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Are injectable contraceptives advisable? (Hindu)

The government is aiming to control women’s fertility rather than uphold their reproductive rights

The government is aiming to control women’s fertility rather than uphold their reproductive rights

Sulakshana Nandi

Instead of putting its efforts into improving the delivery of existing contraceptive methods, the government has recently chosen to introduce the injectable contraceptive, depot medroxyprogesterone acetate (DMPA), which is known to have adverse effects on women’s health.

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The articulation of population as a ‘problem’ or talking in terms of a ‘population explosion’ is deeply problematic, for it brings with it the spectre of ‘control’ and eventually, in a country like ours, control over women’s body and fertility. Countries that have achieved lower fertility rates have done so due to economic and social development and improvements in public services, including health services. Simply put, if a family is convinced that their one child or two children will not only survive but be healthy, they won’t have more children.

Women, even rural women, today want fewer children. However, they are forced to have more children due to several reasons that range from economic compulsions, lack of negotiating power within the family, to limited access to health services including contraceptive services.

Women’s groups and various health groups have been cautioning the government for decades against introducing injectable contraceptives in the public health system.

Case against injectables

First, there are concerns regarding the preparedness of the government health system to implement this contraceptive method. DMPA may be easy to administer, but health workers need to be capable of assessment before administering it and of managing side effects that some women may experience. Also, DMPA requires administration once every three months. The Government of India guidelines on the injectable contraceptive mention side effects like menstrual changes, irregular bleeding, prolonged/heavy bleeding, amenorrhea (stopping of menstruation), weight gain, headaches, changes in mood or sex drive, and decrease in bone mineral density. Moreover, studies from Africa have shown that the risk of HIV infection may increase for women who have been administered injectable contraceptives. Second, the government needs to introspect whether existing methods have been made available to people through informed choice, in a safe manner.



Gaps in the system

Regular stock-outs of oral contraceptives and condoms, lack of training to the auxiliary nurse midwife or ANMs on intrauterine contraceptive devices (IUCDs), instances of lack of informed consent for post-partum IUCD, and the rampant violation of the guidelines for sterilisation, which in 2014 led to the deaths of 13 women, all reflect gaps in implementing and monitoring such programmes. It is strange that while the existing contraceptive methods are not being provided properly, the government has gone on to introduce a method that raises so many questions and may prove to be more complicated in its implementation. Why didn’t the government put all its efforts into promoting male vasectomy, for instance, which is a safer option and less of a problem for women?

By introducing DMPA in the public health programme, the government also has to answer whose interests are actually being served. There are serious concerns that some agencies are pushing this for profit. Experience from the private sector, where these contraceptives had been made available previously, shows that very few women had opted for injectable contraceptives.

The government should have been more cautious in introducing this method. It appears that by introducing injectable contraceptives under the guise of ‘expanding the basket of choices’, the government actually aims to control women’s fertility rather than uphold their reproductive rights.

As told to Anuradha Raman

Sulakshana Nandi is national joint convener, Jan Swasthya Abhiyan (Peoples’ Health Movement, India)

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RIGHT

This is about expanding the basket of choices. Injectable contraceptives are just an option


ALSO READ

Think twice before popping a pill

S.K. Sikdar

The Health Ministry is in the process of introducing injectable contraceptives in the National Family Planning Programme (NFPP), with the aim to expand the basket of choices available to women. Introducing modern methods of family planning is a major part of the reproductive, maternal, newborn, child, and adolescent health (RMNCH+A) strategy to improve maternal and infant health indicators, with a special focus on delaying the first birth and the spacing between births. Including injectable contraceptives in the NFPP will ensure access to preferred contraceptive methods for women.

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Stress on quality

Every new programme has to go through a cycle of proper training and capacity-building. Under RMNCH+A, we are trying to ensure that Indian women make an informed choice when they pick a type of family planning or spacing method. After Bilaspur (where 13 women died in a government-run sterilisation camp), we have tried to improve the quality of sterilisation services, a fact that the Supreme Court too appreciated in its 2006 judgment, which set guidelines for female and male sterilisation services on that case. We take quality assurance seriously and are thus in the process of doing away with the camp approach in a phased manner. We have already introduced a permanent cadre of counsellors, to ensure there is information provided to the couple on all the contraceptives available in the basket of choices. Nobody can force this on women in this country, coercion is against the law and the programme is not target-driven. Injectable contraceptives are just an option.

