Shades of Grey: Injectable Contraceptives - Are They Good Choice? - Sashwati Banerjee & Alka Dhal

All is not black and white… and we want to explore the shades of grey. Feminism is diverse and we don’t always agree totally with one another, though we may share a similar perspective.

While we don’t want to silence other viewpoints, we want to focus on the finer distinctions between arguments used by people who are on the same side of the table.

Though sexuality is often linked with reproduction, most often it is tied up with concerns about how not to reproduce. Given that most contraceptives are made for women, women’s groups have rightly focused on the benefits and harms of different contraceptive methods.

Injectable contraceptives have attracted a lot of attention as well as criticism. Possible negative side effects, long term action, ethical concerns such as informed choice, the role of the State’s health machinery,  and so on are constantly debated. We are aware of the arguments used on both sides. These for and against arguments will continue, and that is not the purpose of this column.

Sashwati Banerjee and Alka Dhal give us their reasons why they think injectable contraceptives offer a good choice to women. Here’s what we asked them: How do injectable contraceptives really function? What are the issues to consider? What are the risks and benefits? And, why do you think they are a good choice?

Sashwati Banerjee

In the course of my work I meet many women from all socio economic groups, who are using DMPA (depot medroxyprogesterone acetate).  I hear many stories – they all have one thing in common. Barring minor issues, they are all happy to have taken DMPA.  They feel empowered and in ‘control’. They also feel ‘tension free’. In a recent workshop in Agra, at a focus group discussion, the research agency asked women what was their number one fear – they all said ‘anchaha garbh ka theherna’ (fear of unwanted pregnancy). For them it either means abortion and related guilt feelings associated with abortion or it means bearing a pregnancy which they don’t really want and guilt feelings associated with that.

For the last 50 years, India has relied on only three spacing methods to ensure that women are safe from unwanted pregnancy – the pill, the IUD and the condom. Unfortunately one woman dies every five minutes in India due to pregnancy-related causes. She doesn’t need to. Delaying first marriage and preventing unwanted pregnancy through access to safe, effective and affordable methods of contraception is the most cost-effective intervention for ensuring safe motherhood and better maternal health.

A woman should have a choice on whether, when and how many children to have. She should have a choice to make that decision and her decision must be respected. She should be in a position to take that decision based on an informed choice. The only contraceptive method that’s currently in her control is the pill (oral contraceptive pill). But the pill requires her to remember to take it daily, it is not suitable for women who cannot use estrogen and women who are lactating (breastfeeding). The intra uterine device (IUD), the only other temporary method cannot be recommended for women who have heavy menstruation, painful periods, or have not had a child yet. And we are all aware that the condom comes with its problems. Negotiating use and incorrect usage resulting in high failure do not exactly instill confidence in women – especially when their whole sexual and reproductive life is spent under constant tension the minute they miss their menstrual date!

In other words, all these spacing methods come with strings attached – they are not ‘perfect’ (if at all a contraceptive could be perfect). And they cannot be used by every woman.

Then how can a woman who really doesn’t want to get pregnant and can’t use any other contraceptive method protect herself from unwanted pregnancy? DMPA is another option. DMPA is a three monthly injectable contraceptive, to be injected intra-muscularly (the tetanus injection your neighborhood quack gives you is intra-muscular!). It is 99.7% effective. It is reversible. And it is so safe that WHO as recently as June 2005 has again reviewed all evidence for and against DMPA and has given it a green signal for long-term use. Yet arguments continue about its safety profile; ‘severe side effects’ has been cited as the reason why women cannot be provided this method.

The fact is that DMPA is a really safe drug because it contains only progestin (also called progesterone). Progestin is a ‘good’ hormone in the body. But there are hassles in using it. Some women may experience spotting and irregular bleeding for the first two-three injection cycles. Eventually most users stop menstruating as long as they are on the injection. Exactly like our grandmothers, who did not menstruate for 13 – 14 years of their prime reproductive age as they were giving birth and getting pregnant almost every year!

