His M.O.

By, Diepiriye S. Kuku-Siemons

The people in the front row mumbled amongst themselves, and peered around to take a good look at him, but said nothing. The couple next to him shifted in their seats each time it happened, but also could not be bothered to confront him. The gentlemen on the other side of him continually cleared their throats in an abrupt attempt to silence him. His mobile phone rang endlessly; after the third time the other moviegoers were tiring of being disturbed.

It was the same each and everywhere he went. His mobile phone had to ring. He had chosen a piercingly loud ring tone whose volume increased with every ring. In the car, he would take calls while cruising along the city streets. He had several mere brushes with bikes, motorcycles and auto rickshaws. While yelling at a telemarketer who tried to swoon him to another mobile service provider, he had once tipped a cow, making a narrow escape before the ensuing mob. Every since that near miss with a tractor after coming home from a disco one late evening, his girlfriend had hissed at him not to speak on his mobile while driving. He was bold, and determined to do as he wanted whenever he wanted, no matter how many people he inconvenienced.

He behaved as if he were the boss of anyone in anyone that he entered. His general modus operandi was to enter a room while speaking loudly on his mobile about the most mundane of things, trying to sound nonchalant as he divvying out instructions to each and every person is sight. Once he had walked into a lunch meeting at a posh new restaurant and barked out his drink order to his new boss’s husband, taunting him when he protested! He had gall.

His mobile phone was his expensive prop that he used to announce his power and demand respect. He loved when his phone rang in public places, and enjoyed the attention he received when folks glared at him whenever his loud mobile chimed in public places. Yet, for all of his nerve, his sex life suffered. For all his audacity to disturb the peace, he really did lack courage. In fact, it was all a cover. For, when it came to getting down to the act, he was a total flop. There was no mobile company, no loud ringtone to ring that would compensate for the fact that he could not bring himself to walk into a chemist and ask for a condom. This was his real M.O.

The Broomstick Method.

“And she still became pregnant. Now, what should I do?” The man was simple, yet earnest in his inquiry to the NGO staffer. The staffer had shown the simple man how to use a condom, succinctly and thoroughly. The demonstration even concluded with all of the participants showing what they had learned: How to correctly store, open, use and dispose of a condom. The staffer even gave a few specific pointers about conquering embarrassment around getting a condom from the local pharmacy. In fact, the simple man was so excited that he and his wife finally had a virtually foolproof method of avoiding pregnancy.

The simple man had told the group of peers gathered by the NGO to learn about men’s responsibility in birth control that he and his wife regularly have open and frank discussions about the matter. Regardless of the couple’s decision to wait several years after their marriage before having their first child, and several more still before possibly having a second child, the methods they had used in the past were unsuccessful. Moreover, the second child was born just two years after the first one, and his wife felt that she had not even fully recovered from nursing and looking after the first.

A health worker had taught the simple man, his mother and his wife the importance of breast feeding exclusively for the first six month and as long as possible even after introducing food. The couple understood that breast-feeding not only gave strength to the child to fight off disease, but it also served to help her space pregnancies. The simple man’s wife complained that she felt weak for months after the first and second births and though she was able to rest, eat well and quickly recuperate, she was not anxious to repeat the ordeal. When she became pregnant again, she resided to give her all given the situation, but worried about her health and that of the coming child. The health worker had also made clear to the couple the possible dangers of closely spaced births.

Only the husband’s mother cheered at the news of both the second and third pregnancies. The mother-in-law chided that the family desperately needed a son, and that having two girls was simply a waste. After all, the mother-in-law had given birth to four girls, all closely spaced, before she finally took things into her own hands and had a son. The simple man’s mother resented his wife and constantly insulted her for not having a son soon enough and that his wife even had the audacity to space her births- making it less likely, the mother-in-law incessantly criticized, of gifting a son to her in-laws. She blamed the wife for corrupting her son with foreign ideas of birth spacing and doting on having a girl-children. The simple man’s wife really suffered from the constant tongue-lashings; she convinced herself that the only way to save her sanity was to immediately have a son.

The couple had tried this new method, condoms. The simple man diligently fetched a new broom from the market. He had meticulously chosen a fancy, ‘foreign’ style broom with a smooth handle, just like the one the health worker had used in what turned out to be the first time that many of the participants had ever seen a condom. The simple man had paid close attention to the demonstration and took mental notes of each step. “Squeeze the air out of the tip,” he reminded himself over and over, and “Don’t use hair or cooking oils as this could break the condom.” He explained to his wife each step of using a condom, almost as if he were training her as a trainer. He was even patient enough to entertain the myriad of questions his wife posed about the condom, like “Why is it so slick,” and “What kind of magic is this western know-how?”

The simple man and his wife carefully sat the broom next to the bed after having carefully placed the condom on top and rolled it down. “This will protect us, and we can easily enjoy,” they said. It was only a short time before the simple man’s mother noticed differences in his wife. She suspected that another grandchild would be coming soon, and started praying for a boy. It was she who broke the news to the simple man that his wife may finally be able to prove herself to the family by giving them a son. Overhearing this, the wife was in tears. The couple had invested a great deal of trust in condoms, and the “broomstick method,” as she and her husband had grown to call it over the months, had failed.

Men as family planning stakeholders

Despite the fact that men are often the decision-makers in family planning matters, many studies suggest that men lack sufficient knowledge about family planning, spacing, and the variety of available contraceptives to make life-affirming, informed choices. Advancement and adoption of contraceptive technology demands male support. Women should expect support from partners and kin in her environment to understanding and coping with the responsibility and changes in menstrual cycle accompanying a variety of methods of contraception.

There are a variety of broader implications surrounding male responsibility and involvement in family planning. A study published in the Journal of the American Medical Association of 6,695 husbands aged 15-65 in the state of Uttar Pradesh revealed that men with less than five years of formal education, had more than one child, or were classified as extremely poor were factors that were all independently associated with elevated odds of (self-reported) incidence and frequency of abuse.

Both pre- and extra-marital sex, symptoms of STIs and unplanned pregnancies account for elevated odds of physical and sexual spousal abuse, even when controlling for social and demographic factors. In fact, “Abuse was more common among men who did not practice contraception than among those who did (49% vs. 42%), and was reported more frequently by men who had experienced an unplanned pregnancy than by those who had not (52% vs. 44%).” The study indicated that each variable was most strongly associated with nonconsensual sex without physical force.

