On April 5, Union Health Minister JP Nadda announced a basket of contraceptive choices for women including injectables and oral pills – all of which will be made available through the public health system under the National Family Planning programme. The contraceptive choices in question are – the hormonal injectable contraceptive depot medroxyprogesterone acetate, or DMPA, Cenrchroman, a non-hormonal, non-steroidal drug, and progesterone only pills.
Speaking at the National Family Planning Summit in Mumbai, Nadda said reducing fertility would lead to overall economic development in the country, particularly by reducing morbidity. The success of the programme will be beneficial for the “economic health of the nation,” he added.
The function hosted by the Ministry of Health and Family Welfare is an indication of the revival of family planning measures in India in tandem with a similar push in the rest of the world – a development health activists refer to as a “neo-Malthusian revival” (a reference to Thomas Malthus, who believed that left unchecked, population could outgrow resources, leading to poverty). Dr Jagdish Prasad, the director general of health services, left no doubt about that when he said that the department should concentrate 90% of its energies on family planning. “It impacts female health, maternal mortality, and child mortality,” said Prasad. “If the family suffers, the nation suffers. We need to stabilise the population by 2045.”
However, there are two problems with the health ministry’s fresh push for family planning.
The first relates directly to the contraception choices unveiled. For instance, DMPA has been introduced in the programme despite two decades of activism against it, including a case in the Supreme Court. Though DMPA has been available in private hospitals in India since 1993, it’s not a popular form of contraception. The injection can prevent pregnancies for three months after administration, but it is also linked to a host of side effects, and comes with a boxed warning (designed to call attention to serious and life-threatening risks on its label) in the US that warns of the loss of significant bone density that is possibly non-reversible. The warning says that it should be used only if other birth control methods are inadequate. The government has decided to introduce the contraceptive only at district hospitals and tertiary level hospitals.
In fact, last October, activists and scholars working in the field of medicine, public health and women’s rights wrote to Nadda protesting against the government’s approval to introduce injectable contraceptives in National Family Planning programmes, saying they were harmful to women’s health.
Its champions don’t think so. The side effects of DMPA are innocuous, said Dr Ravi Anand of ABT Associates in Lucknow, which works on the DIMPA programme – a network of private gynecologists working to increase demand for, and access to, DMPA in Uttar Pradesh, Uttarakhand and Jharkhand. “They may irritate women, like a cold for instance,” said Dr Anand. “They require counselling after which the women can handle it. If you can help them tide over that time, then they can deal with it.”
But others flag its side effects, which do not subside for at least three months. “Can you imagine having a headache for three months? Or heavy bleeding? Or spotting for months?” asked Dr Veena Shatrugna, former deputy director, National Institute of Nutrition, Hyderabad. “Where will they get the menstrual cloth from, and the water to wash the rags and dry them out in the sun during the days of heavy bleeding and spotting? Can you imagine the chaos during the rains, or days considered auspicious?
Dr Shatrugna added: “Why is it ok for poor women to be administered this contraceptive?”
Another question over its introduction is that the use of injectables in the private sector has also been extremely low, as per the National Family Health Survey-3 data. Also, more than half the women who took injectables discontinued it within a year.
The other contraceptives introduced include Centchroman, popularly known as Saheli, a non-steroidal, non-hormonal oral contraceptive pill which claims to have no side effects. Centchroman was the result of indigenous research of the Central Drug Research Institute, Lucknow. The progesterone-only pills, which will be made part of the programme next year after the pilot project, also has side effects.
The second problem with government’s revived focus on family planning is an old complaint – that it is women who always have to bear the burden of contraception. Take for instance sterilisation. As per 2014 figures from the Ministry of Health and Family Welfare, 1.48 lakh women were sterilised as opposed to 5,004 men in India. This despite the fact that contraceptive methods for women have severe side effects. Sometimes, they have have fatal consequences too, like in the case of the 15 women who died at a mass-sterilisation camp at Bilaspur, Chhattisgarh.
Tuesday’s health ministry function seemed to have totally glossed over that complaint – it unveiled only contraceptive products for women.
A paper published in the Economic and Political Weekly in October last year said who gets to determine what is in the "basket of choices" is a question that deserves greater attention. It argued that the presumption of economic growth and liberation of women based on successful family planning precluded a “real discussion of which methods are the safest for women and men.”
The EPW paper added: “The entire [family planning] programme is plagued by contemptuous misogyny, and caste and class prejudices.”
But it's not as if there are no tangible benefits. Nachiket Mor, the director of the Bill and Melinda Gates Foundation, India, showed in his presentation at the summit that the addition of one method of contraception for at least half the population (i.e. women) correlates with an increase of 4-8 percentage points in the use of contraceptive methods. The Gates Foundation is a major force behind the family planning initiative – FP2020 – which aims to get 120 million more women and girls to use contraception by the year 2020 worldwide.
However, Mohan Rao, professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, who co-authored the EPW paper, said that the government had its priorities all wrong. “The problem is the emphasis placed on the family planning programme as opposed to creating a public health system which provides quality care,” he said. “We do not have a system that can deal with these kinds of contraceptives.”
At the summit, the government also launched a new communications programme on family planning, which had advertisements, radio spots, and posters with superstar Amitabh Bachchan. “Parivar ko bojh nahi, takat baniye (Don’t make your family a burden, make it your strength),” Bachchan said in one ad. The question is: Why is it women who always have to bear the bojh, or burden, of family planning?