The Morning After

IT was the morning after. Shreya Gupta, 33, woke up with her head in her hands, cursing herself for the night before. Was there anything she could do? No, we're not talking hangovers or Alka Seltzer here. It's the more important issue of contraception, something which had slipped the minds of Shreya and her husband, both high-profile Delhi-based journalists, the night before. They had no clue what to do next. They couldn't afford a pregnancy.

The gynaecologist performed a routine D&C, and later fitted her with an IUD (intra-uterine device). "Even then, she did not tell me anything about emergency contraception pills (ECP). They could have saved me so much tension that day," recalls Shreya.

Six years later, Shreya is relieved to know that post-coital ECP, popularly referred to as the 'morning after pill' and widely used abroad, is actually available in India. But it's rarely used due to lack of information, both on the part of the user and the provider, who, in most cases, is the doctor.

Hopefully, all this is going to change soon with the massive awareness drive being planned by the Ministry of Health and Family Welfare. Says Dr V.K. Behl, assistant commissioner with the ministry: "At the moment, the government is working out the modalities of educating women and providers. It also includes taking permission from the drug controller for the packaging of correctly formulated ECPs complete with instructions and a word on possible side-effects."

 Alka Dhal, a gynaecologist and one of the consultants to the programme, demystifies the ECP by pointing out right at the start that it's no new drug. It's simply an administration of a higher dosage of oral contraceptive pills like Mala-D, Ovral-L, Novelon or Femilon, or alternatively the IUD. In order to be effective, the pills have to be administered within 72 hours (3 days) and the IUD within 120 hours (5 days) of unprotected sex. Cautions Anjali Nayyar, communications specialist at the Population Council, a non-profit research organisation involved in spreading awareness about contraceptive choices: "It does not, I repeat, does not terminate pregnancy if conception has already taken place, and therefore should never be mistaken for some kind of abortive drug."

As suggested by the name, ECPs should only be used for emergency treatment after unprotected sex—either onetime or occasionally. And it's not a substitute for regular family planning. The treatment involves taking specially prescribed staggered doses of oral contraceptive pills within the specified time-frame. If the user throws up within two hours of the first dose, an additional dose is required.

Explains Dhal: "ECPs work mainly by preventing or delaying ovulation or making the uterine lining unsuitable for implantation." For instance, if ovulation has already occurred, it takes about a week for the fertilised egg to reach the uterus and implantation may be avoided by an ECP. In case of an emergency IUD, the intrusion of the device in the uterine cavity makes the uterus unsuitable for the implantation of the fertilised eggs. However, all measures are rendered ineffective if the cut-off period for taking these measures is past. Adds Nayyar: "The 'morning after' tag is actually a misnomer for it can be taken immediately after coitus. It's an option after the act." The success rate speaks for itself with only two out of every 100 women using ECP becoming pregnant.

Like with the normal Pill, ECPs exhibit temporary side-effects like nausea among 50-70 per cent of those treated. About 20 per cent experience vomiting as well. Other less common side-effects include breast tenderness, abdominal pain, headache or dizziness, all of which subside in a day or two. However, Dhal warns against usage without consulting a doctor. "While there are no known contra-indications, it's advisable to go to a doctor for correct dosage and accurate information as the formulations vary from oral pill to pill. And it's a good time to get educated on suitable contraceptive methods." If the patient has a history of heart disease, pelvic inflammation or is already pregnant, medical opinion is definitely advised.

The fact that only about 30 per cent obstetricians in India and less than 10 per cent of women are aware of this method is reinforced by 32-year-old health-care professional Lata Chand's experience. Educated and seemingly aware, she realised how ignorant she really was one fine morning, three years ago. "I was unmarried and in a relationship which I knew was going nowhere, and had been too weak to insist on a condom." Her flatmate advised a dosage of two normal oral contraceptive pills immediately and another two 24 hours later. "Today, in retrospect, I know that was the wrong dosage and that I should have seen a doctor. I had severe nausea and would not advise ECP unless there's a real emergency."

 The awareness programme, says Dr Behl, will be conducted in a phased manner. "In the first stage, we want to educate the urban milieu—users and providers—for whom it's easier to take a quick decision. If we go too fast, trying to address women at all levels with too much publicity and inadequate information, the chances of the programme succeeding may backfire." The ministry has on its agenda the training of 6 lakh doctors at about 22,000 health centres over the next year. And once there's been proper dissemination of information, one-time user-friendly packaged ECPs may be available over the counterifting the veil from this best-kept contraceptive secret.

(Some names have been changed to protect identity.)