Respond.
There are a plethora of policy, advocacy and intervention responses that readily emerge from these findings. First, rejecting violence as a means of conflict resolution and expressing power, particularly in family dynamics, is a worthy, long-term aim that must underscore any effort thereafter. Next, expanding access to contraceptive knowledge and technology synergistically increases life-choices for both men and women; this is a step towards raising standards of education and reducing poverty- both of which positively correlate with reduced spousal abuse and increased contraception acceptance and use. Then, alleviating the mal-effects of poverty lessens the unnecessary burden carried by women and allows men to assume greater responsibility for their lives.

Unwanted pregnancy and sexually transmitted infections decrease the overall quality of life of both partners. Behavior Change Communication efforts to thwart these factors must target both men and women accordingly. The eventual outcome enhances the lives of women and families overall. Expanding the basket, knowledge, availability and usage of contraceptives must consider both women and men, and the synergy in focusing on the empowerment of all genders. Behavior Change Communication can address both the immediate symptoms and eventual outcomes towards reproductive justice, exploiting the links between male responsibility, various forms of abuse and contraceptive acceptance.

Choosing to Involve Men in Family Planning.

The abundance of interventions and Behavior Change Communication campaigns that all primarily target women for family planning seemingly relieves men of the responsibility. Advances in contraceptive technology, such as the introduction of female condoms, injectable contraceptives and progestin only pills, imply a void in research and development of contraceptives that focus on male anatomy and physiology. This apparent irrelevance of men in turn creates even less space for the involvement of men in family planning.

Men often dominate the decision-making process whereby couples seek information about, or adopt any traditional or modern method of contraception. Further studies from India indicate that men overwhelmingly initiate discussions with their partners about contraceptives, and may “respond adversely” should the female partner do so. Research repeatedly exposes the links between male support and continuation of a variety of female-oriented contraceptives. (IPPF, 1984; Wambui, 1994)
Synovate India, a research firm, conducted a campaign tracking study in 2005-2006 in north Indian cities involving 1645 males aged 20-29. Theirs and other studies show that men who act responsibly in one way are likely to carry this attitude over to other areas of their lives. For example, men who accept the contraceptive usage are less likely to abuse their wives; increasing the pool of men in either regard positively influences the other. (IFPP, 2000) Men are stakeholders in family planning.

Many women in urban India find condoms unprocurable due to harassment at distribution points, or even greater embarrassment directly associated with female sexuality. In addition to Synovate’s study mentioned here, an array of quantitative studies suggest that male embarrassment hinders the procurement by men of condoms, the only contraceptive that offers dual protection against both unwanted pregnancy and the transmission of sexually transmitted infections and HIV/AIDS. Taken together, both women and men face social hurdles to procuring condoms, creating a barrier for reproductive justice.

These and similar studies in urban and per-urban India reveal widespread misconceptions about contraceptives among males who are often primarily in charge of decisions concerning family planning. (Khan, 1997) Such environments are non-conducive to dialogue between spouses or partners regarding the reproductive health of either partner; consensus building with spouses or partners regarding their reproductive goals does not exist.

Initial family planning efforts focused on risk reduction associated with pregnancy. These risks have included maternal mortality, excessive child-bearing, unwanted pregnancy, socially enforced pregnancy, emotional sexual abuse, lack of birth spacing, mother-to-child transmission of HIV/AIDS, female feticide and infanticide. Moreover, each risk carries its own set of psychosocial traumas, which largely remain unacknowledged and treated.

Family planning must target men alongside women to take greater responsibility for care towards their partners to conquer mutually undesirable gender-skewed reproductive outcomes such as abuse, sexually transmitted infection, unwanted pregnancies as well as maternal and child mortality.

Men as family planning stakeholders
Despite the fact that men are often the decision-makers in family planning matters, many studies suggest that men lack sufficient knowledge about family planning, spacing, and the variety of available contraceptives to make life-affirming, informed choices. Advancement and adoption of contraceptive technology demands male support. Women should expect support from partners and kin in her environment to understanding and coping with the responsibility and changes in menstrual cycle accompanying a variety of methods of contraception.

There are a variety of broader implications surrounding male responsibility and involvement in family planning. A study published in the Journal of the American Medical Association of 6,695 husbands aged 15-65 in the state of Uttar Pradesh revealed that men with less than five years of formal education, had more than one child, or were classified as extremely poor were factors that were all independently associated with elevated odds of (self-reported) incidence and frequency of abuse.

Both pre- and extra-marital sex, symptoms of STIs and unplanned pregnancies account for elevated odds of physical and sexual spousal abuse, even when controlling for social and demographic factors. In fact, “Abuse was more common among men who did not practice contraception than among those who did (49% vs. 42%), and was reported more frequently by men who had experienced an unplanned pregnancy than by those who had not (52% vs. 44%).” The study indicated that each variable was most strongly associated with nonconsensual sex without physical force.

Respond.
There are a plethora of policy, advocacy and intervention responses that readily emerge from these findings. First, rejecting violence as a means of conflict resolution and expressing power, particularly in family dynamics, is a worthy, long-term aim that must underscore any effort thereafter. Next, expanding access to contraceptive knowledge and technology synergistically increases life-choices for both men and women; this is a step towards raising standards of education and reducing poverty- both of which positively correlate with reduced spousal abuse and increased contraception acceptance and use. Then, alleviating the mal-effects of poverty lessens the unnecessary burden carried by women and allows men to assume greater responsibility for their lives.

Unwanted pregnancy and sexually transmitted infections decrease the overall quality of life of both partners. Behavior Change Communication efforts to thwart these factors must target both men and women accordingly. The eventual outcome enhances the lives of women and families overall. Expanding the basket, knowledge, availability and usage of contraceptives must consider both women and men, and the synergy in focusing on the empowerment of all genders. Behavior Change Communication can address both the immediate symptoms and eventual outcomes towards reproductive justice, exploiting the links between male responsibility, various forms of abuse and contraceptive acceptance.

References

Digest.
• India Men with Higher Socioeconomic Status are more likely to be knowledgeable about Reproductive Health. Volume 26, No.3, September 2000.

International Family Planning Perspectives.
• In India, Poverty and Lack of Education Are Associated with Men’s Physical and Sexual Abuse of their Wives. Volume 26, No.1, March 2000.

