The Central Drugs Standard Control Organisation is mulling banning the sale of over-the-counter oral emergency contraceptive pills (ECP), and to convert these drugs to prescription-only because of ‘irrational use’.
How rational is this move in India? The reality is that the country’s over-stretched health system cannot be relied upon to provide prescriptions for emergency contraception on an every day basis, even more so during a public health crisis such as the recent pandemic.
Contraception is a lifesaving intervention, with health, social and economic benefits. It enables couples to determine the number of children and their spacing; it strengthens women’s autonomy over their bodies. Emergency contraception is capable of preventing 75-99 per cent of pregnancies. Reduced access to ECPs can lead to a surge in maternal and child mortality as well as an increase in unsafe abortions.
In India, according to statistics from the Guttmacher Institute, a research and policy organisation focusing on sexual and reproductive health and rights, between 2015 and 2019, 48.5 million pregnancies occurred annually, of which a staggering 44 per cent were unintended. And 77 per cent, or 16 million of these unintended pregnancies ended in abortion. Maternal deaths, from unsafe abortions, were 80,000 every year. Even among those who continue with the pregnancies, there can be long lasting social, economic and psychological consequences.
ECPs have been found to lower abortion rates, especially in young women (19 years and younger). ECPs have been found to be safe for adolescents and does not make them more promiscuous or engage in risk-taking behaviour. If ECPs are not available over the counter, the sale of the drug is likely to go underground, and those accessing these drugs become more vulnerable to exploitation. Adolescents may in fact need more access to ECPs because of the stigma in obtaining contraceptives, errors in using contraceptives or because of forced sex. The sooner they are used (usually within 72 hours), the more effective they will be. ECPs have also been found to be safe for women living with HIV and on anti-retroviral therapy.
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WHO, as part of its recommendations for self-care interventions, recommends that ECPs or morning-after or post-coital pills should be made available OTC without a prescription. Over-the-counter availability of ECPs removes the need to see a health worker. As it does not involve a third party (parent, partner or spouse), it is likely to increase access and reduce discrimination.
WHO defines self-care as the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health worker. These include medicines, devices, diagnostics and digital products.
ECP use in India
2001: The Drug Controller General of India permits 0.75 mg of Levonorgestrel as a dedicated product for emergency contraception.
2003: Levonorgestrel is incorporated into the National Family Welfare Programme and rural health programmes at highly subsidised rates as one of the strategies to prevent unwanted pregnancies.
2005: From this year onwards, it is made available as an over-the-counter drug.
2011: The Ministry of Health and Family Welfare adds ECPs to the Accredited Social Health Activists’ (ASHA) drug kit.
2013: The Department of Health and Family Welfare introduces ECPs in the National Family Welfare Programme which are to be distributed free to all States and Union Territories.
When access to the ECP is combined with appropriate health education, it in fact encourages people to switch to regular methods of contraception.
A study conducted by the All India Institute of Medical Sciences, Delhi between 1996 and 1997, where 100 women were offered ECPs along with health education about all contraceptives, showed that the use of regular methods of contraception increased from 13 to 70 per cent after ECP use; that the acceptance of oral pills went up from 3 per cent to 44 per cent and the use of condoms from 10 per cent to 18 per cent. ECPs, with counseling, helps women to not only prevent unplanned pregnancies but also gives her a second chance to carefully choose a contraceptive method. Another study found that wide publicity and easy accessibility of ECPs do not push women to start using the drug as a regular contraceptive method.
A paper published in the Indian Journal of Public Health (2020) on the use of ECPs in India showed that only 6 per cent to 13 per cent of women used ECPs, with the most common reasons for not using them being lack of awareness, religious or cultural beliefs and fear of side effects.
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There is thus a need to provide more, not less contraceptive servicesincluding ‘back-up’ services such as ECPs, with information on possible side effects and contra-indications. Side effects can be reduced through mass media campaigns rather than blanket bans. Hotlines should be available in case there are queries and these should be factual and non-judgemental. It is especially important to refer those who have accessed ECPs to other long-term family planning options. However, some women can still get pregnant, despite ECPs, so abortion services should also be made accessible.
Even in 2009, the Drug Technical Advisory Board had decided that revoking the over-the-counter status of ECPs would defeat the basic purpose of an emergency pill. Any policy decision should take into consideration who is adversely affected and how.
Women’s autonomy
In India, women already bear a disproportionate burden of managing family size and of accessing contraception. Men are asked to use condoms, which they may or may not do. Families also dictate to women the kind of contraception they may use or prevent them from using contraception at all.
In this scenario, over-the-counter access to ECPs is a small step towards supporting women’s autonomy and reproductive rights. Is India prepared for a surge in unwanted pregnancies, illegal abortions, and the consequent harm to women’s health, both physical and mental?
Morning-after pills have been made available over-the-counter by the government of India ‘to give women rights over their sexuality and fertility’. Bringing in a ban will take away these very rights from women.
Shaibya Saldanha is a practicing gynaeocologist and advocate for women’s health rights.
Sylvia Karpagam is a public health specialist who focuses on the social determinants of health.
Both the authors are medical doctors.
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