Ask the Women!

The introduction of contraceptive Depo Provera in India might spell health disaster for millions of women, especially rural and poor women. And if city women too get hooked, it might also spell an urban disaster
Shaweta Anand Delhi 

Two weeks before her term as Union health secretary ended in November 2010, Kanuru Sujatha Rao suggested to the Drug Technical Advisory Board (DTAB) to introduce Depo Provera (Depot medroxy progesterone acetate/DMPA or Depo) injectable contraceptive in the national Family Welfare Programme (FWP), previously called the Family Planning (read 'sterilise women only') Programme. The only exception to the women-only rule was the time when 'Sanjay Gandhi's totalitarianism' led to forced vasectomy (nasbandi) of men during the notorious Emergency (1975-77), among other widespread atrocities, including press censorship, torture and imprisonment of thousands.

No matter what the FWP is technically called, the government's mainintention has been to curb population growth for it holds that as thebasic cause of poverty. There by it intends to target women, officially or unofficially, especially poor women, in the name of either maternal and child health services or reproductive and child health programmes --- as if women's health, and their life itself, begins andends strictly between the reproductive period of 15-45 years. Indeed, this uncanny conjecture implies that the only threat to their life and social condition is complication from childbirth.

Somehow, widespread nutritional deficiency, systemic misogyny since birth (high levels of foeticide, infanticide and domestic/ work place violence) and lack of education, equal employment opportunities andequal wages, have never qualified to become areas of aggressive government interest or activism, unlike sterilising FWP targets, namely women.

This highlights the official fixation with birth control through the two-child norm strengthened by advocacy for birth control by women,including by the use of hazardous Depo Provera injectable contraceptive, according to Prof Mohan Rao of the Centre for Social Medicine and Community Health, Jawaharlal Nehru University (JNU), and member of theNational Commission on Population. "Other than the Supreme Court upholding the Haryana government's law prohibiting a person from contesting or holding the post of a panch or sarpanch in Panchayati Raj Institutions (PRIs), if s/he has more than two children, there are more state governments like Andhra Pradesh, Madhya Pradesh, Rajasthan, Chhattisgarh and Orissa that also advocate the two-child norm by offering a battery of incentives and disincentives through their population policies," he told Hardnews.

In his note on 'Population policy and the two-child norm', Rao elaborates: "... (desperate to curb population at any cost,state governments are) restricting schooling in government schools to two children; restricting employment in public services to those with two children; linking financial assistance to PRIs for developmentactivities and anti-poverty programmes with performance in familyplanning; linking assessment of public health staff to performance infamily planning and so forth. Indeed, service rules for governmentemployees have been altered in several states making a two-child normmandatory." This implies that for all the above reasons, primarily a large number of poor women are being coerced to go through sterilisations as permanent contraception. 

"The way things happen in our country, the government pressurises the poor only for population control and therefore contraception. As women, we finally get cornered both by the government and our husbands, until we get the (sterilisation) operation done, no matter how physicallysick or psychologically weak that makes us feel afterwards," said anold village woman interviewed in Deepa Dhanraj's documentary, Something Like a War.

Most poor women interviewed in this film made 15 years ago, on the subject of coerced family planning, said that pushed by the government's (mostly false) promises of money, some land or foodgrains, it's their husbands who finally decided that they 'need to' get operated. This makes them feeltotally powerless. This is quite the opposite of what promoters of new contraceptive technology claim, including promoters of quarterly injectable hormonal contraceptives like Depo.

Talking of losing control, women (or 'cases', as they were being referred to in the film by 'motivator' health workers and doctors), were brought in, their saris removed, and they were hastily mounted on the operation table almost upside down for the doctor to easily perform the quick surgery -  like an animal is pinned down fortests in a biology lab.

The doctor, while performing operations, simply could not control his boastful monologue, looking straight into the camera, jabbering about having performed 3,50,000 tubectomies (female sterilisations) in the past 12 years, with an efficiency rate of one procedure per minute. "In the interest of the nation," he said, while one of the woman he was "fixing" moaned in excruciating pain and hurled profanities at him.

Women came and women went while the doctor went on about his businessof operating upon them most nonchalantly, "like the women wereproducts being rolled out on a conveyor belt, who he is fixing," commented Abha Bhaiya of Jagori, a women's group which played an instrumental role in the making of this documentary. The attitude shows total lack of sensitivity towards women by family members, community workers and doctors. There are many similarities in the experiences of women who went through sterilisations in Dhanraj's film and those who got injectable contraceptive Depo Provera administered in a 'public hospital' setting in Delhi. 

This, despite a recommendation against Depo's use in the FWP by the DTAB in 1995 after a Supreme Court direction, even though the injection continues to be available off-the-counter in certain local chemist shops. The 'hospital' had received a stock of injectables directly from Pharmacia and Upjohn, who made the drug before they were taken over by Pfizer, the current manufacturer of Depo.
 
'UNVEILED REALITIES', A study conducted by Sama - a Delhi-based resource group for women and health - involved recording in-depth experiences of women from a resettlement colony who were administered the injection. Sama also documented how ethically and within medical guidelines was this actually done in a publichealth set-up.

