How has the pandemic impacted women’s health and reproductive health at a broader level?
The pandemic has had a major impact on family planning and welfare services from the month of March. Data indicates that 26 million additional couples in India were not able to access contraception, with 1.9 million additional unintended pregnancies. Safe abortion services have also been impacted.
Family welfare and contraception services were affected due to limited capacity at clinics and hospitals, as well as personal fear of infection, or lack of transport. There were also supply limitations, meaning pharmacies needed to be open in sufficient numbers with adequate contraceptive stock. Thus, only a small percentage of women were able to access contraceptive care. However, tremendous efforts have been made by the Government to address this situation.
The first priority has been to safeguard the health of women who are already pregnant and to ensure safe deliveries. The Government declared family planning care as an essential service, which corroborates with FOGSI’s statements in the released GCPRs (good clinical practice guidelines). Contraceptive care should never be denied to any women seeking it. Fortunately, all the services are recovering, and everyone is geared up now to provide family planning services.
Can you explain FOGSI’s strategies to counter this extraordinary situation?
FOGSI has declared family planning services as essential. Essential care refers to care that is necessary for a good health outcome for mothers and their children, not only for optimum quality of life but also saving their lives as it will prevent unintended pregnancies and unsafe abortions. We have also facilitated the provision of more counselling to clients, immediately after delivery, miscarriage, and post-partum.
There is also a need to ‘plug or seal the leaking bucket,’ by firstly ensuring more couples take contraception, and secondly preventing couples already on contraception from discontinuing. One way to address this is to offer newer and modern methods of contraception, thus increasing the ‘basket of choice.’
Are there contraceptive options with a longer lasting effect, to help ensure couples on contraception do not discontinue?
Certainly. Multiple methods are long-acting. One option is sterilization though surgical services such as tubectomy and vasectomy. There are also other long-acting contraceptive options which have the same efficacy as sterilization but are reversible. These include intrauterine devices or IUDs (these release copper into the reproductive system) as well as levonorgestrel-releasing intrauterine systems (LNG-IUS). Another option is injectable contraceptives, which have to be administered every 3 months, intramuscularly. One need not necessarily visit the hospital to take this injection. If you have a prescription, the injection can be administered by a local nurse instead of seeking a specialized clinic, or can even be self-administered as in the subcutaneous version.
Implants, which are also long-acting reversible contraceptives, are matchstick like devices containing Etonorgestrel. This device is subdermal, placed under the skin by the doctor. It needs to be changed only once in three years. These have been used by millions of women across the globe, but are available for widescale use in India this year.
How safe is contraception for long-term use in family planning? Are there any harmful contraceptives / techniques you want to raise an alarm about?
Generally, all contraceptives are safe. They are well-researched. As long as the method chosen is suitable to the patient and as per the eligibility criteria laid out by WHO, contraception is extremely safe.
However, some women may be at high-risk or not suited for certain contraceptives. These are rare situations, but I will discuss a few examples of such situations. A woman may have malignancy or cancer such as breast cancer. Since this cancer is hormone dependent, it is very important that a woman doesn’t become pregnant, as pregnancy increases the aggressive behaviour of the tumour. Contraceptives must also be chosen carefully. Hormonal contraceptive options should be avoided, and we would instead advise methods such as an IUD, until the woman is fully treated. To provide another example, it is important to rule out thrombosis or blood-clotting in women, as such women should not opt for the combined pill which contains estrogen. In the event of any disease of the uterus that causes it to become enlarged, for example, fibroids, we avoid prescribing IUD and usually prescribe hormonal contraceptives. Also, for women who are diabetic or hypertensive, we tend to avoid hormonal contraceptives, unless these disease conditions are ‘very well-controlled’.
The bottom-line is that medical eligibility criteria must be applied correctly and we should fine-tune contraceptive methods advised accordingly, and allow a choice of safe methods to the woman. Once she picks her preferred option from a basket of safe choices, that’s the battle more or less won. The next battle is she should start and continue it, thus meeting the unmet contraception need.
Going beyond contraception, what are some other aspects of family planning you would like to call out?
We have a high propensity towards advising self-care for women – we counsel them towards protection against sexually transmitted diseases and prevention of unintended pregnancies through contraceptive methods. But the patient also has to be taught and trained on picking up pregnancy as early as possible by knowing the signs and symptoms. They should also ensure to test it, through easily available home test kits.
It is important women are aware that teleconsultation can play a huge role. Short-acting reversible contraceptives can be easily prescribed during a teleconsultation without any need to visit the doctor in-person, via email or phone. Whatever platform the doctor and patient choose, it should be reliable, and encrypted, ensuring patient confidentiality. Of course, there are still certain cases, with long-acting reversible contraceptives, where face-to-face meetings are required, such as if the patient is choosing an IUD device.
Finally, every couple should understand that emergency contraception is available as an option, both directly over the counter and through prescription too. This should be considered when no contraception was used or when the contraceptive method failed at the time of intercourse. These have a 90% and more protection guarantee from unintended pregnancies. When couples use this option, they also receive counselling so they can opt for an ongoing reliable method of contraception.
How has teleconsultation changed the way pregnancies are handled?
Pre-natal and ante-natal care can be, to some extent, managed by telemedicine. A reassuring fact is that pregnant women afflicted with COVID-19 can be managed with good outcome if the disease is detected early. In the case of uninfected mothers, we can reduce the number of ante-natal visits from 8-10 visits to 4 to 5 visits. The remaining times teleconsultation is offered.
Clinics and doctors must also be on high alert regarding when care should change from digital platforms/teleconsultations to in-person care. Women should also be alert to which symptoms cannot be handled via teleconsultations.
When a couple wishes to abort an unintended pregnancy, what are some key considerations to bear in mind during these times?
Safe abortions can be managed during the pandemic with minimal visits to the hospital. If a couple decides to discontinue the pregnancy, by law it is permissible in India to do so within 20 weeks of gestation, even if it is a normal pregnancy.
It is important to make that decision as early as possible, ideally before 7th week. The procedure requires a primary visit and consent forms to be filled, and either a medical or surgical method is followed. The follow-up can happen through teleconsultation. The healthcare provider can initiate a conversation on post-abortal contraception, to see why the unintended pregnancy happened and how future occurrences can be prevented.