Freedom at midnight

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Freedom at midnight

By Ipshita Kumar, Jayashree Maji, Meenakshi Dwivedi, Sangeetha G., Shruti Verma,

Urvashi Jha, Falaknaaz Syed May 09 2010 , New Delhi

While the whole world celebrated Mother's Day on May 9, very few were probably

aware the day coincided with the golden jubilee of a dynamite that comes in a

small package and, ironically, negates the idea of motherhood.

When you see two women talking about how their life is like walking on a

tightrope, and then when the other tells her friend about the pill and how it

has made her more confident in life, you realise the power of the pill. This is

one scene of a contraceptive pill awareness advertisement that used to come 10

years ago. Small but effective, as they say, the pill has travelled 50 years

after it was first approved in the US.

Call it sexual revolution or a tool for women's emancipation, the pill is no

longer just another measure to put a check on population.

While most people consider the pill to be one kind of contraceptive, in reality

there are three varieties. First, there is an oral contraceptive pill, which is

supposed to be taken following a regime (generally 21 days), such as Mala D,

Mala N, Ovral, Ovral L, Loette and Intimacy Plus 2. The second pill is the

abortion pill that contains very high levels of oestrogen, as they are used to

diminish the already formed zygote. Mifepristone, RU486, Mifeprex and Mifegyne

are some of the commonly available abortion pills. Then there is the most recent

and popular pill, which is the emergency pill that is a low dose oestrogen pill

supposed to be taken within 72 hours from the time of intercourse. I-pill,

Unwanted-72, Pill72 and NorLevo are the most popular in this category.

History of the pill

According to Rakesh Budhraja, general manager of marketing at government-owned

Indian Drugs and Pharmaceuticals (IDPL), the first oral contraceptive pill was

approved for sale by prescription by the US Food and Drug Administration (FDA)

on May 9, 1960. It was then used mostly to cure menstrual irregularities and

later its contraceptive effects were discovered.

In India, several pills were available in 1960s. Ovral and Ovral L were marketed

by Wyeth of the UK, while Loette and Intimacy Plus 2 were marketed by

others. In the 1960s, the government used to distribute oral contraceptive pills

through government hospitals and clinics. In the 1970s, the government decided

to give it a name -- Mala.

Mala N continues to be distributed free in government hospitals and centres of

National Rural Health Mission, while Mala D is distributed through chemists and

social marketing organisations.

According to Dr Neena Singh Kumar, senior gynaecologist at Fortis Hospital, Mala

D, Mala N, Ovral, Ovral L, Loette and Intimacy Plus 2 are low-dose oestrogen

pills. These have lesser side effects and lesser weight gain problems. Low-dose

pills are given for 21 days after which there is gap of 7 days due to

menstruation. It is then repeated. Such pills are different from emergency

contraceptive pills such as i-pill and Unwanted-72, which are high-dose hormonal

tablets and are taken in case of emergencies.

For married women, doctors suggest oral contraceptive pills, as the 21-day

concept is most systematic and suitable to the body. Advertisements and open

sale lead to misuse of emergency pills. The i-pill causes menstrual

irregularities and has higher chances of ectopic pregnancy (pregnancy at the

wrong site). Repeated abuse of i-pill can also cause some tumours.

Role of government

The government's target is to produce 307 lakh cycles of Mala D. Each cycle

consists of 28 tablets -- 21 Mala pills and seven tablets of ferrous fumerate to

increase haemoglobin levels during menstruation. Hindustan Latex gets about 55

per cent of the government order while the rest goes to IDPL. Though the

government pays IDPL Rs 3.60 for making 28 tablets, it is priced at Rs 3 for the

public. For 2010-11, the government has given an order worth Rs 10 crore to

IDPL. Government's family welfare department procures another 300 lakh cycles,

which are sold by social marketing organisations, mainly NGOs.

Distribution pattern

States where women have lower literacy levels such as Bihar, Madhya Pradesh,

Uttar Pradesh report lower demand for government's oral contraceptive pills.

Southern states like Kerala and Tamil Nadu with high literacy levels report more

sales of Mala D.

Advertising the pill also has had a big role to play in the success of the

product. Network Advertising, the firm that created the i-pill ad, could not be

contacted for comments.

