Insights into Editorial: Are injectable contraceptives advisable?

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Insights into Editorial: Are injectable contraceptives advisable? 


 

Summary:

The government has recently chosen to introduce the injectable contraceptive, depot medroxyprogesterone acetate (DMPA). However, women’s groups and various health groups have been cautioning the government for decades against introducing injectable contraceptives in the public health system.

 

What are injectable contraceptives?

Contraceptive injections are available as a type of hormonal contraceptive for women. Commonly known as Depo, Depo-Ralovera and Depo-Provera, contraceptive injections are considered as a long-acting option for hormonal control. The injections have artificial progesterone called Depot Medroxyprogesterone Acetate (DMPA). A single contraceptive injection is effective for 12 to 14 weeks.

 

Mechanism of Action:

Contraceptive or progesterone injections are administered either in the gluteus muscle, thigh muscle or the arm. They are normally given during the menstrual cycle in the first five days. The injections can only be administered by a health professional. The injection itself stops the ovaries from the process of ovulation. It also helps increase the thickness of cervical wall so that male discharge cannot enter the uterus during intercourse.

Once a contraceptive injection has been administered into the body, it releases the hormone into the bloodstream over an interval of 12 to 14 weeks. This protects the woman against pregnancy for a period of three months.

Background:

Over eight years to 2016, as India’s population surged, the use of contraceptives declined almost 35%, as abortions and consumption of emergency pills–both with health hazards and side effects–doubled, according to health ministry data.

Despite a 14% percentage-point rise in national literacy over a decade to 2011, hazardous birth-control measures of the last resort, emergency birth-control medication and abortions, are becoming the first choice among both poorer and wealthier, better-educated Indians. The result is that India’s population, now estimated at 1.32 billion, is expected to surpass China’s within the next six years and reach 1.7 billion by 2050, according to World Health Organization projections, even as millions of women die from unsafe abortions. 

 

Case against injectables:

  • 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.
  • Besides, 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.
  • Another practical objection to injectable contraceptives is that it is “provider-controlled” — medical professionals must give the injection and the contraceptive effects are irreversible for the period of efficacy. As against oral birth control pills, which are “user-controlled” and can be stopped soon as a woman develops complications.

 

What are the main concerns?

While the injections are popular around the world, a 2010 report by USAID-India noted that India’s contraceptive choices were highly skewed towards single method use. Over 75% resort to female sterilisation, followed by condoms (10%), birth control pills (6%), and intrauterine devices (4%). Herein lies the fundamental problem with the introduction of hormonal injectable contraceptives. In India, women don’t make a choice when it comes to family planning. They make a sacrifice. Women are not making informed choices or giving consent with full understanding of what the drug does to their bodies. The first choice offered to these women is sterilisation. This is extremely regressive situation.

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.  

 

What needs to be done?

The government should fill the gaps in the present system first. 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 all reflect gaps in implementing and monitoring such programmes. The government should ensure that the existing contraceptive methods are provided properly.

 

Way ahead:

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.

The government needs to introspect whether existing methods have been made available to people through informed choice, in a safe manner. 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.

 

Conclusion:

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. Instead of relying on DMPA, which is known to have adverse effects on women’s health, the government should put efforts into improving the delivery of existing contraceptive methods.