International Planned Parenthood Federation.
• Male Involvement in Family Planning. 73–76, 79–80. 1984.

Khan, M.E. and Patel, Bella C.
• Male Involvement in Family Planning: A KABP study of Agra District. Final report. The Population Council, India. June 1997.

Martin S.L et al.
• Sexual behaviors and reproductive health outcomes: Associations with wife abuse in India, Journal of the American Medical Association, 1999, 282(20): 1967-1972.

Population Council.
• Maternal and Child health. Mixed Success Involving Men in Maternal Care Worldwide. Population Briefs- reports on Population Council research. Volume 11, No.1, January 2005.

Touré, Lalla MD, MPH.
• Male Involvement in Family Planning: A Review of the Literature and Selected Program Initiatives in Africa

Wambui, Catherine.
• Male Only Centers: A New Concept in Family Planning. Published in Conveying Concerns: Women Write on Male Participation in the Family, Population Reference Bureau, Inc.: 18–19. 1994.

Zavier, Francis and Padmadas, Sabu S.
• Use of a Spacing Method before Sterilization Among Couples in Kerala, India. Volumbe 26, No.1, March 2000.

WOMEN, FREEDOM OF CHOICE and CONTRACEPTION?

By Diepiriye S. Kuku-Siemons

In examining the issue of freedom of choice, several factors must be taken into account. An Indian woman's reproductive decisions are influenced by societal factors which include the social, political and economic context in which she lives and the gender norms that shape her life. Also to be taken into consideration is a woman's life cycle stage and other socio-demographic characteristics that govern her contraceptive use, her childbearing experience and the three domains of her life - family, community and individual.

The majority of women in India are married off at a young age, sometimes even before they are able to understand the bodily changes that accompany puberty. As soon as she is married, family members pressured her to prove her fertility by getting pregnant before the first year of her marriage has lapsed. In most cases, if her first issue is female, she is again subjected to great pressure to produce a male progeny. This vicious cycle of events hinders a woman from educating herself about contraceptive use, the choices available to her, the methods she can use to effectively space her children and how she can conserve her own health, maintain a balance between household chores and child-bearing and manage her various roles effectively to the satisfaction of her husband, in-laws, and herself.

Whether she is an urban woman or from a rural area, she is most likely unaware that she can seek advice from her doctor. This is mainly due to a lack of awareness since most government programmes and campaigns are run sporadically. Moreover, there is little involvement of private practitioners in educating/ counseling a woman on her reproductive health options.

Only a very limited number of Indian women have the opportunity to choose whether or when to have a child. Women, particularly women in rural areas, do not have access to safe and self-controlled methods of contraception. The public health system emphasizes permanent methods like sterilization, or long-term methods like IUD's that are provider dependent and require trained (health personnel). In fact, sterilization accounts for more than 75% of total contraception, with female sterilization accounting for almost 95% of all sterilizations. (Office of the United Nations Resident Coordinator in India, 2001)

The idea of contraception is that it should be seen as a pillar of reproductive health rather than a means of population stabilization. Ideally, it should include spacing, safety and the health of mother and child. Presently, a plethora of contraceptive methods that are available India, with newer options intermittently introduced. There are oral pills (both low dose combined oral contraceptives and progestin-only contraceptives), the DMPA injectable contraceptive (which is excellent for mid-term spacing),Norplant implants, Intrauterine Devices (IUD's), condoms, vaginal creams and spermicides, and terminal methods such as female sterilization and vasectomy. Users have a range of methods of contraceptives from which to choose. But the question is, 'Can they make an informed choice? 'This means, when a person makes a freely thought-out decision based on accurate, useful information, it is called informed choice. How many couples have access to such information?

There are multiple benefits from informed choices: People use contraceptives longer if they choose the methods for themselves; access to a range of methods makes it easier for users to choose a method they like and to switch to other methods whenever needed. What's more, this process initiates a trusting partnership between users and providers and enables individuals and families to take more responsibility for their own health.

To make informed choices, people need ample, easy to grasp information about methods of contraception. An informed choice requires access to a range of methods and support for individual choice from social policies and community practices. The outcome should be a free, informed, conscious decision by the individual about whether or not she or he desires to obtain contraceptive services, and if so, what method or procedure she or he will choose and consent to receive!

The solution lies in providing information on safe, effective and tested contraceptive methods that have been used successfully in countries throughout the world. It also means a concerted effort by medical practitioners in the public and private sectors to disseminate correct, comprehensive and user-friendly information to women in the child-bearing age about the contraceptive options available to them. It further requires greater male participation in matters of maternal health, spacing and contraception as well as respectful dialogue amongst partners. Finally, it means that limiting family size is not the only objective, rather, complete reproductive health should be the target - which includes safe pregnancy, the well-being of mother and child, spacing options which allow a woman to plan her family effectively, general gynecological care, protection from sexually transmitted diseases (STD's) and their proper diagnosis and treatment. An underlying factor is improvement of the quality of counseling services to help women understand their reproductive requirements.

The increasing number of abortions proxy as evidence of widespread unmet needs for contraceptive methods and their apparent unavailability or inaccessibility. Therefore, the need for more options is already imperative. Meeting these needs permits women to exercise their reproductive rights and choose appropriate options from a basket of contraceptive choices.

A Contraceptive Bonus

By, Diepiriye S. Kuku-Siemons, MPH

Most urban women are preoccupied with the many roles that they have to play as homemakers. The decision to use contraception is often taken hastily, without knowledge and consideration of the many options that are now available. Whether a combined oral contraceptive or a hormonal patch, an injectable or a condom, most women are unaware that most contraceptives have benefits attached to their usage, over and above the function of preventing unwanted pregnancy.

Many of these benefits are not health-related, and provide beauty and skin enhancement, a feeling of well-being, a release from tension, secure in the knowledge that they are protected from unwanted pregnancies. Regularizing of an unpredictable monthly period, improvement in acne and a glowing skin due to the hormonal content of the contraceptive, and protection from osteoporosis are just some of the non-contraceptive benefits that hormonal methods.
Many non-contraceptive benefits- Many methods available today!
Women who take the combined oral contraceptive pill are helping prevent ectopic (tubal) pregnancies, ovarian cysts, endometrial cancer (cancer of the lining of the womb), ovarian cancer, pelvic inflammatory disease and benign breast disease.

