Why Is India Using Unsafe Injections As Birth Control On Poor Women?

Being able to pop minuscule pills 21 days a month to avoid pregnancy or manage our own reproductive health is something we rarely consider as a luxury. The fact that they’re demarcated to let us know which day it is too, is just an added benefit. But if you happen to belong to a more unfortunate strata of society in India, your choices differ drastically. This is exactly the case with the ‘big injection,’ a new contraceptive drug called Depot Medroxyprogesterone Acetate (DPMA) that’s been on the market since late August of this year. One that doctors are more than willing to endorse, even as they readily admit they wouldn’t it prescribe it to their patients in the private sector. So is it safe to assume that poor women are nothing better than guinea pigs when it comes to public healthcare, in the eyes of our system?

If we were to take a cursory glance at history, both around the world and in India, the answer to this question would be a resounding yes. As Menaka Rao, an investigative journalist reported for The Ladies Finger, “Medical care and women’s reproductive health has always had a difficult history, plagued by issues of ethics, consent, and hanky-panky by pharma companies and developed nations.” She reiterates her point by reminding us that the birth control pill in its earliest form was actually tested on non-consenting psychiatric patients and destitute Puerto Ricans by American researchers. It would certainly explain why, even after performing dismally in the Indian private sector, this drug is being seen as fit for ‘family planning’ purposes in the country.

So what is DPMA and how harmful is it really?
Delivered in the form of an injection to either the buttocks or the arm every 13 weeks, it’s available over the counter under various brand names, and is made by the US pharma giant, Pfizer. By thickening the mucous in a woman’s cervix, it stops sperm from reaching the egg, thereby preventing pregnancy. It’s also much cheaper than other contraceptives available in India. Available for just Rs.150 for an injection that’s good for 3 months, it’s much more appealingly priced than contraceptive pills like Diane35 (Rs. 225 for one month usage) or intra-uterine devices like copper-t (Rs. 350 or Rs. 550 depending on the brand), but at least the latter lasts for three years.
Still, if the price point seems appealing, the statutory warnings that come printed on its box in the US are anything but that. “Bone loss is greater with increasing duration of use and may not be completely reversible. […] Depo-Provera Contraceptive should be used as a long-term birth control method (longer than 2 years) only if other birth control methods are inadequate,” it reads.

There’s a reason, then, that women’s organisations, activists and healthcare groups have been consistently contesting the use of injectable contraceptive drugs in the public healthcare system for family planning. India’s Drug Technical Advisory Board (DTAB), the most powerful decision-maker within the Ministry of Health, had held in 1995 that DPMA was not recommended for inclusion within the National Family Planning Programme (NFPP).

If everyone’s signed off on it, does it make it safe? 
Considering they signed off on it without a second thought 20 years later, you would think something significant has changed in the drug but this isn’t true at all. All the scary side-effects, including depression, irregular periods, lowering of bone mineral density and more, are still very much there. They are, in fact, the reason that almost all women in the private sector who have tried the drug, have discontinued its use within a year. In a country where malnutrition grows with poverty, women have already consequently developed low bone density, these risks are only amplified further by a drug like this. A large percentage of women in the reproductive age also suffer from anaemia. And to this heap of medical risks, we now add an injectable contraceptive that can cause irregular and heavy bleeding and even lead to osteoporosis, according to some studies.

It’s not just that the injection comes with a long stack of side effects, but how it’s delivered is important too. If not administered properly, there is an increased risk of HIV infection to the women injected, and of Down Syndrome in babies born, among other birth defects.We also count increased chances of still births; increase in the risk of breast cancer, cervical cancer, weight gain, fluid retention, skin discolouration, insomnia--the list goes on. Suffice to say that these are risks that women would most probably never succumb themselves to and still end up doing so in public healthcare, without the knowledge of their  existence.

Attention public healthcare: Where is the accountability?

