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The Oral Contraceptive Contraceptive Method Brief

No. 3

Oral contraceptive use can be expanded by removing barriers that affect demand and supply.

This document identifies some of these barriers and suggests several ways to overcome their

effects in urban Uttar Pradesh.

Overview

• Despite efforts to increase the use of oral contraceptive pills in urban Uttar Pradesh, rates of use remain

very low (3.2 percent).

• Although oral contraceptives are available from both the public and the private medical sectors, most

women purchase them from pharmacies or chemists without a prescription—or obtain them from their

husbands, who presumably procure the pills from the same sources.

• Demand-side barriers to oral contraceptive use include general mistrust of hormonal contraceptive

methods, fears about not remembering to take the pills, and inappropriate and insufficient targeting of

potential users with socially marketed brands.

• Supply-side barriers include inadequate access to affordable brands and limited knowledge on the part of

pharmacists, staff at chemist shops, and health care providers.

• Expanding the provision of oral contraceptives, neutralizing negative attitudes and perceptions about the

pills, and appropriately targeting the poorest women with subsidised products could improve rates of use.

Background

Oral contraceptives have been available through the

National Family Welfare Programme (NFWP) since

1968.[1]

Although high-dose oral contraceptives

were the first pills introduced through the NFWP,

the programme now offers low-dose combined oral

contraceptives and progestin-only pills. The

Government of India regulates the provision of each

differently: combined oral contraceptives can be

sold over-the-counter without a prescription[2]

and

progestin-only pills require a prescription and are

less widely available.

Oral Contraceptive Use

The rate of oral contraceptive use in India (3.1

percent) is quite low when compared with the rate

in other nations. Similarly, only 3.2 percent of

married women in urban Uttar Pradesh use oral

contraceptives.[3]

• In urban Uttar Pradesh, the rate of use is highest

(6 percent) among women with two children and

lowest (with almost no use) among women

without children.

• Use is highest among married women in the

middle and upper-middle wealth quintiles (see

Figure 1). The rate of use peaks among women in

the second-highest wealth quintile (6 percent) and

is lowest among the women in the lowest wealth

quintile (1 percent).

Oral Contraceptive Provision

Although oral contraceptives are available from both

the public and the private medical sectors, women

in urban Uttar Pradesh do not rely heavily on these

sources, likely because combined oral

contraceptives can be obtained without a

prescription.

Expanding Contraceptive Use in Urban Uttar Pradesh

Contraceptive Method Brief — The Oral Contraceptive


Figure 1. In urban Uttar Pradesh, oral contraceptive use is highest among married women in the middle and

upper-middle wealth quintiles and lowest among the poorest women. Source: Third National Family Health

Survey, India: 2005–2006.

• The majority of oral contraceptive users in Uttar

Pradesh have acquired the pills most recently

through a retail outlet. Approximately 48 percent

of the women who use oral contraceptives

procure them from pharmacies or chemists;[3]

another 31 percent of users receive them from

their husbands, who presumably also purchase

them from pharmacies or chemists.[3]

• The next largest source of oral contraceptives is

the private medical sector, where approximately

15 percent of users obtain their pills. Less than 1

percent of women in urban Uttar Pradesh obtain

their contraceptive pills from the public health

sector.

• The hormonal contraceptive market in India is

dominated by three commercial manufacturers:

Wyeth, Organon, and Remedie. All three

manufacturers supply oral contraceptives to the

free, social marketing, and commercial

distribution chains. The free government brand,

Mala N, is procured by the government and

distributed primarily through the public health

system. The government also provides pills to

social marketing organisations at subsidised

rates. These social marketing organisations then

sell the pills under their own brand names or as a

low-priced version of the government brand,

called Mala D.[2]

• In a survey conducted in four districts (urban and

rural) of Uttar Pradesh, only 38 percent of

women who used contraceptive pills reported

that they obtained their initial pill supply from

the public or the private medical sector. Thus,

most women in the survey likely did not meet

with a medical provider before initiating pill use.

Moreover, only 25 percent of the women

surveyed reported that they obtained resupplies

of their pills from the public or the private

medical sector, indicating that most women do

not have ongoing contact with a medical

provider regarding their oral contraceptive use.

In fact, the survey showed that husbands were

the primary source of both the initial and the last

resupply of pills.[4]

Unmet Need for Family Planning

The need to expand oral contraceptive use is strong

in urban Uttar Pradesh, particularly to help women

who wish to space their births.



• Approximately 6 percent of women in urban

Uttar Pradesh report an unmet need for birth

spacing. Because implants are not available and

injectable contraceptives have limited availability

in India, oral contraceptives are the only

hormonal method that can currently meet this

need. The unmet need for limiting births

(9 percent) is higher than that for spacing births

in India, but limiting needs can be largely met by

sterilisation.

• Women with no children and women with only

one child have the highest unmet needs for

delaying or spacing births (9 percent and

16 percent, respectively).[3]

Despite this need,

women with fewer than two children are also

the least likely to use oral contraceptives.

