The news

The Indian government’s decision to make injectable contraceptives available to the public for free under the national family planning programme (FPP) has stirred a debate about women’s choices in the world’s largest democracy and second most populous country.

The Government of India has expressed its intention of introducing the controversial injectable contraceptive Depot Medroxyprogesterone Acetate (DMPA; brand name Depo-Provera) into the family planning programme (FPP) of India.

It is delivered in the form of an injection and works by thickening the mucous in a woman’s cervix which stops sperm from reaching the egg, thereby preventing pregnancy.

It is also much cheaper than other forms of contraceptives available across the country.

Injectables have been part of family planning programs in many countries for the last two decades.

They have also been available in the private sector in India since the early 1990s though not through government outlets.

The debate
  • Advocates of injectable contraceptives say that their inclusion in the government’s programme will now offer women more autonomy and choice while simultaneously lowering the country’s maternal mortality rate (MMR). Nearly five women die every hour in India from medical complications developed during childbirth, according to the World Health Organization (WHO). Nearly 45,000 mothers die due to causes related to childbirth every year in India, which accounts for 17% of such deaths globally, according to the global health body. The use of injectable contraceptives is also backed by the WHO, which has considered the overall quality of the drug with evidence along with the benefits of preventing unintended pregnancy.
  • But the reality is that 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 sterilization. This is extremely regressive situation.
  • To add to the lack of informed consent is the growing controversy over safety issues concerning injectable contraceptives. They have side effects ranging from menstrual irregularities, migraine headaches, and abdominal cramps to bone degeneration.

The Indian civil society seems divided on the issue. Several bodies like the Population Foundation of India and Family Planning Association of India support the government’s move. The Federation of Obstetric and Gynaecological Societies of India, an apex body of gynaecologists and obstetrics in the country, is also supportive of their use based on scientific evidence.

Women right activists have, however, opposed the initiative as a part of the national programme. They point to a report by the country’s premier pharmaceutical body — Drugs Technical Advisory Board (DTAB) — which has noted that DPMA causes bone loss.

The report emphasises that the osteoporotic effects of the injection worsen the longer the drug is administered and may remain long after the injections are stopped, and may even be irreversible. The DTAB had advised that the drug should not be included in the FPP until discussed threadbare with the country’s leading gynaecologists.

Advocates of women’s health and reproductive rights add that the contraceptive is harmful to women as it leads to menstrual irregularity, amenorrhea and demineralization of bones as a result of its long term use. Users have also reported weight gain, headaches, dizziness, abdominal bloating as well as decreased sex drive. The latest evidence from Africa now shows that the risk of acquiring HIV infection enhances because the couple is less likely to use a condom or any other form of contraception to minimize infection.

The road ahead

Women’s groups, along with health advocates and concerned individuals, have fought a long and hard battle over two decades to prevent the entry of injectables into the FPP.

They questioned the poor public health facilities of the country and the control of women’s bodies by technology.

They also questioned the absence of monitoring mechanisms to help women who face side effects and of public health facilities to ensure that all women undergo full body check-ups for contraindications.

The groups opposed the medicalisation and control of women’s bodies and the reductionist understanding of reproductive rights post the Cairo Consensus, 1994. Many argued that this “consensus” brought out a change in the semantics of rights in the policy, but the “rights” having been narrowed down to “contraceptive choice” and “women’s empowerment,” became a tool to decrease population.

The entry of injectables will most severely affect the poor and marginalized women, who do not have the means to take care of their health in the case of long-term side effects.

This debate has to be placed within the context of the socio-economic backgrounds of the women who are targeted for population control programmes. It is clear that the conditions under which the women’s movement opposed the injectables still remain very relevant today and debates in this regard are necessary.

The public health facilities continue to remain in abysmal conditions and the poor budget allocation to the health sector means increased out-of-pocket expenditure.

Reproductive rights when reduced to “choice of contraceptives,” without considering the overall health and well-being of women, results only in control and unfreedom of women. It has to be strongly argued that it is the opposition of “certain women’s groups” that saved a generation of women, and by ignoring these voices the government will be failing the women of India.

Practice question

“In India, women don’t make a choice when it comes to family planning. They make a sacrifice.” In the light of the above critically examine the benefits and shortcomings of hormonal injectable contraceptives being introduced in India’s national programme.