Reproductive Health

Indian Docs Worry Emergency-Contraception Misused

Thursday, October 16, 2008

Three years ago emergency contraception became available over the counter in India and now doctors there say it's being misused. The solution, according to a tabloid sex columnist: more sex ed and better product information.

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Dr. Duru Shah

MUMBAI, India (WOMENSENEWS)--First the iPod, now the i-pill.

Until 2005, emergency contraception in India was relatively scarce because it was available only by prescription and little known.

But that year the government made the so-called morning-after pill available over the counter.

In August 2007, Indian pharmaceutical giant Cipla launched the i-pill, a single-dose morning-after pill available for around $1.80. Around 200,000 units of the drug have been sold every month since its launch.

Doctors such as Mumbai gynecologist Dr. Ashwini Bhalerao Gandhi worry about the strong sales. "I see young, unmarried girls taking the i-pill as many as three to four times a month. Sometimes, their boyfriends even call to ask if it is OK to take the i-pill before sex."

Other doctors leaven that concern by acknowledging the drug's role in reducing the country's abortion rate.

"We gynecologists pressured the government to make emergency contraceptives available over the counter because many Indian women, especially those in rural areas, endured botched abortions in unsanitary conditions," says Dr. Duru Shah, another Mumbai gynecologist. "The morning-after pill may be misused by some women, but is a huge blessing for the majority,"

Cipla's marketing campaign includes TV and print ads of attractive married couples using it responsibly.

But in interviews gynecologists, pharmacists and counselors say that many young people are using morning-after pills on a regular, not emergency, basis.

The i-pill TV ads do carry a warning in small print stating that it should be used only as an emergency contraceptive to prevent pregnancy after unprotected sex and that it does not protect against AIDS and sexually transmitted diseases.

Louder Warnings

Dr. Bhalerao Gandhi says the warnings should be more emphatic. "I think the ads need to carry a clear, bold warning that the i-pill should not be used as a routine contraceptive."

Dr. Jaideep Gogtay is head of medical services at Cipla, based in Mumbai, formerly Bombay. "The ad campaign is just a part of the whole strategy," he says. "We also have a helpline and a Web site which give information about the i-pill and the package clearly says it should only be used in an emergency."

Doctors say that many users nonetheless rely on recommendations from their friends and don't take the instructions on the package seriously.

On the Internet, teens with usernames like "Scared Soul" and "Terrified" plead for information about the i-pill, some confessing to taking it five or six times a month.

"I know many friends who take the i-pill four times a month, because they don't know any better," says a 22-year-old advertising professional, who says she has used it three times when she'd run out of other contraceptives. She asked to have her name withheld.

"Even educated girls confuse the i-pill with regular contraceptive pills and ask me if they can take it daily," says Dr. Shah. "Most young girls don't use any contraception at all, because they have sex on the spur of the moment."

The long-term effects of overuse of the morning-after pill are still unclear.

Single, Stronger Dose

Like its counterpart Plan B in the United States, the i-pill contains levonorgestrel, which is considered safe but can pose some risks to diabetics, women with high blood pressure, women who are allergic to levonorgestrel or women who are already pregnant. Plan B has two doses of 0.75 milligrams each which should be taken 12 hours apart, while the i-pill--like the morning-after pill sold in the United Kingdom--has a single, stronger dose of 1.5 milligrams.

In August 2006, the U.S. Food and Drug Administration made Plan B available over the counter but in a controversial move it restricted it to women over 18 because it said younger women needed medical supervision when taking the pill.

Many users report heavy bleeding and nausea, though gynecologists say this is not dangerous. While Plan B is not believed to cause ectopic pregnancies, the FDA recommends that doctors alert women to that possibility if they complain of lower abdominal pain after taking Plan B.

However, Dr. Bhalerao Gandhi says few Indian women consult doctors until it is too late, even though the instructions specifically advise users to seek medical advice if their periods are delayed or if they suffer pain.

A more serious concern raised by abuse of the morning-after pill is that it could replace the condom, leading to the spread of AIDS and other sexually transmitted diseases.

Thirty percent of India's AIDS victims are between the ages of 15 and 24. Dr. Shah worries that young women engaging in casual sex who might have used a condom in the past will now rely entirely on the i-pill. "The girls I see refuse to even consider the possibility of sexual diseases because they think, foolishly, that their boyfriends are faithful."

Preventing Unsafe Abortions

Despite the risks, the doctors say they support the i-pill on principle, particularly if it can save women from unsafe abortions. They just want women to use it more cautiously.

The Federation of Obstetric and Gynecological Societies of India, based in Mumbai, estimates that between 6 million and 7 million abortions are carried out in India annually and about 20,000 women die of botched abortions, a figure likely to be conservative since the cause of many deaths are not reported to the authorities.

Abortions are legal in India, but doctors and researchers say they can often be lethal due to poor hygiene and insufficient medical care.

Many Indian women also fear the social stigma of seeking an abortion, and therefore go to uncertified abortionists, according to Ipas, an international organization based in Chapel Hill, N.C., that works to protect reproductive rights.

"With any drug, you have to weigh the benefits versus the risks," says Cipla's Gogtay. "For years, Indian women have had to suffer backstreet abortions in horrific, unsanitary conditions. The i-pill gives them a way out."

Dr. Mahindra Watsa writes a sex advice column in a popular Mumbai tabloid. "Young teens will not go to a doctor because they are too ashamed or scared, and pharmacists in India don't have the training to advise patients," he says. "It's better to make the i-pill freely available rather than have women going to quacks for backstreet abortions."

The best solution, says Watsa, is better sex education and proper product information. "We need to educate people about safe sex and contraceptives. We especially need to educate children between 10 and 14, not necessarily about sex, but about how to treat their partners with respect and take care of their bodies."

Dr. Bhalerao Gandhi agrees. "Indian women now have the freedom to have sex," she says, "but they don't have the weapons to protect themselves. We need to give them those weapons."

Kavitha Rao is a Mumbai-based freelance writer.

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