• Poor women in urban Uttar Pradesh have a

disproportionately high unmet need for family

planning. The unmet need for limiting births is

higher than that for spacing births (as in the

general population), but poor women have a

disproportionately high unmet need for both.

For example, 8 percent of women in the lowest

wealth quintile, as compared with only

1 percent of women in the highest wealth

quintile, have an unmet need for spacing (see

Figure 2).[3]

0

10

20

30

Pe

rce

nta

ge

of

ma

rrie

d w

om

en

poore st second

poore st

mid dle second

w ealthies t

w ealthies t

W ealth (quintile)

Unmet need for family planning according to w ealth

limiting

s pa cing

Figure 2. The poorest women in urban Uttar Pradesh have the greatest unmet need for family planning.

Source: Third National Family Health Survey, India: 2005–2006.

Demand-Side Barriers to Oral Contraceptive Use

Private Sector Partnerships-One (PSP-One)

conducted the Goli ke Hamjoli (“Friends of the Pill”)

programme between 1998 and 2004 to increase and

create a more supportive environment for oral

contraceptive use in Uttar Pradesh. Implemented

with support from the Program for Advancement of

Commercial Technology-Child and Reproductive

Health (PACT-CRH), this communications and

marketing campaign generated data that explain

many of the demand-side and supply-side barriers

contributing to low rates of oral contraceptive use in

urban Uttar Pradesh.

Demand-side barriers include general mistrust of

hormonal contraceptive methods, fears about not

remembering to take the pills, and inappropriate

and insufficient targeting of potential users with

socially marketed brands.

• Although women know that oral contraceptives

exist, many distrust them. Negative provider

opinions and commonly held misperceptions



about the pills have helped create this distrust.

The media feeds the myths by presenting poorly

researched, negative articles about oral

contraceptives.

• Annual consumer-tracking surveys conducted

during the Goli ke Hamjoli programme showed

that between 14 percent and 24 percent of

women who chose not to use oral contraceptives

did so because they felt the pills were unsafe.

Among these women, 14 percent to 18 percent

attributed their lack of use to their husband’s

opinion of the pills, and between 18 percent and

19 percent attributed it to concerns about side

effects.[2]

• Incorrect use of oral contraceptives can decrease

their effectiveness. Many women in the

programme reported fears that they would not

remember to take the pills daily.

• Efforts to increase the use of oral contraceptives

in India have failed to adequately target women

from the lowest wealth quintiles. Some of the

poorest women still report using commercial

(fully priced) oral contraceptive brands, and a

large portion of the wealthiest women are using

socially marketed (subsidised) brands (see

Figure 3). However, because a large portion of

the women in this survey did not know the name

of the brand they were using, this information

should be interpreted cautiously.

Figure 3. Throughout India, more than half of the wealthiest oral contraceptive users report using a free or

subsidised brand of pills. The proportion of these women using a commercial or fully priced brand is much

lower (less than 30 percent). However, 20 percent of women could not name their brand. Source: Third

National Health Survey, India: 2005–2006.

Supply-Side Barriers to Oral Contraceptive Use

Given that oral contraceptives are available over the

counter from pharmacies and chemists, few supply-

side factors limit their use. However, inadequate

access to affordable brands of the pills at

pharmacies and chemists, limited knowledge on the

part of service providers, and provider bias might

play a role in the low rates of use in Uttar Pradesh.

• An estimated 90 percent of women with an

unmet need for birth spacing and 85 percent of

slum residents live within one kilometre of a

pharmacy or chemist (the two main sources of

oral contraceptives in Uttar Pradesh). However,

not all of these retail outlets carry affordable,

socially marketed oral contraceptives.[1] [2]

Many



of the pharmacies and chemists also lack up-to-

date information about low-dose pills.

• Even though low-dose oral contraceptives are

safe for prolonged use, many doctors don’t

encourage use beyond 12 months. Previous

experience with high-dose oral contraceptives

and their side effects, combined with concerns

about the use of steroid hormones, have

contributed to this bias.[4]

Reducing Demand-Side Barriers

Although the Goli ke Hamjoli programme was not

successful at increasing oral contraceptive use

among the general population, it did increase use

among middle-class, married, 18- to 29-year-olds

who want to space or delay pregnancy (the

programme’s main target audience). Oral

contraceptive use rose from 4 percent in 1998 to

11 percent in 2003 among these women.

Based on the successes and failures of that

programme, the following approaches are

recommended to increase access to and demand for

oral contraceptives:

• Target specific brands and create better brand

identity to encourage poorer women to use

socially marketed products and wealthier

women to use commercially available ones.

