitor the
II Client and
III Effect on women’s health
Provider-monitoring would include
Provider profile –medical / para medical
of provider – need for refresher training
Place of providing EC services
• Facility for
other RCH services (FP, STI screening)
Client-monitoring would include
Client-profile including age, residence, marital status, parity, literacy, economic
status, previous use of contraception, indication for use, interval between intercourse
and EC use, LMP, evidence of STI and source of information
Follow-up of client for information on further intercourse, side-effects, date
of menstruation, change in menstrual pattern, failure, etc.
III. Monitoring for effect on woman’s health will
include information on
Effect on regular contraceptive use
repeated or injudicious use
• Monitoring of
pregnancies resulting from failure
data need to be compiled by all providers. An exhaustive form for doing so was
presented by the discussion Group.
framework of monitoring
providers will be required to provide information for monitoring by appropriate
record keeping at village, sub-centre, PHC, district hospital as well as private
clinic level. The information thus gathered will be compiled and sent to district
EC control cell each month, which, in turn, will send quarterly information to
a National Monitoring Cell.
The national monitoring
of this programme will be under the following areas
To find out the number of women in the reproductive age group who need Emergency
Contraception in a population of a particular zone. This will help monitor the
demand and supply ratio of this particular zone.
To monitor how good and how effective is our counselling. After a certain regular
period, survey of population is to be made to find out how much awareness regarding
EC has developed and how knowledgeable they are regarding EC.
To monitor how effective is one specific regime of EC in terms of preventing pregnancy.
This needs continuous follow-up of all the clients.
Monitoring the compliance of the clients in terms of reporting for drugs in time,
follow- up visits and acceptance of the drug.
Monitoring for side-effects of the drug along with monitoring of pregnancy resulting
• To monitor how much coverage
of EC can be done for a said demand in a defined population. This will indirectly
measure the effectiveness of our information, media campaign and distribution
system and will help in setting the priorities.
Very important long-term monitoring to find out whether women who are aware of
EC gradually use a regular contraceptive method.
For proper monitoring, a National Monitoring Cell needs to be created with its
chairperson acting as “National Advisor to the Government of India on Emergency
The Expert Forum felt that such
detailed recording as suggested by the Group is not possible even during research
protocols, and will not be feasible. Though it is a good idea to record the client
and the provider profile, but most will not accept it and nobody will be willing
to fill out such elaborate forms. Monitoring should be as simple as possible.
A simplified monitoring form is proposed, which will be inserted in the packet
as a stamped card or pre-paid inland letter, to be posted to National Monitoring
Cell / Consortium Secretariat.
follow-up form is as follows :
- Pack No.
- No. of living children
- MTP/abortions if
- Date of ECP use
- Reason for use : Condom
failure/forgotten pill/no contraception used/sexual assault/ others.
- Date of periods after taking ECP
• Each pack
of ECP will have a pack no. assigned to it. It is proposed that each state will
have its own alphabetical code followed by a numerical code, something similar
to the licence plate on vehicles. This will aid in having a rough idea about client
location and will help in monitoring the progress of the programme. Client’s name
or address is not required for monitoring.
Besides the monitoring form and the pills, the pack will also contain product
information and instructions for use in English/Hindi/local language. For illiterate
clients, the form can be filled by the provider during the follow-up visit.
• It was also felt that though monitoring may be possible
in the clinical-setting, it will not be feasible in community-setting. At village
level, instead of individual monitoring, a catchment area survey may be more useful.
• The preceived risks of EC are largely inaccurate and exaggerated.
The ability to reduce these concerns and to inform the clients about the actual
risks in comparion with documented risks from unintended pregnancy is crucial
for realizing the potential of EC in preventing unwanted pregancies and unsafe
abortions in India. It should be appreciated that the risk off pregnancyy and/or
induced abotion is greater than the risk of using ec. After elaborate discussions
on the issue, the Expert Forum agreed that a simplified monitoring is desirable.
Monitoring is needed specifically during the initial years of pilot introduction
so that the programme can be modified appropriately.
It was also considered vital during discussions that both national and regional
problems be given due consideration as service-delivery conditions may not be
optimal in all parts of India. In India, sometimes, family planning and contraception
have been introduced in a coercive manner. Though current family planning policy
is a target-free approach, yet counting the number of users continues.
Emergency Contraception is one method where there is no
scope for coercion and user number means nothing. A high number of users may reflect
increasing awareness, whereas, in contrast, a low number may be due to poor awareness
or greater use of regular contraceptive methods, limiting EC requirement.
Unresolved issue/action required
To constitute a National Monitoring
2.6.1 Monitoring is essential to find out about efficacy and misuse of services.
2.6.2 Monitoring will help in setting priorities based on assessment of need and
acceptability to women.
2.6.3 Monitoring the factors which facilitate or
inhibit programme success through feedback from all levels will help in making
appropriate modifications in the programme.
2.6.4 The client monitoring
form should be kept as simple as possible. The provider should be able to help
the woman fill out the form and return it to the monitoring cell.
This monitoring form will provide useful information about frequency of EC use
in various locations, as well as review women’s health parameters.
There is need for a National Monitoring Cell consisting of members from the health
ministry, scientific advisors, demography experts and statisticians.
Data should be reviewed every six months and the programme should be modified