Gender

Battle Lines Shift in Debate Over Injectable Contraceptives in Public Health System

NEW DELHI: After having successfully managed to stall the introduction of injectable contraceptives in the Indian public health system, some women’s groups and advocates of women’s health and reproductive rights now appear to be inclined for a fresh debate on the controversial issue that had dominated ‘family planning’ discourse more than two decades ago on the grounds that the method was harmful to women.

The main health concerns raised by these groups after the government allowed injectable contraceptives in 1994 in the private sector related to menstrual irregularity, amenorrhea, screening and follow-up of clients on the method and demineralization of bones as a result of its long term use.

“Why should we control women’s access to choice? We have not followed up on the issue for 20 years. Is it not time to re-examine the issue and initiate a fresh debate,’’ says Poonam Muttreja, Executive Director of the Population Foundation of India. Muttreja was among the major voices who had opposed the introduction of Progestin (hormone)-only injectable contraceptives Depot-medroxyprogesterone acetate (DMPA) and Norethisterone Enanthate (NET-EN) in the National Family Planning Programme.

The DMPA shot is to be given every three months and NET-EN every two months while fertility returns after four and one month respectively once the shots are discontinued. Both injections are said to be highly effective and scientific evidence shows that DMPA helps in protecting against risk of pregnancy, cancer of the lining of uterus, uterine fibroids and anemia.

However, users have reported weight gain, headaches, dizziness, abdominal bloating and discomfort, mood changes, decreased sex drive, and loss of bone density. Those using DMPA have reported changes in bleeding patterns with irregular to prolonged bleeding in the first three months and no or infrequent bleeding after one year of use while NET-EN users have reported fewer days of bleeding in the first six months of use. The latest evidence from Africa now also shows that the risk of acquiring HIV infection increases because the couple is less likely to use a condom or any other form of contraception which can prevent infection.

Unsafe abortions

One of the main arguments put forth by Muttreja is the unacceptably large number of abortions in India – estimated to be between 6 to 10 million annually – a large percentage of which are to deal with unintended and mistimed pregnancies. In more than 72% of  abortions, ‘contraceptive failure’ is cited as the basis which is legally accepted under the Medical Termination of Pregnancy Act, 1971. Shockingly, 56% of abortions in India, according to the Abortion Assessment report 2002-03, are unsafe. Even worse, the Registrar General of India – Sample Registration System (RGI-SRS) attributes 8% of maternal deaths in India to unsafe abortions. The track record of sterilizations, too, has not been too good in India with the latest being botched up surgeries in a camp in Chhattisgarh resulting in several deaths.

International data over 27 years show that as each additional contraceptive method became available to most of the population, overall modern contraceptive use rose. An additional method available to at least half the population correlates with an increase of 4-8 percentage points in total use of six modern methods.

The total Contraceptive Prevalence Rate (CPR) in India among married women is 54.8% with 48.2% using modern methods. This is comparatively lower than neighbouring countries like Bhutan, Bangladesh and Sri Lanka, whose CPR stands at 65.6% cent, 61.2% and 68.4% respectively. The method mix (basket of choices) picture in India shows that the primary method of family planning is female sterilization – at 65.7% cent with over 90% being female sterilizations, which is the highest in the world. One of the key reasons for this is the limited availability of a wide range of contraceptive methods in the public sector, though injectables are available in the private sector.

Diversity counts

A more diverse contraceptive method helps meet the individual and varied family planning needs of women and couples. Contraceptive preference varies according to the stage in the reproductive cycle and reflects differing needs based on age, levels of exposure to risk of pregnancy, economic activity and socio-cultural norms. Access to several different methods allows a woman to select a method based on her specific needs and preferences. The biggest advantage of injectable contraceptives is privacy and is particularly helpful to those women who cannot negotiate contraceptive use with men and are not empowered enough to adopt spacing methods.

Pilot studies in Uttar Pradesh and Rajasthan have shown that while women prefer injectables to other methods of contraception, more than 50% discontinued their use after the first shot because of side-effects. However, advocates of injectable contraceptives point out that these were in use in several countries like Bhutan and Indonesia where the health status of women was the same as those in India, and that there had been no serious health impacts reported from these countries.

The method mix in some of India’s neighbours presents a varied picture. In Bhutan and Indonesia, the use of injectable contraceptives is the highest – 42% and 55% respectively – whereas in Bangladesh it is oral contraceptive pills that is the most popular method. India Nepal, female sterilization dominates.

These four countries offer a basket of 7 contraceptive methods to communities including implants and injectables whereas India gives only four options in the public sector – condoms, sterilization, pills and intra-uterine devices. India does not provide injectables, diaphragms, and female condoms through its public health programme .

“It is unfortunate that the women’s movement in India has failed women, as women have not kept themselves abreast with latest scientific evidence. Opposition to inclusion of injectable contraceptives in the public system by women’s groups is just a rhetoric of negativity,’’ says Kalpana Apte, of the Family Planning Association of India that has been advocating the inclusion of injectables for long now and was part of the expert group set up by the Health Ministry to decide on the issue.

While the Health Ministry is keen on making the option available in the public sector also, the move is being stalled by the Drug Technical Advisory Board (DTAB) – the highest decision making body on drugs – which now wants the issue discussed with the leading gynaecologists of the country.  The Federation of Obstetric and Gynaecological Societies of India (FOGSI), an apex body of gynaecologists and obstetrics in the country, has been advocating the use of injectable contraceptives for long now.

Describing the movement against injectibles as a ‘conspiracy theory’, Apte says objections are being raised without considering the latest scientific evidence the side-effects and benefits. “Just like any other contraceptive method or medicine, injectables also have side-effects. But women also have a right to be informed about them and to decide whether they choose them or not,’’ she insists.

“Thanks to ill-informed opposition we are blocking a system that reaches the poorest. Those who can afford it or are empowered buy it from the private market in any case. In India, now the public sector is considerably strengthened. We have health care professionals who are trained to counsel and give shots or even insert PPIUCDs, so why this opposition ?’’ she seeks to know, adding that choice for her meant giving choice to women and let them decide.

Disagreeing with this argument, Brinda Karat, former MP and Communist Party of India (Marxist) Polit Bureau member says says she stands by her earlier concerns about the injectables being unsafe for women’s health. She also feels another dimension has now been added because of the manner in which some Bharatiya Janata Party and sangh parivar leaders have been voicing concerns about the growth of the Muslim population in the country.

Fearing that the community might be targeted with this invasive technology which is ‘damaging and hazardous’ for Indian women, Karat – who led the anti-injectable contraceptive movement – says that while she agrees with enlarging the basket of choices, pushing invasive hormone-based technology is also what she objects to. “Globally, some international NGOs are pushing vaccines, injectable contraceptives and other technology in the developing world. These NGOs are funding pharmaceuticals for producing vaccines and then these are subsidised for sale to the Third World countries,’’ Karat explains.

While sticking to her earlier concerns about the harmful effects of injectables on women’s health, its potential for abuse and the high possibility of osteoporosis, N.B.Sarojini of Sama—Resource Group on Women’s Health says she agrees the issue needs to be debated afresh. “With the incidence of arthritis and Vitamin D deficiency in India on the rise, not only is demineralization of bones a very serious matter but high incidence of HIV infection among users also needs to be looked into,’’ she says.

Aarti Dhar is a senior journalist who specialises in health reporting

Featured image: Arindam Ghosh, CC 2.0