The private health sector, primarily pharmacies and drugstores, is the major source of emergency contraceptive pills.
Published Oct 08, 2024 | 7:49 AM ⚊ Updated Oct 08, 2024 | 7:49 AM
While the Central Drugs Standard Control Organisation (CDSCO) is considering a ban on over-the-counter (OTC) sales of emergency contraceptive pills (ECPs) in India – potentially making them prescription-only — the government’s last National Family and Health Survey-5 (2019-2021) revealed that 57 percent of women obtained ECPs over the counter.
Currently, Levonorgestrel 0.75mg tablets are sold OTC as emergency contraceptives. Introduced in India in 2002, ECPs—commonly known as the morning-after pill—prevent pregnancy if taken within 72 hours of unprotected sex.
The private health sector, primarily pharmacies and drugstores, is the major source of emergency contraceptive pills. According to the survey, 44.4 percent of women obtained ECPs from pharmacies or drugstores, 25.6 percent from government institutions, 16.3 percent from private doctors and clinics, and 7.2 percent from other shops.
Interestingly, the survey found that less than one percent of women have ever used emergency contraceptive pills. In urban areas, 0.9 percent of women had used ECPs, compared to 0.6 percent in rural areas, making a total of only 0.7 percent—or 7 out of 1,000 women.
The survey also revealed that only 0.4 percent of women had used ECPs in the 12 months preceding the survey. However, among those who did use them, 38.8 percent used ECPs three or more times, 23.7 percent used them twice, and 37.5 percent used them only once during that period.
A sub-committee formed by the Central Drugs Standard Control Organisation (CDSCO) is preparing to recommend changes to the Drugs and Cosmetics Rules of 1945, which would require a prescription for emergency contraceptive pills (ECPs). Currently, ECPs are available over-the-counter (OTC) under the National Reproductive and Child Health Programme.
This proposed ban follows the formation of a six-member expert sub-committee after the Tamil Nadu government pushed for a ban on OTC hormonal contraceptives at the 62nd Drugs Consultative Committee meeting in September 2023, citing “irrational usage.” The sub-committee’s task is to assess whether such a ban is necessary.
Concerns about the safety and misuse of hormonal contraceptives, particularly among vulnerable populations, have driven this move. Experts worry that unrestricted access to ECPs could lead to misuse. Health risks such as pulmonary embolism and irregular bleeding have raised alarms, prompting the call for a prescription-only policy to ensure that a healthcare provider evaluates each case before prescribing ECPs.
While some support the ban to prevent misuse, others argue that restricting access could lead to higher rates of unwanted pregnancies and unsafe abortions, especially given the limited access to healthcare in many parts of the country.
A meta-analysis titled ‘The Use of Emergency Contraceptive Pills in India’ found that only 6 percent of women have ever used emergency contraceptive pills (ECPs).
Of the five cross-sectional studies that reported repeat use of ECPs, the rates varied significantly, ranging from 12% to 69%. One study assessing the practices of pharmacists revealed that pharmacies sold an average of 62 packs of ECPs per month, with 62 percent of pharmacists stating that most of their customers repeatedly purchased ECPs within the same month. In extreme cases, some customers bought ECPs up to 30 times in a single month.
A 2019 market study revealed that the annual volume of EC pill sales was around 33.5 million units.
Multiple studies found that primary reasons cited for using ECPs were unprotected sex or condom failure. Other reasons included missing oral contraceptive pills (OCPs), miscalculating fertile periods, unplanned sexual encounters, and the unavailability of regular contraception.
On the other hand, common reasons for not using ECPs were rooted in religious or cultural beliefs, fear of side effects, and a lack of knowledge about dosage, timing, and access points. The study also highlighted the moral policing role that many gynecologists adopt in India when it comes to ECP use.
For instance, a study found that three-quarters of gynecologists believed that marriage should be a prerequisite for ECP use. One gynecologist remarked, “I do feel that the easy availability of ECPs has increased sexual activity among young girls. There is a lot of misuse of ECPs by the current generation. With the influence of Western culture, young people see casual sex as normal, and the pill has become a powerful tool for women.”
The review also examined the societal context influencing family planning and ECP use in India. Although ECPs are readily available, various sociocultural factors, such as gender norms, power relations, and deeply ingrained beliefs, limit women’s ability to make decisions about their own reproductive health.
In some cases, a woman’s “value” within her family is often tied to her ability to reproduce. A study reported that many women opted out of pursuing higher education because their husbands disapproved, with 67.6% of participants seeking their husband’s permission before participating. In-laws were also consulted in 1.7% to 10.8% of cases, reflecting the strong influence of male family members in decision-making.
The same study also pointed out that “While removing the requirement to go through pharmacists or clinics to obtain EC increases use, the public health impact may be negligible because of high rates of unprotected intercourse and relative underutilization of the method. Given that there is clear evidence that neither pharmacy access nor advance provision compromises contraceptive or sexual behavior, it seems unreasonable to restrict access to EC to clinics,” said the study.
