Are injectible hormonal contraceptives a viable and reliable method of family planning? The World Health Organization (WHO) gives this long-standing debate a new turn by dubbing injectibles a "safe, effective and convenient form of contraception, particularly for lactating and estrogen-sensitive women".
Ever since injectible contraceptives were introduced in 1962, doctors and health professionals have been concerned about their impact on bone mineral density, especially the progesterone-only contraceptives - whether taken as pills, injectibles or implants. Progesterone contraceptives have been known to raise blood pressure, and cause obesity and water retention. An overdose of estrogen, on the other hand, could cause blood clots, raising the risk of heart ailments.
The WHO findings, thus, reassure in some measure. "What is most reassuring is that the decrease in bone mineral density is completely reversed once the contraceptive is stopped. The decrease, in any case, has never been serious enough to result in fractures in women," says Dr Mandakini Parihar, Chairperson of the Family Welfare Committee of the Federation of Obstetrics and Gynecologists of India (FOGSI).
According to WHO guidelines, contraceptive-use risk has been classified into four categories. The first category is when there is no restriction to its use; the second is when the benefit is greater than the risk. Category three is when the risk is greater than its benefits, while category four are not to be used if it is contraindicated (because of blood pressure, diabetes or other reasons). Injectible contraceptives mostly fall in category one and two, says Parihar.
FOGSI - which has 172 societies affiliated to it and over 19,000 practicing gynecologists across the country as its members - confirms and endorses the WHO guidelines, and adds that proper counselling regarding menstrual irregularity will improve compliance with the recommended regime for use of hormonal contraceptives. FOGSI also advises its members to use injectible hormonal contraceptives within the WHO guidelines.
Parihar believes that what is needed is for everyone to realize that there is no contraceptive that is ideal for every woman all the time. "According to a woman's needs and requirements, the type and choice of contraceptive also changes, and it is only right that we give her this choice," she adds.
To reinforce this message, as well as address the unmet need for safe and effective contraceptive services in India, a group of organizations working in the field of reproductive health in the country converged in Delhi in August 2005 and formed a coalition, Advocating Reproductive Choices (ARC). It aims to make available a range of effective and safe methods of contraception for men and women, and to "foster informed reproductive choices within a rights-based framework".
A majority of Indian women do not exercise any control over their reproductive functions and this is compounded by the fact that most women in India are not comfortable with their bodies, says Sudha Tewari, Managing Director of Parivar Seva Sanstha, a Delhi-based NGO, which houses the ARC Secretariat.
Citing data to illustrate the dismal condition of women's reproductive health, Tewari says over 100,000 women die every year in India due to pregnancy-related causes. Infant mortality is three times higher for a child born less than two years apart. Recent studies, she notes, show that 28 per cent of Indian women do not want more than one child, and nine per cent of all recent births or pregnancies are unwanted.
In this context, stresses Tewari, there is an urgent need to improve access to information and services that enable women and men to choose appropriate contraception to help delay, space and stop childbirth. This includes overcoming myths and misconceptions - like the belief that it increases chances of cancer or infertility - associated with various available contraceptive methods.
ARC proposes to work closely with both the government and the private sector to achieve its reproductive goals without any coercion by increasing the opportunities for choosing from a wide range of safe and effective methods. ARC's partner organizations include the All India Institute of Medical Sciences; Family Planning Association of India; Janani, an NGO working in three of the poorest states in India (Bihar, Jharkhand and Madhya Pradesh); and Population Services International India. In addition, the United Nations Population Fund and WHO have agreed to provide ARC with technical support.
The coalition's efforts will concentrate on advocacy with policymakers, politicians, parliamentarians, NGOs, institutions and groups involved with women's health. The thrust areas will be reproductive health of women, child health, contraceptive need and available choices, male responsibility and the use of contraception by men (condoms and non-scalpel vasectomy), contraceptive methods for women with emphasis on injectibles and emergency contraceptives, and evidence-based communication on all these issues.
An important objective of the coalition will be to offer women a basket of options that will ensure both control over fertility as well as protection against HIV/AIDS, says Madhu Bala Nath, Regional Director, South Asia Region, International Planned Parenthood Federation.
This assumes added significance in view of the fact that the only contraceptive that can prevent the spread of sexually transmitted diseases (STDs) and HIV/AIDS is the condom. Agreeing, Parihar observes that if there is a risk of HIV infection, the woman should insist on dual protection. "She should protect herself against unwanted pregnancy by using a woman-controlled method and insist that the male partner uses condoms as protection against STDs, including HIV," she urges.
But this is easier said than done, given the prevailing socio-cultural patriarchal set-up, which denies Indian women control over their own bodies and fertility. "We are dealing with two issues here," Bala Nath says. "One is the issue of women's disempowerment because she does not control her fertility. We have to empower her by giving her a range of contraceptive options. At the same time, we have to look at women-controlled means of HIV prevention."
The basket of options has to include methods that ensure protection against HIV/AIDS and give women control over fertility, she states, adding, "We should include and promote the use of the female condom in the basket of contraceptive options."