We are trying to change the fact that female sterilisation remains the more popular choice, accounting for over 75% of contraceptive use in India. It disempowers them. Sterilisation should be the last choice and we are trying to ensure that clients understand the consequences of undergoing a sterilisation operation in a language that they understand through our counsellors and service providers.

‘Drug vetted’

As far as the debate around the side effects of the injections is concerned, this drug has been rigorously vetted. The World Health Organisation and most professional bodies have advocated its use. Our programme focuses on telling women about all the choices she has available, depending on her situation. We have post-partum methods, spacing methods for new parents, and the programme aims to help women select the option most suitable for them, depending on their situation in life. There has been concern about the effect of an injectable contraceptive on bone density and it has to be categorically stated that the bone marrow density is reversible. Global data show that the average number of doses a woman takes is around two to four at a stretch, which is sufficient for her to space her next birth, thereby giving her time to recover from the stress of childbirth and a chance for the child to get the attention she needs to grow.

We are also introducing injectable contraceptives in a phased manner. They will first be available only in medical colleges and district hospitals and then move downwards. The Health Ministry took this decision to not compromise on quality. We will only make injectable contraceptives available when we have the capacity to deliver counselling at the health facility. Further, the Ministry is painfully aware that male participation needs to increase. There is a programme specifically designed to increase male participation. Meanwhile, women still need to be offered all the choices that are available.

As told to Vidya Krishnan

S.K. Sikdar is commissioner of the family planning division of the Health Ministry

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CENTRE

The real conversation we should be having is about prioritising men’s participation in family planning

Poonam Muttreja

Family planning is a crucial public health programme, directly linked to the health of women, children and families. The government has estimated that if the current unmet need for family planning could be fulfilled within the next five years, India can avert 35,000 maternal deaths and 12 lakh infant deaths.

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The real conversation we should be having is about prioritising men’s participation in family planning. We need to stop referring to family planning and sexual and reproductive health and rights as women’s issues. They are as much men’s issues, society’s issues, moral issues, ethical issues, and issues of social justice and human dignity.

Address gender bias

Sustained engagement of men in health and family planning not just as clients of family planning and reproductive health services, but as responsible partners to women is the only way to address the severe gender bias in the programme.



In 2005, the National Family Health Survey-3 (NFHS) revealed that 1% Indian men were opting for sterilisation services. In the last 10 years, this number has gone down to 0.3%. We need more doctors trained in providing vasectomy, more counselling for men instead of addressing only women. Evidence suggests that the involvement of men in family planning has many benefits. It can act as a catalyst towards improving maternal and child health indicators, increasing contraceptive uptake, and enabling women to exercise their autonomy and reproductive rights. However, the acceptance of male methods of contraception is marred by many myths and misconceptions, such as loss of virility and libido.

To address these challenges, a systematic integrated approach with information, education and communication activities for men aimed at dispelling myths and misconceptions could result in a better uptake of contraceptives and an increased shared responsibility towards family planning.

New methods, new fears

In 2015, the Ministry of Health and Family Welfare (MoHFW) announced the introduction of three new contraceptive methods — Progestin-only Pills, Centchroman and injectable contraceptives — to the basket of contraceptive choices. However, the introduction of DMPA has led to concern in terms of the possible side effects of the injectable contraceptive and the likelihood of women making uninformed choices.

The Population Foundation of India has advocated strongly with the MoHFW to ensure full preparedness, including the training of service providers, for the roll-out of all new methods. It is critical to address the concerns raised on quality of care and counselling services. The roll-out of injectables must be done by sharing evidence-based information on the benefits and side effects to ensure that a woman makes an informed choice.



There is a direct correlation between the number of contraceptive options available and the willingness of women to use them. Studies indicate that an addition of a contraceptive method leads to an increase of up to 12% in contraceptive usage. Given that NFHS-4 data show that the use of contraceptives has declined, we must ensure that women and men are provided with more choices of contraception.

Women should not be bound to use a method due to lack of contraceptive choices, which would be a direct violation of rights. An expansion in the basket of choices is an effort to ensure that family planning doesn’t become coercive due to lack of choices, and can cater to the needs of all individuals, keeping in mind affordability and accessibility.

As told to Vidya Krishnan

Poonam Muttreja is executive director of the Population Foundation of India, a not-for-profit organisation working towards gender sensitive policies and programmes for family planning

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