The biggest advantage for women who take the 3-monthly injectable DMPA is that it does not affect the quality and quantity of mother's milk. Therefore, nursing mothers as early as six weeks after childbirth can use DMPA. Injectable contraceptives also do not have any estrogen side-effects. They do not increase the risk of estrogen-related complications such as heart attack. In addition, injectables provide protection from iron deficiency and to help prevent ectopic pregnancies, endometrial cancer, uterine fibroids, as well as ovarian cancer. For those women suffering from epilepsy and sickle cell, DMPA may reduce the frequency of seizures and sickle cell crisis and even reduce the pain associated with the episodes.

The most significant advantage of using condoms is their high effectiveness in preventing sexually transmitted infections (STI's), including HIV/AIDS, when consistently and correctly used during intercourse. Condoms are safe and have no hormonal side effects. Condoms also prevent pregnancies. Further, condoms safeguard against exposure to STI's and even HIV/AIDS that either partner may not even be aware of carrying.

These are just some of the benefits attached to contraceptive usage. Every method has its share of advantages and disadvantages. Ultimately benefits of using a particular method differ from person to person and depend on the physical and mental make-up of the person using the method. Through raising awareness and spreading comprehensible information and availability of options, consumers are able to make knowledgeable reproductive health choices.

Heinous Histories collide: Down but not Out.

By, Diepiriye S. Kuku-Siemons
May 2006

Thalidomide was sold in the 1950s as a sleep aid and as relief for morning sickness associated with pregnancy. Originally manufactured by Grünenthal in northwest Germany, the drug was sold in over 50 countries worldwide. Usage of the drug spread like wildfire as pregnant women finally found concerted relief from the myriad of hormonal effects on the body during pregnancy. Until 1960, it was for many a wonder drug. For others it was a nightmare. Recent research is shedding new light on the drug.

Thousands of women gave birth to children with missing or stunted limbs. Discursive reports from around the globe suggested a link between the drug and infants born with stumps instead of limbs. In a total vacuum of empirical evidence proving thalidomide’s link to birth defects, in 1960 Grünenthal sought to expand its market to the United States. Though reports of birth defects associated with thalidomide emerged from around the globe, FDA approval of the drug was initially thought to be facile, if not for one persistent newly appointed FDA reviewer, Frances Oldham Kelsey. Her persistence earned her the highest civilian award in the United States, the President’s Award for Distinguished Federal Civilian Service.

Drug manufacturers, quick to regain public confidence in their products and ethics, looked towards extensive testing on animals before introducing innovations to human testing and later for FDA approval. As a result of the lack of extensive knowledge about thalidomide’s adverse effects on the human fetus, lack of adequate legislation and monitoring of testing, as well as flagrant negligence on the part of the profiteers at the time, many countries passed new laws that required extensive animal testing of pharmaceuticals.
Thalidomide and DMPA
In 1998, the FDA approved thalidomide for the treatment of erythema nodosum leprosum, which is associated with Leprosy or Hansen’s disease. Thalidomide has also proven an effective treatment as a first line therapy in combination with dexemathosone for multiple myeloma. Research is already underway to investigate premature indications of the efficacy of thalidomide (1) in treating HIV-related symptoms, prostate cancer, gliblastoma, lymphoma and Crohn’s disease. Since 2002, Australian researchers have found a doubling of T-cells in 224 cancer patients, promoting the body’s autoimmune response to attack cancer cells.

Despite the newly discovered efficacy of thalidomide, many clinicians are reticent to prescribe the drug to women, given its tainted past. Many medical providers refuse to administer thalidomide to any female of fertile age regardless of the suffering from the very cancers or inflammatory diseases where thalidomide is showing great promise. Sufferers of Behcet's Disease, for example, where symptoms may include debilitating internal ulcers, find relief from thalidomide. A myriad of treatments have failed to relieve these symptoms, rendering many wheelchair bound.
Hope.
There is hope. Some doctors have begun pairing thalidomide treatment with long-tern contraceptives for women of fertile age. Usage of Depo Medroxyprogesterone Acetate (DMPA), also known as Depo Provera, allows patients to benefit from thalidomide, since its 99.7% long-term efficacy alleviates concerns over the birth defects associated with thalidomide.
DMPA is the most pliable method of contraception to pair with thalidomide treatment. As a tri-monthly injectable contraceptive, DMPA eliminates the human error, inconsistency and non-compliancy associated with other methods such as oral contraceptives. Moreover, as opposed to permanent sterilization (e.g. tubal ligation), DMPA is reversible, making it a better option for women who wish to maintain the option to conceive at least four weeks after ending thalidomide treatment. (2) DMPA stimulates appetite, which is often a hurdle in cancer treatment and post-surgery recovery. (3) DMPA assures that both male and female sufferers of some of humanity’s most debilitating diseases can benefit from the most up-to-date advancements in medical research.


(1) http://en.wikipedia.org/wiki/Thalidomide
(2) http://www.fda.gov/cder/news/thalidomide.htm
(3) http://www.cancersymptoms.org/anorexia/medications.shtml

WHO reaffirms DMPA's safety!

By Diepiriye S. Kuku, MPH

More than 16 million women worldwide use DMPA (Depot Medroxy Progesterone Acetate) which is the third most prevalent form of reversible contraception.

DMPA has been one of the most extensively researched drugs with an accumulated clinical research experience of more than 3 million months and over 1000 published scientific papers and reviews since the 1960's.

In India, increasing the choices related to contraception is critical for programs striving to cater to unmet family planning needs. According to a study on DMPA undertaken by the United Nations Population Fund, India (UNFPA) in October, 2004, "Over the past few decades, there has been a substantial increase in the use of contraceptives in India." As per the Rapid Household Survey results (2002), use of modern contraceptives is nearly 46 percent. Another 6 percent of couples use traditional methods. Despite impressive gains, several issues continue to hinder progress. A significant proportion of pregnancies continue to be unplanned: Contraceptive needs of millions of couples remain unmet; several population groups, such as adolescents and men, continue to be ignored or underserved; and contraceptive choices remain conspicuously absent, as is quality care within the program. The National Population Policy (2000) affirms the Government's commitment to address unmet demands of contraceptives by making safe, effective contraceptives accessible to people.

