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.