According to Santosh Desai, a brand strategist and CEO of Future group, the

advertising scenario for pills has not changed significantly over the years.

" Basically, the pill has never been able to penetrate as much in India as it has

penetrated the west. Other kinds of contraceptives, such as UID and condom, are

more acceptable. But products, such as I-pill or Unwanted 72, have a radical

effect on sexual activity in India. They are positioned not as contraceptives

but as substitutes for abortion. Moreover, emergency pills are not healthy for

daily use. They are mainly targeted at young women who can use it in case of an

emergency. But, it is not here to replace other contraceptives. Moreover, the

pill is not a preferred contraceptive in India due to its obvious side effects. "

The abortion pill, RU486, was brought to India by the government in 2002, almost

15 years after its launch in Europe and China, despite protests by women

activists who called for safer abortion facilities. RU486 has been embraced by

city doctors and they have slashed surgical abortions. Despite its usefulness,

however, the concerns are not baseless after all. The recommendation that they

be administered only by professionals certified to perform medical termination

of pregnancy has not been followed, resulting in its misuse.

" The complications arising from surgical abortion far outweigh the ones that

result from misuse of medical abortion. So, instead of singling out abortion

pill we should ensure that there is enough knowledge among women about it, " says

P S Chandrashekar, consultant with Reproductive Health, which is the official

journal of the Geneva Foundation for Medical Education and Research.

There are even speculations that abortion rates have increased since the launch

of the pill. But experts see no merit in them. " I think it's silly to say that

abortion rates have gone up just because abortion pill is freely available. In

fact, maternal mortality has dipped from 16 to 18 per cent in 2002 to 6 to 8 per

cent in 2008. Though we can't attribute it to the pill, we can safely assume

that it has helped women greatly, " says Chandrashekar.

According to abortion statistics, compiled by ston, an internet

blogger and research physicist, in India, the number has fallen to about 606,000

in 2009 from 669,298 in 2004.

But it was only in 2005 that women in India did not require a doctor's

prescription to buy emergency contraceptive pills after the health ministry made

the pill an over-the-counter drug. This decision was taken to stem unwanted

pregnancies and unsafe abortions. At that time, pills such as e-pill and E-Pill

72 made by Panchsheel Organics were freely available. Interestingly, the pill

that cost Rs 40 was available for Rs 5 in 2005 as it was included in

government's social marketing list. At the same time, emergency pills expensive:

i-pill is priced at Rs 100 a pack, which, by the way, contains only one pill.

Dr Duru Shah, who runs Gynaecworld — a women's clinic in Mumbai, said with a

population of over a billion, India needs a comprehensive family planning

programme and a contraceptive culture in place. As more women concentrate on

careers and delay marriages and pregnancy, contraception assumes significance.

According to the department of family welfare, fertility rate has come down from

3.40 in 1992-93 to 2.85 in 1998-99.

A government of India study in Andhra Pradesh, Bihar, Jharkhand, Maharashtra,

Rajasthan and Tamil Nadu found that while 95 per cent of youth had heard of

contraception and HIV/AIDS, in-depth awareness was limited. About 15 per cent of

young men and four per cent of young women also reported experiences of

pre-marital sex within romantic and/or other partnerships. While, young men

tended to initiate pre-marital sex earlier than young women, youth in rural

areas tended to initiate pre-marital sex earlier than their urban counterparts.

At the same time in cities, awareness about the benefits of pills and their side

effects were high among women.

Village women came to know about pills through health workers and were not

completely aware of side effects. The contraceptive pills, unlike emergency

pills, prevent ovulation in women. This has side effects like weight gain and

nausea in early stages. But in cities, the availability of pills with lower

progesterone and oestrogen levels reduced side effects. Many women are also

apprehensive about the long-term effects of the pill and doctors face difficulty

in reassuring them.

Doctors across the country agree on the usage and effects of the pill. According

to Dr J Bandana, consultant gynecologist at Apollo Hospitals in Hyderabad, most

urban Indian women consider emergency contraceptive pills as an option for

avoiding unwanted pregnancy. However, women in rural India still take it as an

abortion pill. " Sadly they are still perceived as a substitute for abortion.