• Supply doctors, pharmacists, chemists, and other

community-level providers with technical

updates on oral contraceptives. Also disseminate

job aids to encourage evidence-based practices

and share simple pamphlets to support

interactions between health care providers and

their clients.[2]

• Encourage health care providers to discuss birth

spacing and the use of modern contraceptive

methods with women during antenatal care,

during postnatal care, and at the time of

delivery. The percentage of women who obtain

maternal and child health services is expected to

increase as a result of the Government of India’s

Janani Suraksha Yojana programme, which

provides cash incentives for community health

workers and for women who give birth in a

health facility.[5]

This is expected to create new

opportunities to reach some of the poorest

women with messages about modern

contraceptive methods including the pill.

• Encourage community health workers to address

myths and biases regarding oral contraceptives,

and to share accurate information about the pills

through outreach activities with both women

and men.

Reducing Supply-Side Barriers

The following recommendations could help improve

the provision of oral contraceptive services:

• Educate health care providers about the

importance of discussing effective methods of

contraception with women who have had an

abortion. The global nongovernmental

organisation Ipas recently demonstrated the

need for increased provision of highly effective

contraceptive methods after medical

termination of pregnancy in India.[6]

Women who

have just had an abortion are clearly motivated

to delay or limit childbirth, and postabortion

contraceptive uptake is good if high-quality

services are offered before a woman is

discharged from a health facility.[7]

• Change government policy to make progestin-

only pills available over the counter; requiring a

prescription for progestin-only pills limits the

provision of the pills to the health sector, which

ultimately constricts supply. Because progestin-

only pills are more appropriate than combined

oral contraceptives for women who are

breastfeeding, wider availability of progestin-

only pills could increase the overall use of oral

contraceptives during the postpartum period in

urban Uttar Pradesh.

• Ensure that women are adequately counselled

about the potential side effects of oral

contraceptives and how to manage them.

Because combined oral contraceptives are

available over the counter, women usually do

not visit a medical provider before starting the

pills, and resupply most often occurs in the retail

sector (with purchases often made by men).

Thus, new materials and methods of reaching

women with adequate information about oral

contraceptive use may be needed.

• Train health care providers in addition to doctors

(such as chemists and practitioners of indigenous

systems of medicine) to provide appropriate

information and counselling about oral



contraceptives to women who contact them for

health care. The results of the Goli ke Hamjoli

programme suggest that training is generally

inadequate for all levels of health care providers.

The tools developed by the programme,[2]

FHI’s

checklist for screening clients who want to

initiate COCs,[8]

and other tools can be used to

improve training.

• Do more to reach women in the lowest wealth

quintiles with affordable oral contraceptives.

Socially marketed brands of oral contraceptives

should be better targeted to the women who

need them most. By capitalising on the

government’s supply of free pills and the

availability of COCs without a prescription,

community health workers could distribute more

free pills to women in the poorest communities.

Acknowledgements

This work was supported by the Bill & Melinda Gates

Foundation, and this document was produced by the

Urban Health Initiative, which is implemented by

FHI. The contents of this paper do not necessarily

reflect the views and policies of these organizations.

Several people were involved in the production of

this document: Alok Banerjee, Deeksha Sharma,

Sudha Tewari, Robyn Dayton, Miriam Hartmann,

Barbara Janowitz, and Conrad Otterness. We also

thank Parvar Seva Sanstha for its contributions.

Notes

1. Parivar Seva Sanstha (PSS), Strategy Summary

Recommendations on Oral Contraceptive Pills -

Urban Reproductive Health Initiative of FHI in

Uttar Pradesh (New Delhi: PSS, 2009).

2. USAID/India, ICICI Bank, and PSP-One, "Gole Ke

Hamjoli" Promotion of Oral Pills in Urban North

India, 2008.

3. International Institute for Population Sciences

(IIPS), The Third National Family Health Survey

(NFHS-3), India: 2005–06 (Mumbai: International

Institute for Population Sciences, 2007). (UHI

analysis of NHFS-3 data.)

4. Mackenzie Green, Barbara Janowitz, Mario Chen,

Conrad Otterness, and Ashish Gupta,

Perspectives on Using the Private Sector for

Family Planning: Uttar Pradesh, India (Research

Triangle Park, NC, and Delhi: FHI, 2010).

5. Vikas Dagur, Katherine Senauer, and Kimberly

Switlick-Prose, Paying for Performance: The

Janani Suraksha Yojana Program in India

(Bethesda, MD: Abt Associates: 2010).

6. Ipas India, Post Abortion Family Planning

Services: Assessment of Current Status and

Proposed Strategies under URH Initiative. Report

prepared for the Urban Health Initiative, 2009.

7. Ali Ceylan, Meliksah Ertem, Gunay Saka, and

Nurten Akdeniz, “Post Abortion Family Planning

Counseling as a Tool to Increase Contraception

Use.” BMC Public Health 9, no. 20 (2009).

8. FHI, Checklist for Screening Clients Who Want to

Initiate Combined Oral Contraceptives (COCs)

(Research Triangle Park, NC: FHI, 2008). Available

at http://www.fhi.org/en/RH/Pubs/servdelivery/

checklists/cocchecklists/index.htm

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