Self-Injectable Contraceptives: A Liberating Shot

IN A RED sari and orange blouse on her four-foot frame, she looks like a child in a fancy dress competition. Her bangles jangle as she lifts her hennaed hands to take an injection. “My 12-year-old daughter put mehndi on me last night,” she says. This is Kaushalya’s third trip to the clinic to take a shot of Depo-Medroxyprogesterone Acetate (DMPA). Her first visit was last year when she heard from a doctor in her slum locality that the Government had launched a new contraceptive injection that she would need to take just once every three months. Married at 14, the 28-year-old mother of four narrates her story without a grimace. Her mother passed away before she barely began walking. The youngest of five siblings, her father and brothers got an unschooled Kaushalya married off to a rickshaw driver and she moved from Mujbartal village in Bihar’s Katihar to Delhi. She had three daughters in a span of six years, all for want of a son. She finally had a son three years ago.

Life went on, engulfing her in the daily grind of her job as a domestic help and taking care of four children, but the fear of becoming pregnant again never left her. “Mere bachche school jaate hain. Main nahin chaahti ki meri betiyan kothi-bari karein. Unko toh life banana hai (My children go to school. I don’t want my daughters to work as housemaids. They have to build their life),” she says. Kaushalya, who weighs a mere 32 kg, laughs and says her daughters will not be able to go through labour pangs so many times. She then rushes back to her one-room dwelling where her children are waiting for her. Her life took its course before she could even start dreaming. Now, she just has one dream— getting her children educated. Hers is a hackneyed story, one among innumerable such tales, but she has taken a baby step to alter the narrative.

DMPA, a progestin-only (similar to female hormone progesterone) reversible contraceptive injection for women, was named Antara after the Ministry of Health and Family Welfare considered around 100 names first. Antara, meaning ‘space’, comes closest to the concept of birth spacing envisaged by the Ministry, says a senior official in its family planning division.

Since 1952, when India became the first country to initiate a state sponsored family planning programme, governments have rolled out only five options: female sterilisation, male sterilisation, IUCD, oral contraceptives and condoms. Last year, the Modi Government added three more choices for women—DMPA, Centchroman Pill (Chhaya) and Progestin Only Pill (PoP)—as part of the National Family Planning Programme. The decision to roll out injectables followed persistent and diligent efforts for over a decade by experts, NGOs and the Ministry. Experts expect the number of women choosing injectables as a contraceptive method to go up sharply by 2018-19. In the pipeline are subcutaneous contraceptive injections, which women can administer themselves. The Drug Controller General of India (DGCI) has already given permission for it, and the Ministry will launch it with all necessary precautions, says the official.

Soon after JP Nadda took over as Health Minister in November 2014, he had come face to face with an infographic on contraceptive use in six developing countries, including India. A large patch of deep blue on the colourful chart showed women’s sterilisation accounting for 75.3 per cent of the contraceptive methods used in India, as against 0.63 per cent for men. The data was disturbing. The percentage of women’s sterilisation was just 8.5 in Bangladesh, 6.4 in Indonesia, 10.9 in Bhutan, 32.1 in Sri Lanka and 38.1 in Nepal.

Poonam Muttreja, executive director of Population Foundation of India (PFI), recalls that 45-minute meeting with Nadda. “He gave a patient hearing, was receptive to suggestions and was open to exploring options for promoting spacing methods of family planning,” she says. That was when the Minister saw that the use of injectables—which have been offered by the private sector since 1992—was so minimal in India that it did not reflect in the charts, while it was already used widely in the neighbouring countries—Bhutan (44.1 per cent), Sri Lanka (28.5 per cent), Nepal (27.5 per cent) and Bangladesh (23 per cent).

EXPERTS ACKNOWLEDGE THAT the Government has taken pro-active steps in a sector politicians have shied away from, particularly after the experience of the compulsory and controversial ‘nasbandi’ sterilisation programme undertaken during Indira Gandhi’s 1975-77 Emergency.

Rajiv Gandhi, who became Prime Minister after Indira Gandhi’s assassination in 1984, showed keen interest in a population policy and even set up a committee to focus on the ‘Bimaru’ states, which had higher birth rates. In his book titled JRD Tata: Letters, the late industrialist writes that in 1988, when he heard about the initiatives, he wrote a letter to Rajiv Gandhi: ‘I was delighted to learn from newspaper reports that, while addressing the full meeting of the Planning Commission on 8th April, you had asked for policy papers on seven strategic areas, including family planning.’

Tata, who had underlined the importance of women’s education as an effective tool in reducing birth rates and wiping out gender discrimination, consistently took up his concern over India’s growing population with prime ministers and experts. In 1953, he wrote to the then Prime Minister Jawaharlal Nehru. As detailed in JRD Tata: Letters, Nehru replied saying ‘broadly speaking, I agree with you that we should tackle this problem. But we have to proceed with care so as not to raise a hornet’s nest around us which might make progress more difficult. Also progress in this direction cannot be fast enough in the near future to react on our economic problems. However, we have to think of the distant future also.’

“My daughters will not be able to go through labour pangs so many times. I want to get them educated. I don’t want my daughters to work as housemaids” – Kaushalya: 28-year-old mother of four from Bihar who uses injectable contraceptives

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Over half a century later, demographic fears have continued, even as India’s fertility rate dropped from 3.5 in 1995 to 2.3 in 2013 and 2.2 in 2016. From 846.4 million in the 1991 census, India’s population has grown to 1,320 million, while the decadal population growth rate showed a decline from 23.9 per cent in the 1981-91 census span to 17.7 per cent in the 2001-2011 period. According to PFI, a declining trend in population growth can be seen across communities. The unmet need for family planning was estimated at 12.9 per cent in the country, while the unplanned fertility rate was put at 30 per cent by the National Family Health Survey-4 (2015-16). Bimaru states are still areas of concern, with Bihar and Uttar Pradesh showing the highest fertility rates, lowest modern contraceptive prevalence and highest unmet need for family planning, according to data thrown up by District Level Household Surveys (DLHS). Bihar, Rajasthan, Jharkhand and UP have the highest number of women married below the legally permissible age of 18. Despite the law, every fifth girl in India gets married before that age.

