The golden jubilee of contraceptive pill

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 John 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 Robert Johnston, 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.)