In India, Banking on the Morning After

While American women celebrate the 50th anniversary of the Pill this month, women in India are embracing a different method of personal contraception. By the end of today, over 100 million will have taken a birth control pill, but it's acceptance in the world's second most populous nation has been dismally low. According to the 2005-2006 National Family Health Survey, only 49% of Indian women use modern contraceptives, and of these, only 3% are on the Pill.

Instead, among urban India's increasingly educated and independent women, it's emergency contraception that has taken over the market. The 'morning after pill' brands, which include i-pill, Unwanted 72, and Preventol, are readily accessible over the-counter drugs throughout India, as they are in at least 40 other countries including the U.S., U.K., and Australia. "There's an alarmingly high utilization of emergency contraception, which has almost become synonymous with the 'i-pill'," says Dr. Rishma Dhillon Pai, a consultant gynecologist at the Jaslok and Lilavati hospitals in Mumbai, and the Vice President of the Federation of Obstetric and Gynecological Societies of India (FOGSI). (Watch a video about the birth control pill's influence.)

Cipla, an Indian pharmaceutical giant which sells the morning after pill for $1.60, has sold an average of 200,000 units of the drug each month since 2007, according to local media reports. The i-pill alone outsells both condoms and other oral contraceptive pills. For the year ending June 2009, American research firm ACNielsen valued India's emergency contraceptive segment at over $16,850,000 - a 245% growth in sales since the drug's release. Last month, India's Piramal Healthcare bought the rights to the i-pill from Cipla for some $20,800,000 in an all-cash transaction.

New Delhi has promoted emergency contraception as an option for women since 2002 and made it available over the counter in 2005. But it wasn't until Cipla came out with the i- pill in 2007, marketing it to modern young women through television and magazine advertising, that women took to it. Pai says when asked about their primary method of contraception, many of her young female patients say they use the i-pill. "Sometimes, they're using the pill three or four times a month," she says.

In 1966, two Yale University researchers, gynecologist John McLean Morris and endocrinologist Gertrude van Wagenen first discovered the morning after pill, but it took years before the first prescription- only version of the drug became available in 1984 in the U.K. In the US, after much politically charged debate, the FDA approved over-the- counter sales for Plan B, manufactured by Duramed Pharmaceuticals, to women and men 18 and older. It had been available by prescription since 1999. (See a brief history of birth control.)

But doctors and healthcare workers worry that young women may be at risk by taking the morning-after pill too often. "When a product is cheap, available over the counter, completely [anonymous], and is something you don't have to plan for, it's extremely convenient," says Pai. "But extreme convenience doesn't mean extreme safety or extreme rationality." Similar to Plan B in the U.S., the popular i-pill contains levonorgestrel, which, though generally considered safe, can cause side effects such as nausea, vomiting, weakness, and menstrual changes. "I didn't realize that using the i-pill a few times a month could have negative consequences," says a 21-year-old college student who asked that her name be withheld. "There was never any need to consult a doctor about it, and it's weird talking to my mom. I just asked friends and that's what they said they did." Doctors in India have also reported finding an increasingly high level of hormone changes in young women who're using the emergency pill three or four times a month, and are concerned that even though pregnancy may be avoided, by shunning condoms, women are making themselves vulnerable for sexually transmitted diseases, including HIV. "Ten years ago, I had never treated a patient with herpes," says Pai. "Now they come through regularly."

Though preventative oral contraceptives are widely regarded as the most reliable method of birth control, the Indian government's past focus on surgical female sterilization may have slowed their adoption. "Around two or three decades ago, the concern was that India's population was a burden and it needed to be controlled," says K.G. Santhya, an associate with the poverty, gender, and youth program of the international non-profit Population Council.

Now, they are up against the mass advertising effort of the companies that manufacture the morning after pills. The ads, some experts say, use catchphrases such as "tension free" to appeal to young women, and don't emphasize that the products are meant for use in emergencies only. Though the upsurge in use of emergency contraceptives mostly effects women in India's cities, health advocates are nevertheless stressing the need for educating women both in urban and rural areas about the morning after pill, which, when used wisely, can be instrumental in changing the way women approach sex. Seventy-eight percent of pregnancies in India are unplanned and at least 25% unwanted, according to FOGSI.

Pai agrees that the morning-after pill should continue to be sold over the counter. What's needed, she says, is proper sex education that covers how different contraceptives work. Many young women coming to her today, she says, aren't even aware of the differences between emergency contraception and preventative oral contraceptives. So when young girls arrive at her hospital, they're already in a crisis situation. "Our system hasn't moved as fast as the girls have," she says. "The girls are leading a modern lifestyle, and our system is still stuck a whole generation behind. As a result, we're not keeping up in terms of genuinely liberating our girls."