A perusal of method-mix clearly shows a burdening of women insofar as contraception in general, and a bias towards female sterilization. Overall, sterilization accounts for three-quarters of contraceptive use. The current use of reversible methods is low at 10 percent. Use of injectable contraceptives is negligible, although in many countries in the world injectables contribute significantly to helping couples to achieve their reproductive intentions.

There is empirical evidence to indicate that the addition of any new method in the program will increase contraceptive uptake. Research clearly suggests that a choice of several contraceptive methods is more likely to result in contraceptive use. As quality improves and more methods become available, more couples use contraceptives. For each additional method that is widely available in a country, contraceptive prevalence increases by an average of 3.3 percentage points. Recent studies have shown that 28 percent of Indian women do not want more than two children and 9 percent of all recent births/pregnancies are unplanned. Further, 13 percent women reported that they would like to wait for two years before bearing another child. Thus there is significant unmet need for spacing and reversible methods of contraceptive.

DMPA fills all the above gaps and can be considered as an additional contraceptive choice for Indian women. There is no method of contraception free of non-contraceptive effects. In the case of DMPA the most common concerns are related to changes in bleeding pattern, return of fertility and the schedule of injections for continued protection from pregnancy. The fact is that many women take relief in the reduced menstrual cycles. The key to all these concerns is proper counseling by providers to inform and reassure users about the bodily changes that occur and the return to fertility after discontinuation of the method.

Recently however, issues relating to loss of bone mineral density (BMD) with use of DMPA have been raised. Women in India and around the world lose BMD during pregnancy and lactation. This loss is reversible and not significant enough to cause osteoporosis. Studies have reported that BMD is typically regained postpartum following resumption of menstruation, although whether it returns to pre-pregnancy values has yet to be established.

The World Health Organization (WHO) recently released a statement on Hormonal contraception and Bone health that recommended that there should be no restriction on the long - term use of the combined oral contraceptive and the 3-monthly contraceptive injection, DMPA, among women aged 18 to 45 who are otherwise eligible to use the method.

According to the statement, hormonal contraceptives including the injectables are highly effective and widely used. These contraceptives have important contraceptive and non-contraceptive health benefits. Ultimately, most women choose the health benefits of using a contraceptive over the insignificant risks associated with contraceptive use.

Injectable contraceptives are positioned as highly effective, safe, reversible contraceptives, most appropriately suited for delaying pregnancy after marriage and also to maintain the desired spacing between children.

Spacing - The key to better health for you and your family

Today's urban woman is increasingly taking charge of her own destiny. She is competent in her workplace and runs her home with efficiency. The week goes by in a whirl of activity encompassing work- both inside and outside the home- entertainment, kids and the hundred and one things necessary to keep everything running smoothly. Homemakers, too have hectic schedules, balancing the needs of her husband, children, her own needs, as well as those of other household members such as elderly parents-in-law. Joint families create further demands on women's lives and schedules.

Despite this whirlwind of activity, one area that often gets neglected in all this frantic activity is a visit to a trusted gynecologist. A woman has to begin taking decisions with regard to her reproductive health right from the start of her marital life. She and her partner need to carefully consider their desired family size. If several children are desired then adequate attention should be given to spacing methods that best fit her health needs and lifestyle. Once the family is complete, she and her husband should then consider adopting a method of contraception that is safe, effective and hassle free for years to come. Thus, it is important to have the right information on the myriad of contraceptive choices.

Increasingly various contraceptive options are available to couples during their reproductive years. Unfortunately, however, few couples are aware of their options and lack resources to gain such information. This is where the role of your gynecologist becomes crucial. He/she is the best person to consult for advice on the various methods, whether they would suit your body and your lifestyle and the pros and cons of each method, in order to make a well-informed decision.
There are many facts regarding contraception that you need to keep in mind before making a choice:

* First, it is important to separate fact from myth! Your physician is a wealth of information concerning the most up-to-date developments in family planning.

* Delaying first pregnancy and adequate spacing (ideally 3-5 years) is essential for the physical and mental health, development and wellbeing of you and your child.

* Every person is different! Accordingly, every woman responds differently to every method of contraception.


* Ease of use, discretion and convenience all differ for each method; hence, it is essential to find a method most suitable to your body and your way of life. For example, not all methods are appropriate for breastfeeding, and all are effective for different lengths of time.

Health professionals are great resources for accurate, unbiased information. Nonetheless, couples should take charge of contraceptive decisions and therefore consult several sources of information, including the Internet. Finally, it is important for both partners to reach a consensus about this crucial decision that affects the health and wellbeing of the entire family.

Reproductive Health Articles

Are you breastfeeding your baby? Tips for Lactating Mothers

By, Diepiriye S. Kuku-Siemons

You've just had a child- joy, excitement, worries, are all part of the process of welcoming the newborn into the family. The entire family participates in the initial chores required to make the baby comfortable and happy. The mother however, is the most preoccupied with her new offspring and the time required to take care of the infant. But, in order to ensure that your baby gets your undivided attention and grows up healthy, you need to be aware that ideally you should wait 3-5 years before your next child. But why? Many believe that lactation offers protection. This is a myth that most women believe and therefore they can get caught unawares with another pregnancy when they least expect it!

* During the period of lactation when the mother is breast-feeding her baby, she needs to know some facts about contraception so that she can protect herself from another immediate pregnancy:

* If the woman has not had her first menstrual period since childbirth and if she is fully breastfeeding her baby, she is unlikely to become pregnant during this period. This natural form of birth spacing is known as the LAM (Lactational Amenorrhea Method) of contraception.

* Women who are breastfeeding can start progestin-only methods of contraception as early as six weeks after childbirth. An important fact to remember is that the contraceptive should be estrogen free. Hence, progestin based injectables; condoms, Progestin Only Pills (also called "the mini pill") and IUD's are the best options. If she is not fully breastfeeding, she can use the Combined Oral Contraceptive, (also called "the pill") as well.

* The tri-monthly injectable DMPA can be started as early as six weeks after childbirth. The biggest advantage of this method is that DMPA does not affect the quality and quantity of breast milk or have any adverse effect on the health of the baby. DMPA is long acting and does not require daily action, nor is it coital dependent. Hence, mothers are freer to dedicate time and attention to her health and that of her newborn.

I'm actually feeling better!

