In Tamil Nadu, emergency contraceptive pills are missing from both the vocabulary and the stocks in pharmacies.
Emergency contraceptives, which help terminate a pregnancy before it has happened in cases of unprotected sex, have always been a taboo in India, and Tamil Nadu has been no exception. The state, however, literally cut off access for women to safe sex with the 'shadow ban' on iPills and other emergency contraceptives.
Ever since ECPs made its way to India in 2010, Tamil Nadu's relationship with the iPill has been dicey. First, widely available and found in pharmacies, it suddenly started disappearing off the shelves, and by 2016, they were almost impossible to find.
Chennai, considered to be India's best medical hub, has no iPill. If you want to avail one, you'd have to travel out of Tamil Nadu - to Pondicherry, or to Karnataka. The pill is never available in pharmacies, and most shopkeepers will tell you the same tale, "We don't stock it".
The only way to find the pill in Tamil Nadu's capital city is through the whisper network. You ask a friend, who knows a friend, who knows a different friend who has the pill - because they stocked up on it while visiting a different city. But by the time you get the pill, you run into a lot of problems: You travel absurd distance, you pay more, and then sometimes even find that it has expired or tampered with. In most situations, the biggest risk is losing the first 72 hours after which the pill won't work.
Archanaa Seker, a Chennai-based activist, however, is trying to change the narrative on ECPs. Seker became the go-to person for pills in Tamil Nadu's coronavirus lockdown after she posted about procuring the pills on social media. She was willing to give them out.
"I got them from a friend in Bangalore," she told News18 in an interview. "I realized how much people needed the drug now, in times of pandemic more than ever, and if I could acquire it, it should be available to anyone who wants it," said Seker.
— Archanaa Seker (@Archytypes) July 6, 2020
While Seker's is a very positive approach to the problem, and it shows the gradual shift towards reclaiming back safe methods of contraceptives, if counted alone, it is a temporary solution to a larger problem: Tamil Nadu's pill ban has been shrouded in vagueness for the longest amount of time.
Tamil Nadu, legally, does not have a ban on iPills. But every so often, when someone raises the question on social media about the unavailability of the pill - the government really never takes accountability for it, because according to state regulations, the Tamil Nadu state government, does in fact, allow sale of the pill - there is no ban.
In 2019, their last publicly available recorded statement on the iPill to The Hindu, noted that officials of the Tamil Nadu Drugs Control Administration clarified that there is no ban or restriction on the sale of emergency contraceptive pills.
A senior official said that the advisory was for abortion pills, and there seems to be a misunderstanding among pharmacists on contraceptive pills and abortion pills. “A few compositions including Levonorgestrel are covered under Schedule ‘K’ of the Drugs and Cosmetics Rules 1945, and are exempted from sale licenses,” he said.
Schedule K contains various substances and drugs and their corresponding regulation of Drugs and Cosmetics Rules, 1945. Schedule K consists of those drugs that are exempted from Chapter IV of the Drugs and Cosmetics Act, 1945 which deals with manufacture, sale and distribution of drugs and cosmetics.
'Levonorgestrel' which the Tamil Nadu Government has clarified is under Schedule 'K' drugs, is actually the main component of the iPill.
A report by the Foundation for Reproductive Health Services India conducted early in 2020, before the lockdown, that has not been published but the findings shared with News18, looked at the availability of the pill in five cities of Chennai, Coimbatore, Madurai, Tiruchirappalli and Tiruppur.
The report found that only and 3% stocked Emergency Contraceptive Pills, and 2% stocked Medical Abortion pills.
The reason cited for not stocking the drug was in tune with Tamil Nadu government's official statement: legal regulatory issue. The drug regulatory environment seemed to be such that chemists were not comfortable stocking ECPs and MA drugs. In fact, 90% of those who do not stock ECPs reported that ECP has "been banned."
So while the confusion about the ban persists, and the supply chain is cut off, what repercussions does it have for women, especially during India's coronavirus lockdown?
Tamil Nadu, is unique in India for its contraceptive measures. A study by Foundation for Reproductive Health Services India in the survey earlier this year found that 0.2% of the women relied on the pill as the contraceptive method.
Tamil Nadu's major contraceptive method is female sterilizations, which contribute to 94% of the contraceptive method mix (nationally it is 75%). In other words Tamil Nadu is majorly dependent on female sterilization for contraception and the use of spacing methods like Condoms, OCP, ECP, IUCD is very limited.
"There is a need to improve access to and use of spacing methods in Tamil Nadu, especially with a huge youth population," explains V S Chandrashekar, the Chief Executive Office at Foundation for Reproductive Health Services India.
According to their estimates "around 547,227 clients in Tamil Nadu were unable to access their preferred choice of contraceptives since lockdown and till the situation returns to some level of normalcy by September. Given the high level of infections reported even in July in Tamil Nadu, the actual impact may be higher, since clinical family planning services are unlikely to be easily accessible."
Chandrashekar also shared Tamil Nadu estimates, where even with the 0.2% who showed dependence on pill, with the lockdown, almost 4,522 people would not have had access to them.
In Tamil Nadu, the lack of an ECP during the lockdown would also have more devastating consequences: There will be around 1,24,086 unwanted pregnancies, 35,489 live births, 75,446 increased abortions, many could end up being unsafe and around 91 maternal deaths, suggests the data shared by the FRHS.
For Tamil Nadu's gynaecologists, this meant more risks for their parents.
"Schedule K drugs are usually prescription-based," says Dr. Meenakshi, a gynecologist based in Chennai who practices at leading Apollo outlets. But during the lockdown, or before it, she has almost never written one for an ECP. "Even if I write a prescription, where would they get it? Pharmacists don't stock it," she says.
Facing a surge in the number of calls during the lockdown, Dr. Meenakshi had to come up with a different way to prevent unwanted births. "We had to tell them to wait till their next period," she explains. "Not all unprotected sex results in a pregnancy. If they were sure they had intercourse at the time of ovulation, we'd prescribe them a high dose progesterone pill."
While the efficiency of a progesterone pill isn't proven to be as high as an iPill, Dr. Meenakshi says "That is the only option at the moment."
For married women, Dr. Meenakshi has also recommended a Copper-T or IUDs, which if installed on the first 5 days after unprotected intercourse, also prevent pregnancy.
But not everyone will have access to gynaecologists, clinics, or even abortion methods. Over a 1,24,086 unwanted pregnancies in the absence of a pill now mean unwanted babies and unsafe methods for women risking their health and life. This imply that more women will need to resort to medical abortion methods, which will, in turn, lead to more deaths - all because of a tiny pink pill in bright packaging, which has the name 'Emergency' in it, isn't considered a necessity in Tamil Nadu.