Emergency contraceptive pill prevents the start of pregnancy. It does not work

if the woman is already pregnant, so it is not a substitute for abortion, " she

said adding that women aged 18 to 28 frequently use emergency contraceptive

pill.

Dr Basudeb Mukherjee, a leading gynaecologist in Kolkata and former national

president of The Federation of Obstetric and Gynecological Societies of India,

says: " Indian women are aware of the contraceptive pills but they are not aware

of usage and effects. Mostly women in the age group of 22 and 30 use pills. Over

the past 50 years many changes, shall I say, improvements, have been brought in

through intense research. Nevertheless, Indian women even in urban areas and

among the urban elite still fear that taking the pill may eventually cause

cancer. This is not true at all. The advantage is that new pills ensure that

there is no weight gain or no adverse effect on skin. The success rate is 94 per

cent. And one can continue taking pills regularly as long as one can and want

to. "

Dr Praveena Shenoi, consultant gynaecologist at Manipal Hospital, Bangalore,

says, " I see patients in the age group of early 20 to 40. Compared with past

three years, now I see females are pretty much open in coming forward discussing

these things with a doctor. "

Another gynaecologist Asha Sharma, working with Delhi's Rockland Hospital, said,

" Things have changed. Earlier, even married women were hesitant in taking the

pill. Abortion rates have gone down after emergency contraceptives were launched

in India. Emergency contraceptives have led to sexual liberation, especially

because it is an over the counter drug. We see lot of pill abuse cases also.

Yesterday, a young girl in early 20s came to me. She had taken emergency

contraceptive thrice a month. This is wrong. "

Dr Pushpa Chandra, mother of real estate tycoon Sanjay Chandra and a

gynaecologist for 38 years in Delhi, finds it easy to map the evolution of the

pill since its introduction. " The pill has taken quite some to travel to India.

When I talk of the pill, we doctors generally mean the oral contraceptive pill,

which is very different from the emergency pill that is available OTC. The usual

oral contraceptive was introduced in the States in the 60s, but in India very

few women or men knew of it. Only those who were worldly wise and knew of such

an invention would be the ones to use it. Also, the problem of high cost and

unavailability of the pill kept it away from women. So, for most, we recommended

the usual barrier method, like the loop.

Once Mala-D was introduced, it brought along a wave of revolution among women.

From the early 1980s, women showed interest in Mala-D. Thanks to the government,

these local pills were easily available and were comparatively affordable. Plus

these pills have low side effects, and if one followed the regime properly, one

could happily stay satisfied with these oral contraceptive pills.

But most women consider emergency pills are the same as oral contraceptives and

they start consuming the morning-after pills heavily. This not only affects

their health, but also their mind after a point of time. Women in India still

need more education when it comes to distinguishing between the good and the

bad. "

The pill raises many questions and it still keeps tongues rolling, literally, at

every point. Many films have been made in favour or against the pill, or for

simple informative purposes. A film called `The Pill and I' was made by a Delhi

University student and was screened about two months ago in Jawaharlal Nehru

University.

According to Akshaya Kumar, an arts and aesthetics student, it was rather well

received and sparked a healthy discussion about the pill, its side effects,

abortion fears, etc. But, he said, the film did not discuss grave problems faced

by married women.

Bubbles Sabherwal, a theatre personality and a Financial Chronicle columnist,

says, " The pill falls in the scheme of safety. Whether it's 50 years or 100

years, the pill is here to stay. It is not just a choice, but also a necessity,

especially for population control.

Though the pill might look like a normal birth control pop-in, taking it is

actually a very mature decision. The value of compromise is what shows the most

in a woman when she decides in favour of the pill. There's a lot of inner

strength required to take such decisions. "

There is another twist to the tale. It is often believed that the pill has taken

the liberation of women to a peak, as they can now decide for or against

childbirth at their own convenience. The pill has, on the other hand, tickled

the other sensitive issue — that of the liberation to opt for promiscuous

behaviour. While women are at times pressured to delay or abort the child and

the pill plays a major role in it, the pill also can be seen as an excuse for

indulging in adulterous behaviour.