Urban chaos is what sums up a modern woman's life in metropolitan cities. Early morning household chores, children and elders in the family to attend to, preparing for the day ahead, breakfast, tiffin to be packed, getting ready for office, the daily commute, dashing to shops to pickup some necessary provisions, dinner and homework, housework and entertaining - its an endless whirl of activity!

Today's urban woman is becoming increasingly independent and wants to enjoy a hassle-free life. She takes many important decisions in order to make her life smoother and free of unnecessary complications. If she is a working woman, with hectic work schedules, which includes outstation travel, she has to organize her home front in such a manner that things function smoothly even in her absence. This means getting reliable servants and training them extensively to cook, clean and look after the needs of the children. It also means organizing efficient school transport so that the child is taken care of when in school as well as when she returns home.

An important decision the modern urban woman has to take early in her married life is the number of children she and her husband would like to have and the spacing they want between the children. For this, they have to consider many factors such as the maternity leave to which the mother is entitled, the baby's healthy rearing and the mother's health and well-being so that she can continue to look after her home and office duties efficiently after her delivery.

In all this activity, does a woman have time to think about her reproductive needs? Carelessness about contraceptive requirements could result in an unwanted pregnancy just when neither the woman nor the couple is ready to take up the responsibilities of parenting.

Taking a decision about which contraceptive to use and when to use it are unsolved puzzles in the reproductive history of most Indian families, of which women bear the greater responsibility both socially and technological. To whom should women turn for accurate and tailor-made advice for their reproductive needs and responsibilities? The best option is to consult a qualified nearby gynecologist. Once the doctor has listened to the woman's history and the pattern of contraceptive use, if any, he/she can advise on the mode of contraception that best suits the woman's health and well-being at that particular juncture in the couple's married life.

Countless urban women users of safe and convenient methods of contraception have expressed their relief and satisfaction in their choice of contraception by saying, "My doctor suggested various methods. She told me about the Pill, Condom, Injection, Copper T, etc. but I find the Injection more suitable for me because it is hassle free and effective. We are tension free now, that there will be no chances of my getting pregnant. It will not limit the satisfaction and happiness level of being with my husband."

Today's woman has many more contraceptive options available to her than her mother had, and she can select a method or a combination of methods that are suitable for her health and lifestyle.

Combined Oral Contraceptive

* The COC or combined oral contraceptive contain very low doses of hormones which are similar to the natural hormones in a woman's body.

* They are very effective if used regularly and fertility returns soon after stopping the pills.

* The disadvantages include the hassle of remembering to take a pill each and every day, mood swings and depression in some cases and discontinuation during lactation as it effects the quality and quantity of the mother's milk.

The three monthly injectable contraceptive-DMPA

* It is a safe, effective, reversible and private method of contraception, ideal for spacing families.

* DMPA is very effective for lactating mothers as it does not affect the quality and quantity of the mother's milk.

* It is hassle-free as it is administered as a muscular injection once every three months.

* The side effects are reversible, including irregular bleeding, which may lead to temporary stopping of periods or delayed return to fertility.

In addition to these methods of contraception, it is important to know about emergency contraception as well, incase a couple has had unprotected sex or if a woman has forgotten to take her pill or in cases of condom failure. The important thing to remember here is that this is not a regular method of contraception but an emergency measure to stop pregnancy.

The Emergency Contraceptive

* This is to be used only in an emergency when a woman has had unprotected sex and is an effective way to stop an unwanted pregnancy.

* It can also be used after an incidence of sexual violence or rape and be effective in preventing pregnancy.

* These are effective if taken within 72 hours of unprotected sex.

* The Government of India has recently made this available 'over the counter' in a bid to reduce unwanted births. This means that a woman does not need a doctor's prescription to buy the pills from any chemist.


All the above methods can be used by a liberated, urban woman to prevent unwanted pregnancy and some prefer to use a method such as the injectable DMPA as one shot provides protection for three months. Besides, there are many non-contraceptive benefits connected with taking hormonal contraceptives such as protection from some types of cancers, a glowing skin, a carefree attitude and better health for both mother and child.

However, the key to this feeling of well being is to see your doctor today, select the contraceptive method that is best suited to your requirements and start a new life with confidence and security. Imagine the relief you will feel if you are secure in the knowledge that you have control over your own body and can make decisions regarding your reproductive functions as you and your partner see fit. You can actually feel better and enjoy your life more once you are secure in your choice of contraception and don't have the constant uncertainties surrounding pregnancy looming over your head!

The DMPA Street Theater Project

By, Diepiriye S. Kuku-Siemons

The Banglanatak troupe marched through the neighborhood searching for an ideal space to attract an audience. Their loud rhythmic drumming drove people out of their shops and homes onto the streets to witness the 'disturbance'. Many joined the excitement and procession, prodding the troupe for hints as to what was about to happen.

On the whole, audiences ranged from twenty to eighty, averaging fifty onlookers per show. In some places, people were clambering to see the street theater show, educating the population about the contraceptive Depot Medroxyprogesterone Acetate (DMPA). The DIMPA network project is implemented by PSP-One across nine towns and cities is shortly expanding to cover an additional ten towns in UP and Uttaranchal. The program objective is to promote the use of DMPA by enhancing consumer awareness of this method as a part of the basket of contraceptive choices and to ensure high quality of service provision by private clinics.

The role that women often fulfill in the management of the household, children and elders restricts her mobility and her ability to partake in the animated street theater spectacles. Discussions with the troupe leader revealed that their experience has been that more women attend if the group situates itself deep inside the residential sections of each colony. Earlier performances took place in markets- areas primarily populated by males. Market areas see a great deal of people in transit who are unlikely to assemble for more than two minutes, making it difficult to maintain a captive audience. Crowds in less commercial/more residential areas tend to stick around for the entire duration of the plays, which are brief- at most 15 minutes long. This is especially important in conveying social messages, beyond merely spreading the word that some strangers have appeared in the local area to make a vague public exhibition.

Use of local language or dialect is usually a better way to engage the community. However, in the case of Aligarh, while the troupe spoke in a different accent, this difference did not prove problematic to the objective of the activity. An overwhelmingly positive response after each performance implies that this is not a barrier. The troupe reports similar encouraging and inquisitive responses from males and females of ALL ages, notably including adolescents, youth and the elderly. There were a plethora of questions following the performance, and many were interested in the DMPA information leaflets distributed by the performers. Further, there were several inquiries directed towards the group regarding details of DMPA as well as the location of providers.