As DMPA is a three monthly injection, it is completely reversible, albeit there’s a delayed return to pregnancy compared with other temporary methods. It does not mean that a woman has reached menopause (the dreaded word!), or that bad blood is ‘building inside their body’. Most doctors recommend that DMPA should not be given to women who haven’t had their first child yet. It’s not because it’s medically unsafe, it’s because there is social pressure to produce the first child and prove fertility!

Let’s take a reality check. No contraceptive method is a 100% effective. Heck, no drug is 100% effective. DMPA is 99.7% effective – that’s pretty good. As far as safety profiles of contraceptive methods are concerned, all methods are safe. DMPA is no exception to the rule. Consider this: pregnancy kills 100,000 women in India every year; however no death or severe disease has been reported by women using contraceptive methods – yes, including the hormonal contraceptive methods. In fact even the non-contraceptive benefits of DMPA far outweigh the risks associated with the drug. DMPA prevents cancers of the ovary and uterus; it reduces the risk of pelvic inflammatory disease and menstrual related anemia.

So why has a safe and effective option, particularly viable for women who are breastfeeding been kept out of the reach of women? Controversies surrounding it have not just questioned the safety profile of the method; the health system in India or the lack thereof has been a key reason for not allowing DMPA into a woman’s basket of choices.  The health system is rightly being criticized – the health system in India needs major improvement and quality of care should definitely be addressed. This is not true for just DMPA but also basic primary healthcare. But how will keeping a viable option out of the loop solve this issue?

And make no mistake – DMPA is a viable option. It is a choice. Maybe not a perfect choice, but quite similar to many other imperfect choices – both within and outside the field of contraception. Oral pills. IUDs. Condoms. Sterilization. None of these are perfect choices - they all come with pluses and minuses. So why is DMPA always singled out as the villain of the piece? Why do we only hear some voices that are against DMPA, and not others? Why do we never hear the voices of women who have used DMPA – quite happily?

But the controversy rages on. We let women live with the constant fear of ‘unwanted pregnancy’. Let us go on our candlelit marches, endless rallies, seminars and workshops. Let us continue to protest because we’ve been doing it for ten years. Let us continue to be ostriches with our head stuck in the sand. Let us not rethink our paradigms or challenge conventional wisdom. Let us not look at engaging in dialogue, in resolving issues. While 100,000 women die every year – needlessly.

Sashwati Banerjee has been working in the area of reproductive health for the last ten years. She is a Program Director and Communications Advisor with a US based consulting firm. Sashwati is deeply committed to issues related to women’s rights, health, sexuality and gender.

Alka Dhal

As a doctor I see patients from all walks of life everyday. They visit me, a gynaecologist,  for mainly one reason – pregnancy! They come when they can’t get pregnant or when they are pregnant or to terminate their pregnancy. As a doctor I’m amazed how much of a woman’s time is actually spent worrying about her reproductive health.

Take Anjali’s case. She came to me to terminate her pregnancy when her younger child was only 3 months old. She was anaemic, breastfeeding her child and had had a really difficult pregnancy. I advised her to use a contraceptive, as she was most vulnerable to pregnancy during this time. As she was breastfeeding, and the oral contraceptive pill could not be given, I inserted an IUD for her. She came back two months later with complaints of heavy bleeding and painful periods. I had to take out her IUD and advised her to be careful and use condoms during intercourse. The last thing I wanted for Anjali was for her to get pregnant so soon after her delivery. Needless to say that she came back a month later, and was pregnant again. I had to terminate her pregnancy for the second time. Anjali was distraught and went into depression.

This was twenty years ago. When Anjali left my clinic I was in tears. As a medical professional I had failed to find a solution to Anjali’s problem. As Anjali’s doctor I had lost her trust and belief that I could make her better.

Today I have an option for Anjali. DMPA, an injectable contraceptive which is safe and effective for three months could have been given to her. However, despite it being available in India for over ten years, use of this excellent method is negligible. Lack of awareness, incorrect knowledge and negative bias about hormonal methods has ensured that DMPA is ruled by FEAR (False Evidence Appearing Real).  One of the big fears is that a woman on DMPA stops menstruating and that this is against nature!

