Time for men to stand up and be counted

The government adds injectable contraceptives to the bouquet of choices, but the worry is that data suggest the onus of family planning rests solely on women

One-sided “‘In India, women don’t make a choice when it comes to family planning. They make a sacrifice’.” Picture shows women who underwent sterilisation at a government camp, undergoing treatment after complications, at a hospital in Bilaspur, Chhattisgarh.

In an attempt to offer a bouquet of choices to women in need of family planning services, India has introduced hormonal injectable contraceptives in its national programme.

While the injections are popular around the world, a 2010 report by USAID-India noted that India’s contraceptive choices were highly skewed towards single method use. Over 75% resort to female sterilisation, followed by condoms (10%), birth control pills (6%), and intrauterine devices (4%). Herein lies the fundamental problem with the introduction of hormonal injectable contraceptives.

“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 sterilisation. This is extremely regressive situation,” says Poonam Muttreja, executive director of Population Foundation of India (PFI).

Not meant for prolonged use

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, abdominal cramps to bone degeneration.

The injectable contraceptive depot medroxyprogesterone acetate (DMPA) was introduced in India in 1994 by the Drug Controller General of India as a prescription drug. In 1995, the Drug Technical Advisory Board, on the direction of the Supreme Court, made an interim recommendation that DMPA should not be allowed for mass use in the national family planning programme and its use should be restricted to women who are aware of the implications of its use.

Objections flagged by women’s groups were validated in 2004 when the U.S. Food and Drug Administration asked Pfizer to put a black-box warning on the label of its contraceptive Depo-Provera in view of findings that the osteoporotic effects of the injection grow worse the longer it is administered and may last long after its use is stopped.

“The injections cannot be used by women year after year. This is a short-term option for women deciding whether they want a permanent solution, or if, say, their husbands are migrant workers who visit home for a few months,” explains Ms. Muttreja.

The question of agency

Another practical objection to injectable contraceptives is that it is “provider-controlled” — medical professionals must give the injection and the contraceptive effects are irreversible for the period of efficacy. As against oral birth control pills, which are “user-controlled” and can be stopped soon as a woman develops complications. “Making women more provider-dependent, when better options are available, is a problem. Especially when you consider that the patient-doctor interaction in a health facility is chaotic. The power equation is not in favour of the patient anyway. Most of all, in case of complications, patients cannot access health-care services when they need them,” says Dr. Amit Sengupta, convenor of the India chapter of People’s Health Movement.

The most worrying concern, however, is the “severe and deep” gender bias, which is not being addressed by the government. In 2014, 13 women died and 65 were injured as a government-run sterilisation camp in Chhattisgarh. The laparoscopic surgeon Dr. R.K. Gupta, was found to have used the same sutures, syringes and gloves on all 83 patients, causing life-threatening infections. Between 2015 and 2016, 110 women died in India due to botched sterilisation procedures.

The onus of family planning rests solely on Indian women. Results of the latest National Family Health Survey 4 showed that as against a deplorable 1% men who opted for sterilisation services in 2005, only 0.3% opted for it a decade later. “Sterilization is an easier   procedure for men in comparison to women. A vasectomy is a simple 10-minute procedure. Family planning is not, cannot be a women’s issue. We need to talk about women’s equality and reproductive rights. We need more men trained in providing vasectomy, more counselling for men instead of addressing only women,” adds Ms. Muttreja.

While pills, intrauterine devices and injectable contraceptives now make for a wider mix in the family planning programme, what’s conspicuously missing is the men. It’s time to bring them in.

vidya.krishnan@thehindu.co.in