Surprisingly, youth and adolescents were equally engaged in not only the animated performance and drumming but also the plot of the skits. Elderly women notably paid close attention to the contraceptive method messages. One lady approached the troupe with numerous questions, asserting that her daughter-in-law was not present yet would benefit from knowledge of DMPA. She was so excited about the production that she disappeared, quickly returning with her son's wife at her side. Mothers-in-law have a great deal of influence within the household regarding her daughter-in-law, hence their involvement is key.

At the end of the short production, a moderator from the troupe pleases the crowd with a lively "Question/Answer" recap of the topics carefully covered in the skit. "Three months," one lady hesitantly blurted out, before quickly readjusting her head cover, lifting one length of her shawl to cover her smile. The ladies hovering in the doorways and corners nearby were happily vociferous after of her correct response to DMPA's duration of efficacy.

The real benefit of street theater lies in one fact: It is a spectacle. Spectacles are out-of-the-ordinary events which present an abstraction of life. A plethora of evidence based studies suggest significant unmet needs for a variety of methods of contraception, yet contraception is absent in everyday conversation. The variety reflects the diversity of health, lifestyle and social circumstances in which women find themselves, with varying degrees of personal agency regarding their own fertility. Introducing an external 'spectacle' of sorts, to raise the issue of birth spacing, contraception and women's ability to determine her fertility are subjects that many simply lack facilities to address. Street theater is an effective means by which to introduce topics into public discourse and eventually, raise public awareness.

There were a few service providers from the DIMPA Network
present at one staging of the performance. Abt Program Manager Sashwati Banerjee gave the feedback that their presence lent a greater sense of legitimacy to the message of the street theater play. Additionally, this easily serves to advertise the services of the providers and is an excellent way to link the traveling group of performers directly to the local context. Providers like Dr. Rakhi Mehotra recognized the potential synergy in the collaboration between providers and street theater, particularly among low income groups who may have limited exposure to mass media. One provider even suggested street theater productions near the provider's clinic in efforts to build local awareness.

The presence of local service providers at the performances may well alleviate any concerns about social differences/distances in language and class between the performers and the target community. Service providers should be encouraged to attend the street theater performances and field questions from audience members at the end of the performance. This synergetic relationship would allow both service providers and the local population to engage each other in a non-clinical setting, breaking barriers and diminishing reticence to discuss taboo subject matter in order to build a positive community dialogue about health.

Reproductive Justice: Informed Life-choice

By Diepiriye S. Kuku-Siemons

Depo Medroxyprogesterone Acetate (DMPA) is one of the most widely researched and documented safe and reliable means of contraception. DMPA is 99.7% effective and lasts up to three months, making it a viable alternative to oral contraception and IUDs . Long-acting injectable contraceptives such as DMPA remove the daily tensions surrounding reproductive and sexual health, especially for those who find other methods impractical. Although proven safe and effective, the oral contraceptive pill is impractical for many and does not address the myriad of circumstances and concerns of many couples. Due to a variety of health concerns and individual needs, IUDs are clinically unsafe for many women. Expanding the basket of choices of contraceptives promotes the praxis of reproductive rights.

There are a plentitude of circumstances in which couples in the prime of their fertility may wish to delay pregnancy. For example, young, urban career-oriented couples may choose DMPA as a highly effective means of long-term fertility control. Young couples struggling to meet the needs of existing children may find DMPA a convenient and easy-to-use contraceptive method of choice. Other young couples may be eager to have their first child, yet wish to postpone further offspring. In these cases contraceptives serve as a 'spacing' method, permitting women and their spouses to concentrate on pursuing studies/training or rigorous career paths. 'Spacing' also represents a responsible and mature attitude towards fertility, cultivating better and more informed parenting.

Clinical, demographic and social science professionals alike conclude that an unmet need for contraceptives monopolizes a great deal of women's time. Time spent dealing with fertility reduces precious time for responsible and effective parenting, care-taking of elders, income generation and self-development. DMPA specifically addresses a constraint of parenthood- namely time and stress management. Poverty exacerbates these constraints where reduced access to health care services as well as education and training all work to limit life-choices.

Risky choices

A recent study in the Indian Journal of Pediatrics of pregnant women from six urban slums revealed an 80.6% prevalence of anemia. The researchers concluded that in most instances, anemia resulted from inadequate dietary intake of iron, of which 90.9% of study participants fell far short of the daily recommended allowance. DMPA may reduce menstrual bleeding and promote a slight weight gain, making it a wholly beneficial and life-enhancing alternative. Other non-contraceptive benefits of DMPA include a reduction of pain associated with endometriosis as well as the palliative treatment of certain cancer.

Lactating mothers too often struggle with post-partum health, while at the same time seeking a reliable means of contraception that does not place her child at risk. The combined oral contraceptive pill is not a viable alternative for lactating mothers who harbor concerns over the effects of the quantity or quality of their breast milk. Lactating mothers may shoulder responsibilities towards her newborn child, existing children, spouse and other kin, rendering the daily attention and inflexibility of oral contraceptives an unnecessary hassle. DMPA has no adverse effects on breast milk while providing security and reassurance unparalleled.

Rights to Resources

Reproductive rights theorizes access to treatment and care, while reproductive justice works towards ensuring quality, safety, and practical access for women in a myriad of socio-economic circumstances. Purporting contraceptive choices as a reproductive right overlooks the varying circumstances which mediate a woman's personal agency and ability to decide. To transition from reproductive rights to reproductive justice it is necessary to expand the basket of choices to address the unmet needs for contraception and birth spacing as well as their practicality.

The utility of DMPA gives credence not only to reproductive health as a right, but also to reproductive justice by broadening the element of choice to a wider array of women, particularly those living in poverty or otherwise disenfranchised. Far too little research interrogates the intersection of poverty and unmet needs for pragmatic, safe and effective contraceptives. In real terms, poverty reduces access to education/training as well as quality health care. The unmet needs for contraception across all social-economic strata indicates an urgent necessity to re-examine these linkages in the form of expanding knowledge resources and availability of choices. Enhancing the basket of contraceptive choices can drastically enhance the lives of women in particular, and families in general, especially those traditionally disenfranchised.




References
Shali T, Singh C, Goindi G. Prevalence of anemia amongst pregnant mothers and children in Delhi. Indian J Pediatr [serial online] 2004 [cited 2006 Apr 17];71:946-946.