But Dr Sanjay Chugh, senior consultant neuropsychiatrist who runs a consultancy

at Greater Kailash, Delhi, does not completely agree with the idea: " Women of

all kinds come to me. Some are traumatised because of the side effects that they

have had due to over consumption of the pill, or some others who wish to take

the pill as they don't want children but are pressured to deliver babies at a

young age. Though I personally haven't handled any such case which would prove

that the pill gives rise to or makes way for infidelity or promiscuity, I won't

completely negate it too. "

Sujata Bhaskar (name changed), a 23-year old student in Delhi University,

prefers to avoid the pill and talks about her personal experience. " I would

prefer to avoid the pill because other than the minor nausea that I face that

day, my menstrual cycle gets affected. If you ask me, the concept of an

emergency pill is only ostensibly liberating, but in fact puts women through a

lot more hassles. I support prescription-based sales since I think rampant usage

of hormonal pills can be dangerous. "

According to most drug stores in India, pill sales are down during the first

week of the month. A store manager at Religare, a well-known pharma retail

chain, says he sells around five packs of emergency pills a day, and while most

customers ask for i-pill, a few prefer Unwanted-72. While high street stores

seem to attract both men and women, including college students, neighbourhood

stores mainly see guys asking for the pill.

According to a pharmacy that has chain operations in Hyderabad but didn't want

to be identified said that over 600 emergency contraceptive pills are sold every

day in Andhra Pradesh by just five branded pharmacies including MedPlus, Apollo

Pharmacy and Hetero. i-pill dominates the market with 70 per cent followed by

Unwanted-72 and Pill 72.

A Abdullah, a store manager of Karpaga Vinayagar Medicals, Chennai, said,

" Contraceptive pills contribute one per cent to the overall sales in a city

pharmacy, while for a suburban store it is 5 per cent. On a monthly basis, we

sell 20 strips of 21 pills each. Women in the age group of 28 to 40 years are

our main customers. We mostly sell pills marketed by multinationals such as

Ovral and Duolotin. There are no takers for local brands like Mala-D. However,

there are customers for local brands in the suburbs. As far as emergency pills

are concerned, there are enquiries from women between 23 and 30. "

Amar Lulla, joint managing director of Cipla, promoters of i-pill, which they

sold in March to Piramal, said, " Any country that cares for women must empower

women and the pill is a prime weapon in the armoury of the women. There are

wrong perceptions about the drug. It does not have any particular age profile. I

would not say that just college students are using it; married women are the

single largest block of consumers. "

Cipla sold Rs 30 crore worth of i-pills last year and expects the brand to grow

20 per cent this year. The overall pill market on last count was worth more than

Rs 150-200 crore and growing at about 25-30 per cent.

Ravi Juneja, director of marketing at Mankind Pharma, promoter of Unwanted 72,

says the ethos behind the product is its ability to empower women and give them

the freedom to choose. This is also the reason for the success of the pill.

" Most often in our society, women are forced to have children against their

wishes, often leading to unavoidable abortions, which are just not safe but also

costly. I trust this notion of it promoting teenage sex and infidelity is

totally wrong. Today, youth are well informed and more mature than our

generation.

i-pill and Unwanted 72 are the biggest brands and we did Rs 18 crore plus on the

product last year and would do even better this year growing at about 15 to 20

per cent. We see this as a mainline product that serves a social cause. The

industry has no definite size but it is among the most promising OTC products.

The size would be about Rs 200 crore or more on last count. "

While the pill can be called one of science's greatest inventions, some assume

it is inversely proportional to the call of the conscience. Many feminists still

think it's taboo to talk about the pill in the open. Some drug store owners

refused to talk about the pill to Financial Chronicle, fearing their customers

might get offended. This brings us to debate — are we really living in the 21st

century where free sex is not limited just to muddy music concerts? May be some

questions should better remain unanswered. The pill may be a blob of ivory to

the eyes, but it surely is a dynamite that comes in a small package!

(Reported by Ipshita Kumar, Meenakshi Dwivedi, Urvashi Jha, Sangeetha G,

Falaknaaz Syed, Shruti Verma and Jayashree Maji. Rakesh Khar, N Vasudevan and

Ritwik Mukherjee also contributed to the report.)

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