“Although awareness about these pills has steadily increased over time, actual usage remains low. The review indicated that women with higher levels of education and economic status utilized emergency contraceptive pills more readily. However, the negative and judgmental attitudes of a substantial proportion of service providers served to discourage the use of emergency contraceptive pills. This was despite the finding that use of EC did not lead to more unprotected sex,” said Dr. Shrinivas Darak, Senior Research Fellow at Prayas, Pune in a programme of Population Foundation of India in December 2023 who is also the co-author of the meta-analysis.
“It should be banned. Any drug available over the counter, especially one like emergency contraception, has to be regulated. The problem is that many medical stores employ staff who don’t have adequate knowledge about these medications. These people might not have a proper understanding of what the drug contains or how it works. For example, they may know about common drugs like Dolo 650 but may not even know whether it contains paracetamol or diclofenac. It’s even more crucial when it comes to hormonal drugs like emergency contraceptives,” said Bangalore Society of Obstetrics & Gynaecology president Dr. Rekha Rajendrakumar to South First.
“Also, Hormonal drugs can’t be taken indiscriminately. You can’t treat hormones like vitamins, which you can take without much concern. Hormones are powerful and need to be used carefully,” she said.
She pointed out that many people take emergency contraception without understanding whether they’re actually pregnant. They may have missed a period and think they’re pregnant, but it could be something else, like an ectopic pregnancy. In that case, emergency contraception is dangerous. Medical stores sometimes hand out these pills without checking for pregnancy, not even doing a basic urine test.
“That’s why these over-the-counter drugs should be banned. People are willing to spend money on hotels, cinema, and parties, but when it comes to their own health, they want to save a few rupees by avoiding the doctor. But they need to see a gynecologist, not just any doctor, to ensure they’re using these drugs safely,” she said.
She pointed women are often taking these pills without proper care, which leads to hormone imbalances and other issues. They might try to maintain secrecy, avoiding their parents, boyfriends, or husbands, and take the pill on their own, said the doctor.
“Yes, women have too much liberty nowadays, but when that easy access leads to this kind of misuse, it becomes a problem. It’s creating a dangerous atmosphere, leading to unwanted pregnancies and contempt for the process of pregnancy itself,” she said.
“First of all, pregnancy should not be unwanted, and the Emergency Pill ensures it as a last resort. If you remove ECPs from over-the-counter availability, it may lead to an increase in unwanted pregnancies, which could result in illegal abortions. Many women, particularly those who lack education or resources, might seek unsafe methods to terminate a pregnancy, which can lead to serious health issues like heavy bleeding or even secondary infertility. The number of risky medical procedures would rise if women cannot access proper medical care, and this will only increase their vulnerability to infections and other complications,” said Dr Anuradha Katragadda, Managing Director of Anu Test Tube Baby Centre to South First.
She added this decision will disproportionately affect women in rural areas or those with limited access to healthcare providers. Once you ban the drug, the risk of medical complications will likely increase, along with the need for more procedures. If these procedures are not easily accessible or affordable, women might resort to illegal means, which would further compound the problem.
“The key is educating women on the proper use of ECPs, ensuring they understand that it is an emergency measure and not something to be used frequently. Safe sexual practices should be prioritised over simply banning the pill, as removing it takes away a woman’s right to manage her sexual health and affects her confidence,” said Dr Anuradha.
She also said that if the women we are talking about are using emergency contraceptive pills (ECPs) as a last resort, it means they are already aware of their reproductive health. It’s important to clarify that the ECP itself does not increase the risk of infections, such as STDs; rather, it gives women confidence that they can avoid an unwanted pregnancy. However, relying on it too frequently may expose them to higher risks.
Meanwhile Managing Director at Bengaluru-based Gunasheela Fertility Centre Dr. Devika Gunasheela told South First said that emergency contraceptives, or any contraceptive pill, is that women should have free access to them.
“We’re not living in the Dark Ages or in a time where sex was considered taboo. Nowadays, more and more young women are engaging in casual sex, and that is their right. We can’t and shouldn’t try to prevent it—society is evolving, and we need to move with the times,” she said.
She pointed if we don’t adapt, we’ll be left behind. The idea that women should not have access to contraceptives, whether they are married or unmarried, is outdated and regressive.
“Emergency contraception is available for a reason, and while its usage may not be widespread across India, largely due to a lack of awareness, it’s essential that we normalize access. Studies show that a significant portion of the urban population is already using emergency contraceptives, often purchasing them directly from pharmacies. They’re able to do this without needing to see a doctor every time, and that accessibility is crucial. Without it, what options do women—especially unmarried girls—have?” asked Dr Devika.
“”I just want to clarify something. The use of emergency contraception doesn’t increase STDs—what’s leading to the rise in STDs is that more women are engaging in casual sex, as society’s perception of sex evolves. Whether or not it aligns with our personal or religious beliefs, the fact is that more women are experimenting with sex. And just because emergency contraception is available doesn’t mean it’s encouraging them to do so. People are going to have sex regardless—what emergency contraception does is give them a safety net to prevent unwanted pregnancies,” she said.
She pointed out that enacting regressive laws that ban abortions or contraceptive pills would only put women at more risk.
“I believe every woman, no matter where she is in the world, should have access to contraception if she needs it. It’s about protecting their health and their future. “We can’t stop the way society is progressing, no matter our personal beliefs or moral codes. What matters is making sure women are safe and have the tools they need to protect their health,” the doctor said.
(Edited by Neena)
