National data on prevalence rates of abortions, low birth weights, infant and maternal morbidity and mortality are still high in India and coexist with a high unmet need for contraception. This indicates a need to improve and increase the choice of contraceptive methods within the National Family Welfare Programme. The Indian Council of Medical Research (ICMR) conducted several studies with injectable contraceptives during the 1970s and 1980s. Injectable contraceptives (IC) are available in the Indian market since 1994 but the large majority of the population cannot afford the prices in the open market. Hence it would be relevant to consider their induction into the National Family Welfare Programme.

Injectable contraceptives are offered in several South-East Asian countries like China, Thailand, Indonesia, Bangladesh, Sri Lanka, Nepal, Bhutan and Pakistan where DMPA, NET-EN and/or monthly injections have been introduced (1, 2). Clinicians and social scientists from these countries were invited for an in-depth discussion of their experiences in their population groups. Several aspects of cultural and social factors which affect the use and continuation of injectable contraceptives were discussed in detail.

The progestin only injectables DMPA and NET-EN have comparable efficacy, mode of action and advantages. There are approximately 9 million DMPA users worldwide. A study of long-term side effects shows no adverse effects on blood pressure, blood coagulation, lactation, liver function, cancer, foetal and child development. (1)

Disturbance in menstrual cyclicity is the major reason for discontinuation of DMPA. Heavy, profuse bleeding, irregular bleeding/spotting and amenorrhoea can be troublesome and result in low continuation rates. Medical intervention and proper counselling are essential for management and provision of quality care has to be ensured. Amenorrhoea may be beneficial in preventing anaemia, it can have positive and negative implications and reactions. These side effects are all reversible, after discontinuation. Weight gain may be another side effect, but this more on account of the user’s diet and lifestyle. Other additional benefits include prevention of pelvic inflammation and endometriosis. (1, 2, 3)

There are a few contra-indications which need to be strictly followed at the inclusion/exclusion stage at the time of enrollment / initial counselling. The efficacy rates are comparable to sterilisation. The convenience of two-or three-monthly schedules is also an advantage. (1)

Return of fertility is slightly delayed after DMPA, but after two years, pregnancy rates among former users of DMPA, NET-EN, IUCD and oral pills are the same. (1, 2, 3)

Menstrual irregularities have been eliminated by monthly injections which combine estrogen with the progestins. Thereby better cycle control and less disturbance of menstrual periods are maintained. Monthly injectables are a combination of estrogens and progestin (either DMPA or NET) and are also available as pre-filled single dose disposable injections.

At the end of the meeting, on review of the available data, there were two views expressed. One group opined that injectables should be inducted into the National Family Welfare Programme selectively in suitably equipped health centres and in a gradual phased manner. The users should not be under any coercion. Informed voluntary consent should be obtained. The consent forms should be in simple local language. Trained counsellors and providers should be involved and follow good clinical practices, and proper surveillance should be maintained.

Within these criteria the use of injectables will not pose any risk to the users. Some women will have side effects which lead to early discontinuations. A large proportion of users is able to continue their use as long as they need contraception. The availability of another method choice will certainly increase the contraceptive usage, reduce the unmet needs and lower the need for resorting to MTP both by safe methods and the unsafe, “back-street” methods which are still practised and responsible for maternal morbidity and mortality.

Though the injectables are meant to be administered at intervals of one, two or three months, there is some flexibility of time interval for the next scheduled dose. Thus, women can safely delay their next dose by up to one or two weeks depending upon the type of injectable. Clinical situations where injectables may be very useful are post MTP when a woman needs to be protected from pregnancy till she can think and choose a form of contraception; peri-menopausal women who need contraception, desire for short term contraception among certain groups of the population in view of changing lifestyles and frequent migration.

The emphasis should be to allow women to know their options and exercise their choice.