Review of “The Impact of Menstrual Side Effects on Contraceptive Discontinuation"

By Diepiriye S. Kuku-Siemons
May 2006

Review of “The Impact of Menstrual Side Effects on Contraceptive Discontinuation: Findings from a Longitudinal Study In Cairo, Egypt.” Published in: International Family Planning Perspectives, Vol. 31, No. 1, March 2005

Elizabeth Tolley, Sarah Loza, Laila Kafafi and Stirling Cummings published their findings from the study of 259 first time users of the IUD, the hormonal implant or the tri-monthly injectable (DMPA). The aim was to gauge women's bleeding patterns and perception of changes in their cycles subsequent to adopting their chosen method. Relatively few studies have interrogated women's perception and tolerance of menstrual changes as a result of adopting a new method of contraception , some of which appear to contradict one another. The findings of this study provide important insights for the improvement of counseling to address women's perception of bleeding changes.

The study collated both quantitative and qualitative data from surveys over a period of 18 months and from 48 women who participated in six focus group discussions (FGD). The study sought to shed light on the high discontinuation rate (70%) of DMPA users after one year, compared to 34% and 10% of IUD and implant users respectively. At the baseline study, participants reported an average of five bleeding days per cycle. After starting usage of IUD and DMPA, users reported eleven to twelve bleeding days per cycle. The researchers also noted that those women who chose to use the implant differed from IUD and injectable users: They were more experienced mothers who wished for no more children and had prior experience with another method of contraception. On average, implant users were also slightly less educated than those who chose other methods and averaged two to seven years elder to women who used injectables and IUDs. Though not fully explored in this present study, the authors noted that these differences in personal characteristics at the baseline could have influenced women's choice of IUD, implant or injectables.

In another population based survey of 252 women in New Zealand, bleeding irregularity or heavy bleeding were frequently cited as the primary reason for discontinuation of DMPA within 21 months of first adopting the method. Yet, the same study revealed amenorrhea as the primary reason for discontinuation between two and five years after adopting the method. Another randomized trial of two tri-monthly injectable contraceptives showed amenorrhea to be the cause given for discontinuation within twelve months of adopting DMPA. Another study in Bolivia showed a correlation between discontinuation and fewer (less than or equal to four) children or the belief that menstruation is important for the maintenance of good health.

A 1996 study in Egypt looked at counseling on injectables that women received from physicians, nurses and midwives. More than 50% of those providers and counselors believed that long-term amenorrhea could lead to sterility among other health complications. Many of those providers reported their belief that only couples seeking to effectively limit their family size should adopt DMPA. Such misconceptions may introduce biases when counseling and educating women and couples about the variety of available methods of contraception, including DMPA.

One fallout of provider bias in counseling comes in the conveyance of advantages and disadvantages of the various methods of contraception. IUD and implant users were given counseling that weighed heavily upon the advantages of those methods. In some cases, inaccurate or false information was given. By contrast, the same FGD revealed that many providers were more likely to explain disadvantages of DMPA rather than advantages. One provider explained in detail to those women who chose the implant or DMPA that they should expect their menstrual cycles to stop. When actual experiences deviated from the counseling, women were admittedly surprised, at best; many were alarmed.

Study Findings

Though implants caused many women to bleed heavily or led to amenorrhea altogether, injectables users reported nearly thrice the spotting as IUD users and over 60% more than the implant insofar as number of bleeding days. The unpredictability of bleeding days and patterns of bleeding (heavy, light, etc.) means that what was once a 'cycle' is rendered a variegated appearance of "traces" or "signs." By the second month just over one third had felt changes in their cycles and expressed concern over these changes.

In this study, women who chose DMPA reported "dramatic increases in the length of bleeding episodes" during the first months. Subsequent reports revealed "sharp declines" in bleeding among women who continued the method. These same women reported further declines in average number of bleeding days between the twelve and eighteen month period. One woman explained her understanding of the injectable after having used this method for two years:

"Two or three drops, then it stopped for four months. And it came again for a while, and then stopped. I mean that when the injectable is due, it gives me a sign. It comes down as a drop or two....The first two cycles I had spotting. Then it stopped altogether."

Among the women who discontinued use of DMPA, nearly one third cited amenorrhea as their primary cause for concern while only 7% did so due to other non-contraceptive effects. Notably, none mentioned a desire to return to normal fertility as a reason for discontinuation.

The menstrual diaries recorded by study participants revealed no significant statistical difference among women who continued versus discontinued use of DMPA insofar as "the proportion of total days recorded for each level of bleeding." This reinforces the idea that the unpredictability of the menstrual cycle is the most disconcerting aspect of DMPA use- not cessation of the menstrual cycle. The study found that while correcting for "personal characteristics, spousal attitudes or knowledge," bleeding inconsistency/length predicted likelihood of discontinuation of DMPA users at a rate of 4% per additional day above the average of five bleeding days per cycle reported at the baseline study.

The authors conclude that: "Our findings raise the possibility that counseling about bleeding and other side effects should be tailored to the personal and contraceptive experiences of women, and that partners may play an important role in how well some women tolerate contraceptive-related bleeding." To mitigate these concerns, DMPA providers should discuss the immediate, short-term and long-term changes in adopting this unique method of contraception. Pre DMPA Counseling* should address the specific experience of women with their menstrual cycles in order to better prepare them for the potential changes to her cycle. Spotting and various other forms of irregular bleeding are the greatest indicators of continued use. Addressing these concerns will normalize the experience and reassure women so that they know exactly what to expect from adopting DMPA.

*Pre DMPA Counseling:
- Adheres to pelvic screening guidelines
- Plans injections relative to menstrual cycle and childbirth
- Evaluates medical history including diabetes risk
- Assesses intensity and typical number of bleeding days per cycle
- Addresses perception and misconceptions of menstrual changes
- Incorporates Behavior Change Communication strategies to gain familial support of adoption of family planning






References:
Hubacher D et al., Factors affecting continuation rates of DMPA, Contraception, 1999, 60(6):345-351.
Rivera R, Chen-Mok M and McMullen S, Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD, Contraception, 1999, 60(3):155-160.
Tolley E and Nare C, Access to Norplant removal: an issue of informed consent, African Journal of Reproductive Health, 2001, 5(1):90-99.