“It was a historic decision to introduce three new contraceptives. There was a paradigm shift in the Government’s approach but it decided to go step by step, beginning with district headquarters. The idea was to move cautiously and maintain quality,” says Dr Ravi Anand of ABT Associates based in Lucknow. Chosen as the lead technical person in the National Technical Research Group of five family planning gynaecologists, she has been involved in the push for injectables since the early 1990s. Over 42 million women in 180 countries have already adopted this method, she says. The group has been training doctors on injectables across the country, which is followed by five-six months of groundwork and understanding reference manuals. For the first time, the Government has come out with a National Task Force for Injectables, an advisory committee on its roll out and quality.

According to Dr Anand, the Government had also asked the group to train doctors on subcutaneous injections. But a study conducted on potential clients showed a reluctance on their part to administer the injection themselves, she says. “As long as the woman has a choice, it’s fine,” says Dr Anand, who has been working on family planning for the past four decades.

The Health Ministry is also examining a matchstick size implant under the skin, which acts as a contraceptive for three years. This could take time and is yet to get the approval of DCGI, sources said. Subdermal contraceptive implants are in use in countries like Bangladesh, Indonesia and Nepal.

The ministry is treading carefully, given that even the move to introduce DMPA was resisted by women’s groups on the ground that the Public Health System was not geared for monitoring the effects of hormonal contraceptives. “What we are saying is that injectables and other hormonal contraceptives have side effects and require monitoring. In India, the public health system is very poor,” says CPM politburo member Brinda Karat, who was general secretary of the All India Democratic Women’s Association (AIDWA). While she agrees that contraceptive choice should be left to the woman, she emphasises that the choice should be “safe”.

On the other side of the argument are those who say widening the basket of choices empowers women in a country where condom use by men is only 11.7 per cent of the contraceptive methods adopted. Doctors who have been advocating the use of DMPA say the side effects are reversible, and that misconceptions can be addressed through counselling. “There is concern about amenorrhoea, absence of a menstrual period, and reduction in bone density. But amonorrhea is not bad for a woman’s health and as soon as the injection is discontinued, bone density goes up. We have not seen women suffering from more fractures because of DMPA. What is required is proper counselling,” says Dr Kamla Ram of Parivar Seva Sanstha, an NGO working in the field of reproductive health that has been administering contraceptive injectables since early 1990s.

GAYATRI, A 37-YEAR-OLD housewife who has been taking DMPA shots at the PSS clinic for the past nine year after conceiving three sons, says her husband, a government employee, has never used a condom in 21 years of marriage. That leaves the onus of family planning on her.

The PFI, citing an international study which suggests that an addition of one contraceptive method to at least half the population corresponds with an increase in the overall use of modern contraceptives by 4-5 percentage points, argues that if eight methods had been made available earlier, India’s modern Contraceptive Prevalence Rate (mCPR) would have been 59.8 per cent in 2015-16, 12 points more than the prevalent 47.8 per cent. According to an expert who does not want to be identified, promoting condoms should not be seen as encouraging promiscuity.

The Government’s focus is on the health of the mother and child through birth spacing options to prevent back-to-back pregnancies, says the senior official, adding that these choices should be offered immediately after a delivery when the unmet need for contraception is high. In a country where a large section of women still do not have control over family planning choices and where male sterilisation is shrouded in myth and misconceptions, this could go a long way. While injectables can be administered six weeks after delivery, PoP, which is being piloted, can be given immediately. In another two years, the fertility rate will come down to 2.1, which would mean an average two children per couple, according to the official.

While the introduction of three contraceptives is seen as a step forward, the total expenditure on family planning is 4-5 per cent of the National Health Mission budget. India’s public spending on healthcare is 1.3 per cent of GDP, which is lower than other BRICS countries— China (3.6), Brazil (4.1), Russia (3.6), South Africa (4.1).

““This government is open to making family planning a priority,” says Muttreja of PFI, an NGO founded in 1970 by a group of socially committed industrialists under the leadership of JRD Tata. Muttreja, however, says that a minuscule 1.4 per cent was spent on spacing methods and 85 per cent on sterilisation. The Health Ministry official, however, admits no budgetary constraints on family planning.

India is now a signatory to the International Conference on Population and Development (ICPD), which focuses on free choice in family programme without coercion, involving women fully and moving away from a target-driven approach towards one emphasising improved quality of care. By the ICDP, governments should define family planning goals in terms of unmet needs for information and services. India’s National Population Policy framed in 2000 set socio-demographic goals, prioritising strategies to meet reproductive, child health and fertility rate targets, though it had refrained from coercive measures like in China, which had a One-Child policy at that that time.

While the debate on population will continue, beyond the polemics on contraception lies an overriding concern—giving women the choice, or rather, choices. As the American environmental scientist and writer Donella Meadows once said, “World fertility surveys indicate that anywhere from one third to one half of the babies born in the Third World would not be if their mothers had access to cheap, reliable family planning, had enough personal empowerment to stand up to their husbands and relatives, and could choose their own family size.”

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Amita Shah