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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
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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.
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• 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
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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
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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
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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