Interesting article describing the “rapidly changing” post-mating habits of our Hindustani friends posted in Boston.com . After the article I provide some select information on morning-after contraception from an article “Emergency contraception: America’s best kept secret” by By Mardia Harris Stone, MD, MPH, Elizabeth Westley, MPH, and Vanessa E. Cullins, MD, MPH.
NEW DELHI – A college-age woman, dressed in traditional Indian clothing with her hair in a long braid, nervously whispers into a phone that she needs to find an abortion clinic. The next scene of the popular Indian TV ad shows the woman and a friend peering into a dimly lit alley as a voice-over says, “It’s better to take an I-pill and avoid the quandary of an abortion.’’
The candor of the advertisement is a sign of dramatic change in India, whose traditional society still frowns on public displays of affection. Sexual behavior is increasingly openly discussed – and prevalent. As the nation’s economic boom draws growing numbers of young people into the workforce, they are leaving the confines of family, moving to big cities and often declaring their independence through sex.
Doctors report that use of the I-pill, which can prevent pregnancy if taken within 72 hours of unprotected sex, is soaring. But they also worry that young women are misusing the pill by taking it too often or in place of contraceptives.
“In India, it’s almost like girls are gulping I-pills,’’ said Yash Bala, a gynecologist outside New Delhi. “The biggest problem with this is that girls are not concerned about whether their partner uses a condom.’’
Many young women report using the emergency contraceptive pills several times a month instead of using condoms, increasing the risk of contracting sexually transmitted diseases, gynecologists say. This year, dozens of ads for the I-pill, also known worldwide as the morning-after pill, have flooded Indian TV channels, highway billboards and women’s magazines.
Meher Malik, a belly-dancing teacher in New Delhi, has used the I-pill twice. She said many of her friends also have used it, some of them far more often.
“They definitely want to take the pill if they think that something went wrong last night,’’ said Malik, 21, who is single. “I think it is very apt for today’s generation.’’
Many gynecologists and health workers say that the pills have helped women avoid abortions, which are legal in India but are often performed by untrained workers in unsanitary conditions. Health workers say the pill’s availability also empowers women, who face many hurdles in the country’s tradition-bound, patriarchal culture.
As many as 7 million abortions are performed in India annually, and more than 20,000 women die of botched abortions each year, according to the Mumbai-based Federation of Obstetric and Gynecological Societies of India. The group says that the number of deaths is probably higher in reality because many families and health workers are afraid to report them.
“In India, women are now getting their own identity. They want to make decisions on their own – about financial matters, about their career, and about when they have a baby,’’ said Ajay Pal Singh, a psychiatrist. “The big difference is now they don’t need to go to their family members or anyone. They can go straight to the chemist and buy the pill.’’
Since August 2007, when the Indian pharmaceutical company Cipla launched the I-pill, which costs less than $2, about 200,000 units of the drug have been sold every month.
“Sometimes, for products, getting the timing right is critical,’’ said Arvind Sharma, chairman of the Indian subcontinent division of the advertising firm Leo Burnett in Mumbai. “There has been change in lifestyles, there has been a lot of migration from small towns to big towns. This pill is a symbol of that change.’’
Few restrictions have been placed on the pill’s availability. In interviews, several high school and college students in New Delhi and Bombay said they were using I-pills but not informing their parents.
“I think when used with discretion, it’s a huge tension reliever,’’ said a fashion design student, 20, who spoke on the condition of anonymity to preserve her privacy. She said she recently used it three times in one month. She said she doesn’t want to get married for several years and wants to wait a while after marriage to have children.
Scientists remain uncertain about the side effects of using the emergency pill frequently. Its counterpart in the United States, known as Plan B, is available over the counter, but only to women 18 or older. The drug prevents the implantation of a fertilized egg in the uterus. It does not terminate an existing pregnancy but is opposed by many antiabortion groups.
And selected from the article “Emergency contraception: America’s best kept secret” by By Mardia Harris Stone, MD, MPH, Elizabeth Westley, MPH, and Vanessa E. Cullins, MD, MPH.