It’s a well known fact that healthcare is one of many victims of class warfare, and where you lie in the socio-economic pyramid determines the kind of medical attention you can afford. Free, public healthcare comes with its own set of problems. In an investigative report, several doctors in the private sector stated that they would not recommend its use to their patients owing to the dangerous side effects. So how are the women of poor and rural communities subjected to its use, all to save a couple of bucks? Here’s how, with the illusion of an otherwise empty basket.

As stated in a study conducted bySama, a Delhi-based Resource Group for Women and Health, in 2013, “both manufacturers and propagators of Depo-Provera have been using concepts such as ‘choice’, ‘convenience’ and ‘empowerment’ to support the introduction of the injectable in the market and the Family Welfare Programme. On many occasions, the government too announced that the central idea behind introducing Depo in the Family Welfare Programme – along with other injectables and implants – was what it called a ‘cafeteria approach’, in order to provide a ‘wider choice’ to women. From time to time, a number of pro-birth control institutions and NGOs have talked about a ‘basket of choices.’” The concept of a ‘basket’ of contraceptives is thrown around a lot, which suggests a variety of available options, but the study found that in most instances this basket contains only one option, that of injectables. So, where is the choice?

The study states that “sixty percent of the women who went for follow-ups or complained about side-effects said that the hospital staff, including doctors, were particularly harsh and prejudiced towards them, often displaying complete apathy towards their complaints”. Women who, due to social and financial reasons, can access only public hospitals in rural and urban areas, end up playing human subjects for a trial and error process. That too, for a drug that may not be safe; assurance can’t be given due to the lack of prior clinical trials.

As we step behind the public clinic curtain in rural spaces, we discover the various complex pieces that contribute to the larger health care jigsaw puzzle associated with these contraception injections. For starters,most clinics in rural areas don’t have more than one doctor in attendance, who hold consultations every other day. Activists argue that the government has no required standards for NGOs in terms of care, follow-up or accountability. Follow ups are required for patients using Depo-Provera, along with close monitoring of side effects as they start to show—neither of which are done owing to lack of knowledge, resources and all round interest of the medical staff. And this bleak picture of low resources, mediocre infrastructure and patients in the hundreds, even thousands, on a daily basis is grounds for finger-pointing at government hospitals, but patients’ lack of interest, under staffing and overworking are also cogs in this problematic wheel.

Informed consent and educated choices: An upper-class privilege?

In 1985 Patancheru, Andhra Pradesh, poor and illiterate women were used in a clinical trial for the injectable contraceptive NET-EN. And this, without providing them with all the information, which lead to several protests and the filing of a writ petition in the Supreme Court. After this uproar, several women’s groups have been closely monitoring any other violations of informed consent, and this hawk’s eye has uncovered similar discrepancies in the system.

A study conducted by Sama in 2003 revealed that women in New Delhi were put on injectable contraceptives in a public health set-up. And yet again, the information provided was insufficient. As advocates of voluntary birth control, we maintain that women have the right to control their fertility in a safe and controlled manner, be it contraceptive pills, injections or even the highly-debated voluntary abortion. And in this arena, health safety is the responsibility of the doctor in charge of their care.

While it’s true that both men and women have contraceptive methods available to them, women have been the main targets for most of these. Interestingly, Depo Provera was initially meant to be a contraceptive for men. But, due to side effects such as loss of libido, it was promoted to women instead.

To conclude, we quote from Betsy Hartmann’s book titled Reproductive Rights and Wrongs: The Global Politics of Population Control, which states, “the family planners plan, the contraceptive deliverers deliver, the acceptors accept. What could be simpler? The people on top decide what is best for the people on the bottom. Thus family planning becomes a profoundly technocratic exercise. This is no accident, but rather the direct outcome of three decades in which the philosophy of population control has won intellectual and political ascendancy.”

[Read Menaka Rao’s report for The Ladies Finger to gain more insight on this issue.]