Expanding contraceptive choices

Premium

A recent study published in the journal Contraception X highlighted the potential role of Levonorgestrel 1.5mg for pericoital use. Pericoital contraception refers to methods used at the time of sex, such as condoms and diaphragm. This is a reminder that there is a need to diversify contraceptive choices and respond to the unique needs of women and girls. Data show that in India, the sale of oral emergency contraceptive pills (ECPs) is over 35 million annually, with a decadal compounded annual growth rate (CAGR) of 12%. This proves that women and girls and their partners are choosing to manage their fertility as required.

Emergency contraception

Emergency contraception refers to methods of contraception that can be used to prevent pregnancy after sexual intercourse. These are recommended for use within five days of unprotected sex but are more effective the sooner they are used. ECPs prevent pregnancy by delaying or preventing ovulation.

The World Health Organization (WHO) states that all women, including those who cannot use hormonal contraceptive methods, can use ECPs safely and effectively. Due to the short-term nature of their use, there are no medical conditions that make ECPs unsafe for any woman. The WHO says there are no health risks with using emergency contraception. However, using an ECP is also a reminder to start using a regular contraceptive method in consultation with the healthcare provider because ECPs prevent pregnancy from acts of sex that took place only in the past five days; they will not protect a woman from pregnancy from acts of sex more than 24 hours after she takes ECPs.

While the public sector continues to be the major source of family planning, specifically for female and male sterilisation, and long-acting reversible contraceptives including intra-uterine devices and post-partum intra-uterine devices, the private sector is the major source of oral contraceptive pills as well as ECP and barrier methods such as condoms. Reversible contraceptives place the decision in the hands of girls and women, supporting their agency and reproductive autonomy to decide if they want to have children, when, and how many.

A significant move

Earlier this year, the government included a single-dose regimen of Levonorgestrel 1.5 mg in the National List of Essential Medicines (NLEM). This list is issued by the Department of Pharmaceuticals to make medicines available at affordable costs and assured quality based on the disease burden of the people. It is meant to promote rational use of medicines with focus on cost, safety, and efficacy. This move is significant because this is the preferred regimen for women using ECP and despite the annual sale of over 35 million tablets from private chemists and pharmacies, this was not price controlled, while the two-dose regime (of 0.75 mg tablets) has been in the NLEM since the inclusion in 2015. The emergency contraceptive pill Levonorgestrel 0.75 mg tablet was included in the National Family Planning Programme in 2003 but was later replaced by Levonorgestrel 1.5 mg tablet to be made available free of cost across the public health system. The same pill in the private sector continued to be sold without a price control in the price range of ₹99-110. The two-tablet pack was price controlled at ₹22.53 per tablet by being in the NLEM. This has been a significant market disparity between what women want and what was affordable.

India has reached replacement level of fertility, which means that the average number of children born per woman is such that the population exactly replaces itself from one generation to the next without migration. This has been a result of the government’s efforts to prioritise expanding contraceptive choices, increasing access to quality counselling, contraceptive services, and a focus on education as a pathway to a good quality of life.

There continue to be variations in the demand for contraceptive access and family planning across various regions, and the focus on ensuring access to information and counselling about contraceptive choices and seamless access across public and private sector is critical. The total demand for family planning among currently married women age 15-49 years in India increased from 66% (2015-16) to 76% (2019-21). The unmet need for family planning decreased from 13% in 2015-16 to 9% in 2019-21. What this means is that while more women in India have expressed a desire to use a contraceptive either for delaying first birth, spacing pregnancies, or not having any/more children, there are still 9% (significantly lower than 2015-16) who desire a contraceptive but don’t currently have access for a range of reasons.

With research and technological advancements, contraceptive choices will continue to expand for men and women to respond to the unique needs for contraception. Policymakers need to continue to listen and respond to the needs of the woman and her partner across various life stages with critical decisions like these. This wider availability of the single dose emergency contraception pill is an example of the government’s response to the choices women are making. With the recent introduction of the subcutaneous injectable contraceptive with the opportunity to expand self-care and the sub-dermal single rod contraceptive implant in the national programme, and this decision of price controlling the single dose ECP, conscious efforts are being made to support women in making informed choices.