National data on prevalence rates of abortions, low birth weights,
infant and maternal morbidity and mortality are still high in India and coexist
with a high unmet need for contraception. This indicates a need to improve and
increase the choice of contraceptive methods within the National Family Welfare
Programme. The Indian Council of Medical Research (ICMR) conducted several
studies with injectable contraceptives during the 1970s and 1980s. Injectable
contraceptives (IC) are available in the Indian market since 1994 but the large
majority of the population cannot afford the prices in the open market. Hence it
would be relevant to consider their induction into the National Family Welfare
Programme.
Injectable contraceptives are offered in several South- East Asian
countries like China, Thailand, Indonesia, Bangladesh, Sri Lanka, Nepal, Bhutan
and Pakistan where DMPA, NET- EN and/ or monthly injections have been introduced
(1, 2). Clinicians and social scientists from these countries were invited for
an in- depth discussion of their experiences in their population groups. Several
aspects of cultural and social factors which affect the use and continuation of
injectable contraceptives were discussed in detail.
The progestin only injectables DMPA and NET- EN have comparable
efficacy, mode of action and advantages. There are approximately 9 million DMPA
users worldwide. A study of long- term side effects shows no adverse effects on
blood pressure, blood coagulation, lactation, liver function, cancer, foetal and
child development. (1)
Disturbance in menstrual cyclicity is the major reason for
discontinuation of DMPA. Heavy, profuse bleeding, irregular bleeding/ spotting
and amenorrhoea can be troublesome and result in low continuation rates. Medical
intervention and proper counselling are essential for management and provision
of quality care has to be ensured. Amenorrhoea may be beneficial in preventing
anaemia, it can have positive and negative implications and reactions. These
side effects are all reversible, after discontinuation. Weight gain may be
another side effect, but this more on account of the user’s diet and lifestyle.
Other additional benefits include prevention of pelvic inflammation and
endometriosis. (1, 2, 3)
There are a few contra- indications which need to be strictly
followed at the inclusion/ exclusion stage at the time of enrollment / initial
counselling. The efficacy rates are comparable to sterilisation. The convenience
of two- or three- monthly schedules is also an advantage.( 1)
Return of fertility is slightly delayed after DMPA, but after two
years, pregnancy rates among former users of DMPA, NET- EN, IUCD and oral pills
are the same. (1,2,3)
Menstrual irregularities have been eliminated by monthly
injections which combine estrogen with the progestins. Thereby better cycle
control and less disturbance of menstrual periods are maintained. Monthly
injectables are a combination of estrogens and progestin (either DMPA or NET)
and are also available as pre-filled single dose disposable injections.
At the end of the meeting, on review of the available data, there
were two views expressed. One group opined that injectables should be inducted
into the National Family Welfare Programme selectively in suitably equipped
health centres and in a gradual phased manner. The users should not be under any
coercion. Informed voluntary consent should be obtained. The consent forms
should be in simple local language. Trained counsellors and providers should be
involved and follow good clinical practices, and proper surveillance should be
maintained.
Within these criteria the use of injectables will not pose any
risk to the users. Some women will have side effects which lead to early
discontinuations. A large proportion of users is able to continue their use as
long as they need contraception. The availability of another method choice will
certainly increase the contraceptive usage, reduce the unmet needs and lower the
need for resorting to MTP both by safe methods and the unsafe, “back-street”
methods which are still practised and responsible for maternal morbidity and
mortality.
Though the injectables are meant to be administered at intervals
of one, two or three months, there is some flexibility of time interval for the
next scheduled dose. Thus, women can safely delay their next dose by up to one
or two weeks depending upon the type of injectable. Clinical situations where
injectables may be very useful are post MTP when a woman needs to be protected
from pregnancy till she can think and choose a form of contraception;
peri-menopausal women who need contraception, desire for short term
contraception among certain groups of the population in view of changing
lifestyles and frequent migration.
The emphasis should be to allow women to
know their options and exercise their choice.
References
:
1. WHO Population Reports : New Era for injectables K( 5) March
1996.
2. WHO Special Programme of Research, Development and Research
Training in Human Reproduction. Multinational comparative clinical trial of long
acting injectable contraceptives : Norethisterone oenanthate given in two dosage
regimens and depotmedroxyprogesterone acetate. Final Report. Contraception: 28:
I- 20, 1983.
3. ICMR Task Force on Hormonal Contraception: Return of
fertility following discontinuation of injectable contraceptive Norethisterone
oenanthate (NET- OEN) 200 mg dose. Contraception: 34: 6; Dec. 1986
Dr. Kamal Hazari,
deputy director (medical), Institute for Research and
Reproduction, Parel, Mumbai - 12
