Over the last century, advancements in health technologies have been a key strategy in combating various diseases and significantly bringing down morbidity and mortality rates. The discovery of penicillin, one of the world's first antibiotics, marked a true turning point in human history —when doctors finally had a tool that could completely cure their patients of deadly infectious diseases. Since then, we have made huge strides in increasing access to various vaccines, drugs and diagnostics. However, in India, advancements in sexual and reproductive health (SRH) technologies have not been effectively leveraged to improve women’s health. Two technological advancements that deserve attention are — emergency contraception pill (ECP), and medication abortion (MA).
The unmet need for contraception, as per the National Family Health Survey 2015-16 (NFHS-4), remains high (13 per cent). According to a recent study published in The lancet, nearly half of the estimated 48.1 million pregnancies annually are unintended, and a third of them are terminated. For advancements in technology to make a difference to women, policies governing technologies, and attitudes toward women, sex, sexuality and reproduction need to change. Unfortunately, this is not the case in India.
The ECP is a case in point. ECPs were approved for use in India in 2002 and were made an over-the-counter product in 2005. The subsequent advertising by private manufacturers ensured that women in urban areas had access to them. Women embraced ECPs as they enabled them to exercise control over their sexual and reproductive decision-making. However, certain regressive attitudes about women and sex emerged, including perceptions that women who use ECPs are promiscuous and engage in pre-marital sex and risky sexual behaviour, as well as misconceptions that repeated use can cause problems (although there is no evidence to suggest this). Women’s autonomy, choice and decision-making be damned!
Consequently, advertisements for ECPs were banned in 2009. While the ban was lifted two years later, any advertisement for ECPs now needs to be cleared by a sub-committee. Additionally, harassment of chemists stocking and selling the product in some States ensured that marketers of ECPs stopped advertising and reduced their focus on ECPs. Awareness among women therefore remains low. According to NFHS-4, only 48 per cent women are aware about ECPs, and less than 1 per cent use them. Given the number of unintended pregnancies, we need to scale up advertisements, raise awareness and address misconceptions about ECPs. As a society, we have failed in respecting women’s sexual and reproductive rights. Nothing new, rightIJ
The Medical Termination of Pregnancy (MTP) Act, 1971, legalises abortion up to 20 weeks. The Act was enforced when dilation and curettage, an invasive and risky procedure, was the only method available. While technology, especially for first trimester abortions, has improved over the years, the law has remained the same. Even today, only obstetricians and gynaecologists — just over 34,000 nationally — can provide abortions. Consequently, there are very a few approved abortion providers in India, mostly concentrated in urban areas.
The introduction of MA drugs in early 2000 and the combipack of Mifepristone and Misoprostol in 2008 changed the landscape of abortion in India. According to the study published in The lancet, MA accounted for over 80 per cent of all abortions in 2015. MA is safe, simple and effective for early abortions and is being accessed by women from a number of providers, including a large number of MBBS doctors. However, under the law as it exists today, though safe, most would be considered illegal.
The availability of MA drugs has been impacted with the increasing regulation in recent years, given its misplaced association with sex selection. There have been instances of chemists being asked names of clients and prescriptions (a violation of the MTP Act, which provides women confidentiality), stocks of MA drugs being impounded, and private practitioners being questioned about their MA stocks. This association is flawed as MA can only be used for terminations up to nine weeks when the sex of the foetus cannot be determined through ultra-sonography. Despite clear evidence that shows MA drugs can and are being used in the first trimester, over-regulation is resulting in chemists reluctant to maintain stocks, and many pharmaceutical companies no longer focusing on MA, thereby reducing access.
For increased access to MA, we need to ensure this over-regulation is addressed and as a short-term measure, allow MBBS doctors to prescribe MA legally after a short training. Simultaneously, we need to allow a wider base of practitioners to provide MA, so women are not compelled to approach illegal, unqualified providers, thereby endangering their lives and health. There is evidence from studies in India and other countries to show that MA can be provided effectively by trained and qualified nurses and non-allopathic healthcare providers, which is also recommended by the WHO.
Health technologies offer women choices, but they cannot exercise them unless they are informed, and laws and policies are framed with their interests in mind. When women have access to SRH services and can exercise their rights, a world of opportunities open up for them. Better access to these services will lead to improvement in the health of women, children and communities. Not only will it reduce maternal and child mortality, delay the first birth, prevent unintended pregnancies and reduce unsafe abortions, it will also ensure they lead productive lives — they will stay longer in school, pursue higher education, participate in the workforce and contribute to the economy.
This World Health Day, let us commit to ensuring our girls and women have the right and means to make informed decisions about their bodies, health and future.
(The writer is the Chief Executive Officer of the Foundation for Reproductive Health Services India; formerly, Marie Stopes India)