When taken within 72 hours (3 days), emergency contraceptive pills (ECPs) can reduce the risk of pregnancy by 75% to 89% after a single act of unprotected sex. While we do not fully understand how ECPs work, we do know that they inhibit ovulation and may, in select instances, prevent fertilization or prevent or impair implantation. Unfortunately emergency contraceptives do not protect against human immunodeficiency virus (HIV) or other sexually transmitted diseases.
Possible indications and contraindications
Emergency contraception is appropriate when no contraception was used or when intercourse was unprotected due to contraceptive accidents. The principal indication is unprotected intercourse for any reason; that would include when a male condom breaks, slips off or leaks; when a female condom is incorrectly inserted or removed or is dislodged; when a diaphragm slips out of place or is defective; when the penis or condom is withdrawn too late; when the patient forgets to take two or more birth control pills in a row; when the regular dose of injectable contraceptive is delayed for more than 2 weeks; and when a couple has not abstained from sex on a fertile day of the cycle. Other possible indications are an IUD that has become partially or completely expelled; exposure to a drug that may harm the fetus; and rape.
Since pill regimens involve only limited exposure to hormones, hormonal ECPs are safe for any female who has achieved puberty. Fears about estrogen-related adverse events are unwarranted. ECPs have not been shown to increase the risk of venous thromboembolism (VTE), stroke, myocardial infarction, or any other vascular or cardiovascular event. While confirmed pregnancy is listed as a contraindication, current FDA-approved regimens are neither abortifacients nor teratogens; hormonal forms of EC will not disrupt an implanted pregnancy and if taken during an established pregnancy, will not cause birth defects.
Attitudes toward ECs vary widely
While it’s evident that ECs are readily available in some parts of the world, awareness and utilization varies widely from country to country and among various cultures—a fact that needs to be kept in mind when counseling patients about ECs. For instance, women in the United Kingdom are more aware of EC, use it more often, and have greater access compared to women in the US. By contrast, in Nigeria, almost one quarter of surveyed women (23%) were afraid that infertility is a direct consequence of EC and that it may also induce abortions. Moral or religious beliefs also kept some Nigerian women from using the method. Such misinformation emphasizes the importance of increasing public awareness about EC and points to information that should be highlighted during counseling dialogues. Women should understand the safety, efficacy, and the experiences of other women. Concerns and fears should be discussed with sensitivity and reassurance.
Until EC awareness is widespread and the drug is widely available over-the-counter, the biases of health- care providers will also influence access to and widespread use of this option. Some reports indicate that clinicians are concerned that women might abuse EC. Studies indicate that this paternalistic concern is wrong.
When available through advance prescriptions or pill regimens or by direct provision through pharmacists, phone prescription or over-the-counter, EC gives women a convenient, private, and cost-effective contraceptive option. Furthermore, giving ECPs in advance or as advance prescriptions would significantly reduce doctor and clinic visits and emergency telephone calls to providers, thus saving treatment costs for the patient, provider, and third-party payor.
Increasing public awareness about EC exceeds the capabilities of schools and health-care providers. We need strategies that will make all sectors of the population aware of this option through the media, through patient information booklets, pamphlets or fliers, and by means of an extensive distribution network. Getting the word out through word-of-mouth between friends and family members should be encouraged by all health-care providers.
It’s especially important for women to be made aware of the 72- to 120-hour time frame in which pill therapy is most effective. In addition, the public should understand that emergency contraceptive methods are safe, effective, and do not induce abortion. While it is necessary to introduce the concept of EC to men, one study shows that women are concerned that safe sexual activity may become a problem because men might use their knowledge to neglect using condoms and pressure women into having unprotected sex.
In our view, ECPs should be available over-the-counter. Until such time, all health-care providers serving adolescents and women of reproductive age should routinely assess the need for, counsel about, and provide easy mechanisms for women to obtain EC.
Tej Deol, M.D.