Since puberty, women are brought up on a steady diet of menstrual related myths. ‘If you don’t menstruate you’ll go blind’! ‘If you don’t menstruate you’re a dirty woman, bad blood is building inside you’, or, ‘when I’m menstruating I can’t cook or pray’, are often played back to me. Scientifically they have no basis. Merely old wives tales and traditions that have never been questioned! A woman menstruates, because every month, when her ovary releases an egg, it has a chance to get fertilized. Simultaneously, the endometrium lining in the uterus starts building up to nurture the embryo, like a soft thick blanket. If the egg is not fertilized, the endometrium lining starts breaking and along with the dead egg comes out in the form of menstrual blood. A normal, natural function of the body.

DMPA is a three monthly injectable contraceptive method.  It prevents pregnancy by suppressing ovulation (release of egg from the ova). Exactly like an oral contraceptive (OC) pill. The only difference between the OC pill and DMPA is that unlike the OC pill which is a combination of two hormones – estrogen and progesterone, DMPA has only one hormone – progesterone. The same hormone is produced in a woman’s body when she gets pregnant – in much larger quantities than a DMPA dose. Progesterone thins the endometrial lining. Some women experience irregular bleeding and spotting during this time. Most women stop menstruating after four or five injections. Only till they are on DMPA! Once the injections stop, all reproductive functions, including menstruation return to their original pattern. This is definitely not harmful. In fact, not menstruating maybe more beneficial to women. It reduces the amount of bleeding and menstrual related anaemia, has a protective effect on the ovary and the uterus – the risk of cancer of the uterus actually reduces. Further women who have painful periods, premenstrual syndrome, and heavy menstrual bleeding actually will be free from the pain every month!

Another common myth about DMPA is that is makes women infertile. Given that the injection itself protects a woman for three months plus two weeks, there is a delayed return to fertility. Hence it’s advisable to use this method only if a woman doesn’t want a child in the next 12 months. Compared with other methods, the protection that DMPA provides is long term, because it acts longer as well. Studies have shown that over a ten-year period, women on DMPA  and women on OCs have the same return to fertility. Needless to say in India almost 15% women suffer from infertility and therefore doctors have become cautious about prescribing any contraceptives to women (except a condom!) who have not yet had a child.

The most recent allegation against DMPA has been that it causes osteoporosis! Sensational headlines have added fuel to fire primarily because most people are not aware of the difference between bone mineral density and osteoporosis. Bone mineral density is merely the status of the bone health. It does not mean osteoporosis. Pretty much like having high cholesterol does not mean that you will definitely have a heart attack! A woman can lose bone mineral density for a variety of reasons - when she’s breastfeeding, if she has repeated pregnancies, if she’s on certain medication like the thyroid hormone, or if she’s a smoker. When a woman stops DMPA, her bone mineral density fully recovers in a couple of years. Bone is a complex organ and osteoporosis depends on many factors – lifestyle, lack of sunlight (Vitamin D), lack of exercise and other related problems. The WHO has recently reviewed the evidence on DMPA and bone mineral density and have advised that DMPA is safe even for long term use.

Can all women use DMPA? No. DMPA should not be given to women with current liver disease, long standing (more than 20 years) or complicated diabetes, or high blood pressure (more than 160mm systole or greater than 100mm diastole). But for most women the benefits of using a method like DMPA are manifold. DMPA is a totally private method – women who are not permitted to use contraceptives by their families or partners find this method particularly suitable. It has many non-contraceptive benefits like protecting against certain cancers, reducing the chances of ectopic pregnancy (which can kill a woman) and reducing the incidence of pelvic inflammatory diseases which can lead to secondary infertility.

As a doctor who sees many Anjalis a day, I’m particularly glad that there’s an option, a choice available for women. It’s true that in order to make that choice, the woman needs to be informed. But we need to let the woman make that choice. As health providers, we can at best provide her with correct information – the pros and cons of every method. We can’t stand in judgment and decide what is good for her…where is the empowerment in that?

Dr. Alka Dhal is an Obstetrician and Gynaecologist and has been practising in Delhi since 1993. She is a master trainer and technical consultant for organizations like the Population Council, PSI, TARSHI, IPAS and PSP-One.