Emergency Contraception also called the ”Post-Coital” or the “Morning after Contraception” can in many cases help women faced with the prospect of unplanned and unwanted pregnancy to avoid pregnancy. If a couple had sexual intercourse without using any form of contraception, or if there is a problem with the contraceptive method they are using, for example, a leak or burst condom, a woman can become pregnant. The risk for this varies depending upon the time when intercourse took place during the cycle. Many women do not know that contraception following intercourse is feasible or readily available and wait in agony for the periods to come and, if missed, resort to various methods to terminate pregnancy with their potential hazards.

Different aspects of Emergency Contraception are being considered in this Consortium and I am sure that it is going to set a tone for consensus. The most important requirement of the ideal Emergency Contraceptive is that it should be highly effective. Women who seek emergency contraception definitely want to avoid pregnancy. If a method, such as the condom, has already failed, there is no place for another failure. Methods of emergency contraception have also to be as safe as other methods, even though they are used only occasionally. Emergency Contraception is used after unprotected sex, but before pregnancy has become established. As such, it is considered a ‘back-up’ method for occasional rather than regular use.

We have to consider the technical aspects of various methods. Emergency contraception methods consist of different regimens of widely-available contraceptives and some have been used for decades in some countries. The first method used was the high dose estrogen introduced in 1960s. But the same has a number of side-effects. In 70’s a combination of estrogen and progestins was used by Mr. Yuzpe which is commonly known as “Yuzpe method”. In this method, low doses of estrogen and norgestrel pills are given in two divided doses. The treatment is initiated within 72 hours of unprotected sex and the second dose is repeated 12 hours later. The hormones used are the same as are used in oral contraceptive pill marketed in the country. Recently, levonorgestrel alone has been shown to be equally effective in multi-centric, multi-country trials at HRP, WHO. Copper IUD used as a method of Emergency Contraception is highly effective method with failure rate of around 0.1%. This method has additional advantage as it can be inserted upto 5 days after intercourse and provides additional contraceptive protection for a number of years. RU 486 or Mifepristone has also been used for Emergency Contraception.

Emergency Contraception has not been formally included so far in the National Family Welfare Programme. Though contraceptive pills are available for regular use, their use as ‘emergency contraceptive drugs’ has not been promoted. Moreover, no emergency contraceptive drug is available as ‘brand’ name in India. The Department of Family Welfare has encouraged further research in the field of Emergency Contraception and provided assistance to ICMR and NGOs in this respect. It will be included as a ‘back-up’ to regular contraception and, hopefully, the incidence of abortions and unwanted pregnancies will come down.
Promotion of Emergency Contraception in India needs careful planning and creation of infrastructure for its implementation. The role of government agencies, medical associations, NGOs and women’s organizations needs to be carefully considered. The National Family Health Survey (1998-99) has very clearly shown that ‘unmet need’ of contraception in India is 27% and it is even much higher upto 35-40% in some of the areas. This is despite the fact that women and couples who were interviewed were illiterate, but they did not want to have another child. Particularly in the context of a situation where women have no power, it becomes very difficult for them to get a contraceptive method. Even when methods like oral pill or condom are available, with the type of habitation, with one or two small rooms, it may be difficult to store or use contraception.

There are mainly three main hurdles in making Emergency Contraception available to all women who require it. First, information regarding Eemergency Contraceptives should reach the users and providers on an equal footing. Since, there is a time-frame within which women must use EC, the user must have access and knowledge of the method in advance. Thus, education of the providers and organizations that can educate women at large are the important prerequisites. Easy availability of user kits of emergency contraceptives poses the second challenge. Our pharmaceutical industry along with NGOs and government organizations should jointly initiate action to produce and publicise complete and accurate information regarding the choice and details of methods with indications of use. Third and the most important is the provider’s attitude. In India KAP studies with emergency contraceptives with respect to both providers and users are limited. Providers should broadly identify women for whom Emergency Contraception is appropriate.

There are issues like logistics, packaging, transportation and storage that need to be considered. We have to think of 600,000 villages, 138,000 sub-centres and over 1 million habitations in these villages. Then we have to think of urban slums for providing EC services. This is a time of concern for an “Emergency Situation” with respect to reproductive health and well-being of women and I will put this as a top priority, and then only comes the population-stabilization. Before we reach a consensus, these logistic problems and the issues of women’s health and reproductive health, as well as any thing we do for them, need due consideration.

Our couple protection rate though has been going up and stands at 48% in 1998-99, 5-6% of it is explained by natural family planning, 30-35% by terminal methods (of which 97-98% is female sterilization) and rest a very small 2-3% each is accounted for by spacing methods including condom, pill and CuT, and this is despite all efforts by family planning units. Thus, one has to think of EC in this context. We should consider EC introduction in a phased manner. May be initially with a proper supervision, we can introduce EC in urban areas, both as a social marketing channel as well as provision with regular family planning services. Then we can gradually spread to rural areas.

The issue of providing Emergency Contraception without prescription also needs consideration. In India, young girls, unmarried women and those with less access to family planning methods would experience difficulty in getting a prescription in time. Some of the countries which have introduced Emergency Contraception in the family planning programme initially faced some difficulties in its implementation. In India, we can learn from their experiences. The barriers to the introduction of Emergency Contraception, such as lack of awareness among consumers and service providers, logistics of distribution of drugs, methods and religious and cultural consideration, need to be overcome. The concerns of women’s organizations are also valid and need to be addressed.

It is sometimes argued that promotion of Emergency Contraception would encourage promiscuity. Promiscuity in sexual relations exists all over the world. Many countries have given social sanction to adolescent sexuality. Moreover, pregnancy may occur inspite of using a contraceptive method, and it may not be realised till the next menstruation when it is already too late to start Emergency Contraception. The Emergency Contraception method is of value to those who are using condom, diaphragm or oral pills. Obviously, adolescents and unmarried women who are not using any contraception are also exposed to pregnancy as are the victims of rape. it should be appreciated that risk of pregnancy and induced abortion is greater than the risk of using Emergency Contraception.

Finally, it should be emphasised that Emergency Contraception is not as effective as regular use of contraception. Moreover, undesirable effects are more common after Emergency Contraception than during regular use. Therefore, Emergency Contraception should be promoted as a ‘back-up’ method when regular methods are not used, used incorrectly or fail for other reasons.

The present seminar is an effort to sensitise the providers, the adolescent groups, teachers, women’s advocacy groups and industry in the concept of Emergency Contraception; seek their views and opinions; and identify relevant issues and prerequisites for introduction of Emergency Contraception in India.

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