Debate on injectable contraceptives for women in India

In December 2015, the Indian government has announced to introduce injectable contraceptives for women in the public health system and family welfare programme. The first phase will be implemented in medical colleges and district hospitals with family planning counsellors. But few health groups and women’s organisations are expressing concerns about safety of women with the use of injectable contraceptive drug called Depot Medroxyprogesterone Acetate (DPMA).

Why there is a need for injectable contraceptives in India?

Indian women are scored very low in health parameters with high incidence of mortality and morbidity in the reproductive years. Most of these health problems of Indian women are related to high fertility rates due to unmet need for family planning. As per the District Level Household and Facility Survey-3, unmet contraception in India is about 21.3 per cent. This unfulfilled need is responsible for unintended pregnancies, unsafe abortions, deaths and life-long morbidity.

One of the main reasons for the high unmet need is the limited number of contraceptives available. In India only five contraceptive methods are available whereas in many developing countries seven methods are available including injectables and implants. Out of the available methods, female sterilisation is the mainstay of the national family planning programme. Female sterilisation accounts for 74.4 % of overall contraceptive use in India. According to health surveys, the unmet need for spacing methods among the young married women was 25.1% and 14.9% in the age group 15-19 and 20-24, respectively. It is necessary to introduce injectable contraceptives for expanding the basket of available choices for women with a focus on spacing methods.

What is DMPA and what are the concerns about its use?

DMPA is progestin-only, injectable contraceptive method. It is injected either to arms or the buttocks. The DMPA shot is to be given every three months and fertility returns after four months of its discontinuation. It is one of the cheapest methods available for contraception. Norethisterone Enanthate (NET-EN) is another injectable contraceptive that is to be given for every two months.

But the use of DMPA and NET-EN are reported that it leads to many health problems in women including menstrual irregularity, demineralisation of bones, abdominal bloating and discomfort, mood changes, decreased sex drive, etc.

Few health groups and women’s organisations have arguing that in 1995, the Drugs Technical Advisory Board (DTAB), the highest decision-making body on technical matters in the Ministry of Health &Family Welfare, held that Depo-Provera (a well-known brand name for medroxyprogesterone) is not recommended for inclusion in the family planning programme.

There are also concerns expressed about using injectable contraceptives as a tool to target the growth of Muslim population in the country.

Are the concerns valid?

Injectables as a contraceptive method is widely in many countries as part of family planning programme. It is in use for over two decades. They were first made available to women in Asia in 1970s. Since 1990s, they have been available in the private sector in India. A study on DMPA pilot programs in Rajasthan and Uttar Pradesh showed that women had the positive opinion about the method. The WHO also recommended that, women of age group 18-45 can use DMPA without any restriction. For adolescents and women above 45 years age, its usage outweighs the safety concerns about fracture risk. Studies found that women lose bone mineral density (BMD) during DMPA use, but are recovered after its discontinuation.

Now there is availability of enough scientific evidence to deal with safety concerns, counselling and follow-up, which encourage the launch of injectable contraceptives as part of national family planning programme. There are legitimate concerns about their use but these concerns are equally applicable to other available contraceptive methods. However, the side-effects are out-weighed by the benefits with use of contraceptives in preventing unsafe abortions and unintended pregnancies. Hence the concerns should not hinder the introduction of new methods of contraceptives.

What is the way forward?

Indian women cannot be denied their right to choose the globally acceptable injectable contraceptives. A healthy debate with sufficient scientific evidence is necessary for changing negative opinion about injectable contraceptives.