It was the worst two days of my life,” says Lakshmi (name changed to protect anonymity of the person), recounting the harrowing experience of getting an emergency contraceptive pill (ECP) in Chennai, a month ago.
“I must have gone to 10-15 pharmacies only to be met with plain discomfort at the very question,” she says. “Each ‘no’ felt heavier by the minute as pharmacies turned my emergency into a moral battleground,” she adds.
“There’s a ‘shadow ban’ for ECPs here,” one local pharmacist said, directing her to a government hospital or gynaecologist to get the pills. “In the night, hospitals didn’t have gynaecs and the attending nurses refused to give me the pill without meeting the doctor. So I had to agonisingly wait for the morning.”
“The entire experience felt like navigating a minefield. I was in a perpetual state of anxiety and couldn’t calm myself till I had the pill in my hand,” says Lakshmi.
So why is getting an ECP so difficult?
Discussions involving the pill are getting mixed-up with misconceptions involving abortion, and pill-abuse – putting women’s health at risk, and making access to a medical solution nightmarish, in situations such as rape, say doctors and health activists.
Battle for access
The over-the-counter sale (OTC) of the pill has been the subject of much discussion. But it’s now whipped-up a national controversy following reports that Tamil Nadu had proposed to the Central Drugs Standard Control Organisation (CDSCO), a complete ban on the OTC sale of the drug. The proposal was submitted to the CDSCO in September last year during its 62nd meeting of the Drug Consultative Committee.
A regulatory CDSCO source, however, clarified “There is no proposal to shift the drugs from the non-prescription to the prescription category and there will be no change in the sales and distribution of emergency contraceptives.”
The ”morning after pill” (as it is known), Levonorgestrel, was made legal in India in 2003 and is approved by the Centre as an OTC drug since 2005. Under the National Reproductive and Child Health Programme, the Drug Controller General of India has approved Levonorgestrel tablets (as a single dose of 1 tablet of 1.5mg or 2 tablets of 0.75mg each) for use as an ECP.
It is also approved by the World Health Organization to be taken as an oral emergency contraceptive within 72 hours of unprotected sex or when a presumed contraceptive failure has occurred.
Misconceptions and Misinformation
According to the latest National Family and Health Survey-5 (2019-2021), less than one percent of women have ever used emergency contraceptive pills. The major source of ECPs is the private health sector, primarily pharmacies or drugstores. Nearly half (45 per cent) of pill users received their supply from the private health sector.
Though 91.6 per cent of urban women and 88.7 percent of rural women have knowledge of the pills, less than 0.7 percent – or 7 out of 1,000 women – had ever used an ECP. In urban areas, 0.9 percent of women had used ECPs, compared to 0.6 percent in rural areas.
Use and over use
“If this pill is ever banned, one obvious outcome is that the incidence of abortions will increase,” says Dr A Tamilselvi, a senior gynaecologist. A UN Population Fund report says, unsafe abortions are the third leading cause of maternal mortality in India, and close to 8 women die from causes related to it each day.
“Access to emergency contraception reduces illegal, back-alley abortions. At the same time, the pill shouldn’t be used more than once in a menstural cycle. Overuse will cause long-term hormonal issues,” notes Tamilselvi.
But gynaecologist Dr Premalatha Balachandran disagrees: “Emergency contraceptives need to be available for women at ease, but through prescription only and not over the counter. Making it prescription only pills will prevent abuse and overuse of the pill. People are taking it without basic understanding of what the pill is. It is an emergency contraceptive and not an abortion pill.”
“The Tamil Nadu government has already banned its sale in the state. You cannot get the pills in any pharmacy in Tamil Nadu. You need to go to a government hospital to get the ECP or you can consult any doctor to get the pill,” she noted.
Activists say if ECPs are not available over the counter, the sale of the drug is likely to go underground, and those accessing these drugs become more vulnerable to exploitation.
While gynecologists stood divided on the issue, DMK’s Media relations Deputy Secretary, Dr SAS Hafeezullah, a trained physician wrote on X: “Irrational use of emergency contraceptives has adverse health effects and a continous use may expose them to fatal illness… Early morning visit to the PHC is a more viable option for an expert hormone therapy to avoid a pregnancy.”
Gynecologist Dr Bharathi disagrees. She says, “OTC sale of ECPs is much needed to prevent unwanted pregnancies and unsafe abortions. And there are not many side effects to the ‘i-pills’ when taken within the 72-hour window. The benefits of ECPs far outweigh the risks when used correctly.”
“In fact, a designated setup in primary health centres can be more supportive,” says Tamilselvi, suggesting an alternative that is better than a complete ban or ‘shadow ban’.