As in the documentary, this study also showed that men - either the husband/family or the doctor - were basically deciding about women's sexuality and reproduction, including the method and timing of contraception. It makes no difference whether this was 'new-age' -'liberating-the-woman-by-giving-her-another-contraceptive-choice' kindof technology - or a redundant one.

Most women's social identity and status is defined 'because of the father, husband or son' in the Indian context. As a corollary to that, men tend to decide on behalf of a majority of women; hence Depo is not having anyspecial liberating effect on female contraceptive users. In contrast, it isadversely affecting women's bodies and disrupting their lives withanxiety and illness.

On part of the service provider, the crucial issue concerns following ethical and medical safety guidelines, some of which are mentioned in the literature accompanying a Depo pack itself, before administrationof the injection. One of the crucial considerations is to ensure 'informed choice' of the recipient before suggesting injectable contraceptives as 'the most effective' contraceptive compared to other methods that might actually suit the potential user better.

The doctor should ideally feel responsible and accountable to the patient if something goes wrong after taking the shot, and should do whatever is needed to put the woman's health and well being as his first priority, without worrying about discontinuation of the injection. As studies show, in most cases, the doctor takes upon a businessman's role, pushing aside the women's negative experience after using Depo and 'counseling' her to continue with the shot, no matter what be her expressed experience, helplessness, angst or anger.

As for compliance to guidelines, the Sama study reveals that the majority of poor women were suggested only Depo Provera injectable as the contraceptive they can opt for, a majority were not told about the probable short-and long-term side-effects, proving that their informed consent was not taken before administering them the injection, which could seriously jeopardise their future health prospects.

Majority of the respondents in the study were also not screened for all the tests before administering the injection. This includes documenting detailed personal and family medical history, menstrual history, blood pressure and weight, gynaecological examination to rule out pregnancy, and a pap smear test to rule out risk of infections. Majority of women showed contradictions (like history of heart disease or diabetes in the family, migraine, jaundice, hypertension, abnormal pregnancies), but were still given the  injection,exposing them to grave danger as the hormonal contraceptive causes changes in the body's metabolism itself. 

Not just that, Depo reduces the bone mineral density (BMD)irreversibly that has earned the injectable a black box warning in thepast. It is the harshest warning of adverse effects caused by drugsissued by the US Food and Drug Administration. In its latest package insert, Pfizer acknowledges the issue of BMD, and that women who can use other birth control methods should not continue Depo formore than two years!

"As a Physician,  I am saying that in the case of long-acting, hormonal contraceptives like Depo, adverse drug reactions - not 'just side effects' as Pfizer would like to put it - are a matter of grave concern. On administration of this injectable, healthy women have faced a disruption of their menstrual cycles, possibility of premature menopause accompanied by anxiety, depression and loss of libido, loss of bone density leading to weak, brittle bones, susceptibility to life-threatening blood clots and an increased possibility of HIV transmission, among other problems. All this can happen to normal, healthy women, who might just desire safe contraception, not sickness -inducing contraception, that will notonly increase their suffering but also require additionaltreatment for disorders they never had earlier," argued Dr C Sathyamala,an epidemiologist. Many of these findings are documented in a research study: 'An epidemiological review of the injectable contraceptive, Depo Provera'.

The collective experiences of women reveal that Depo Provera has beenadministered to them in a highly unethical way that could endangertheir lives. Plus, there is data to show that most women have eventually discontinued the injection due to adverse drug reactions,which service providers brush aside, calling them 'minor side-effects'while trying to cajole women into continuing with the contraceptiveto meet population control targets. This has been the experienceof women world over, including in the US!

A related study, Introducing DMPA injectable contraceptives toprivate medical practitioners in urban Gujarat, by Population Counciland others, recommends: "Obstetrics/gynecology specialists may be amore appropriate category of physicians (than generalists or MBBS) forreaching women", to administer the injection and for follow-up care.Indeed, India just does not have that kind of health set-up as yet.

However, after suggesting the inclusion of Depo Provera in FWP, Sujatha Rao had suggested that Accredited Social Health Activists (ASHAs) from the National Rural Health Mission could take up the task of administering the injectable, they being 'gaon ki beti' (daughter of the village) and trusted by villagers. "But the fact is that literacy not being their selection criteria, ASHAs may not be able to read even technical instructions on the Depo package regarding when to administer the injection, probable risks and adverse drug reactions involved, nor do they have much knowledge about a woman's internal bodily functioning like gynaecologists do, to watch out for complications or offer advice in case of ill effects to Depo users. ASHAs cannot do this. It will be like playing with the health of millions of women," said Kalpana Mehta from Saheli, a women's group. 

"The injectable is hazardous to the woman and to her progeny irrespective of whether the government can find someone at the village level - trained or not - to persuade women, who trust them, that it is safe. Its use should be banned from the private sector too," urged Dr Sathyamala.

Indeed, its rampant misuse among young girls and women in the US has become an alarming cause of concern within the health sector. And if the trend catches up in 'unaccountable India', with girls and women also picking it up off the counter, without prescription, or corrupt doctors prescribing it, this might mark an epidemic with dangerous consequences. No wonder, the drug is in the midst of a deadly controversy with a dark, depressive narrative hidden behind its public claims.

This story is from the print issue of Hardnews: JANUARY 2011