Researchers have identified long-acting reversible contraception (LARC) methods as the safest, most effective – up to 20 times more effective than other contraception – and most economical. This is in part because LARC methods, such as the intrauterine device (IUD) and the birth control implant, aren’t user dependent and consequently do not suffer from user errors such as missed doses.
Despite these benefits and recommendations from the American College of Obstetricians and Gynecologists and American Academy of Pediatrics, LARC methods remain underutilized. While in many countries women opt for birth control pills or condoms, the most common form of contraception around the world remains female sterilization.
According to the United Nations 2015 report Trends in Contraception Worldwide, 19% of married or in-union women used female sterilization as a permanent form of birth control (followed closely by IUDs at 14%).
Even though LARC methods aren’t used as frequently as other birth control methods, research shows a trend away from permanent sterilization to reversible methods, such as IUDs. LARC method use has been increasing among teens in the United States and some developing countries have been exploring LARC methods for teens, women who have recently had an abortion, and among women in crisis-affected countries all with positive outcomes.
Ugaz, Chatterji, Gribble & Banke found that in most developing countries around the globe, the use of long-acting methods (both reversible and non-reversible) was associated with higher household wealth. However, India was an exception, demonstrating that poorer women in India are more likely to use long-acting or non-reversible methods due to Indian healthcare policy that actively encourages female sterilization and has been known to incentivize it.
Recently India has gained media attention for its shift away from heavy use of sterilization toward introduction of implants and injectables.
India’s History With Sterilization
Female sterilization accounts for 66% of contraception use in India. While sterilization is a commonly used method in the developing world, India is unique as a country that has established a government program to regulate population growth via promotion of sterilization. Beginning in 1966, the Indian government gave targets to health workers (since removed) and financial incentives for men and women to undergo the procedure in attempts to speed up the process of reducing fertility rates, the Guttmacher Institute reports. Quotas have led to aggressive male sterilization in the 1970s, mass sterilization camps around the country and numerous deaths as a result of unsafe surgeries, yet sterilization remains the most common contraceptive method choice.
Some women may decide to be sterilized without much understanding of the procedure or its consequences. The U.N. reports that it may be the case that many Indian women are given a “one size fits all” solution for birth control that may not coincide with their preferences. In a 2015 report on family planning clinics in Bihar, a state in east India, the International Center for Research on Women (ICRW) identified a lack of counseling of women before they had the sterilization procedure. In the report ICRW explains that most women “were not making informed choices about their fertility and sexual health. Nearly all of those who came to a facility had already decided to go ahead with sterilization.” Similarly, almost three-quarters of women receiving sterilization procedures at a maternity home in Bangalore had no experience using any other contraceptive methods and limited knowledge about less permanent contraceptive methods. ICRW have attributed this preference for sterilization to the prevalence of community-level health workers who continue to promote this method though government goals have shifted. Choosing to become sterilized without considering any other options may lead to sterilization regret, a concept that a 2012 report shows affects at least 5% of Indian women who undergo the procedure.
Aside from sterilization regret, the widespread use of sterilization as the primary method also creates another issue. Most of the women in India begin childbearing in their late teens and have little space between births. This pressure to get childbearing out of the way and then undergo sterilization fails to address an important reproductive health need of pregnancy planning and spacing. Planning and delaying pregnancy is associated with having more resources saved to accommodate the addition to the family. Spacing pregnancies apart by at least two years improves the health outcomes for both mother and offspring by ensuring that infants survive infancy and the mother’s body has time to heal.
Why Is India Moving Towards LARC?
The death of 13 women and the critical state of 90 other women at the state-run sterilization camp in the state of Chhattisgarh in 2014 called into question the use of sterilization, and the aggressive manner in which the Indian government promotes it. A recent New York Times article explains that this catastrophe combined with shifts in politics has led to a reconsideration of the emphasis on sterilization as the primary method. Whereas some civil groups are opposed to introducing new methods such as injectable contraception (depot medroxyprogesterone acetate injection, or DMPA) for distrust of Western pharmaceutical companies, others claim that existing methods have done little to educate and decrease the continuing high fertility rates. The new government of Prime Minister Narendra Modi overruled the opponents and have made plans to introduce new methods.
A 2011 Population Council report on the use of injectables in India demonstrates that there was a strong demand, but the reason most women did not adopt this method was simply due to lack of publicity and education of this method. At the time of the study’s data collection, injectables were only available through the private healthcare sector. This suggests that once widely available through the public sector, it will become a more frequently used method. More recent research from 2016 shows that when given the option, women in India will choose LARC methods over sterilization.
However, LARC methods in India, such as injectables, are not without their issues. The same 2011 Population Council report also noted that some women who tried injectable contraception and experienced unpleasant side effects during the first three injections. Some women experienced unpleasant side effects (most likely menstrual related issues), during the first three injections. Though the side effects diminished afterward, the menstrual disturbances caused women to become alarmed, believing that their disruptions were something more serious, such as diseases or pregnancies. Moreover, the Population Council observed that those who were better educated and had better access to care were more likely to continue using injectable contraception. These findings reveal that in order to increase use of LARC in India, there needs to be a significant emphasis on education surrounding potential side effects, especially for the health care providers counseling women in choosing a method. The Population Council also recommends that beyond more accurate information surrounding LARC, there should be a wide range of contraception options, not only injectables. Informed health care providers and informed patients would be better able to choose the right option for each woman.
Recent reports show that proponents of introducing reversible birth control methods in India aim to diversify the birth control method options in order to meet the demands of millions of women in childbearing years as well as meet the diverse needs of women without relying on a single method. India’s decision to expand its repertoire falls in line with a general increase in LARC methods worldwide. Research shows that LARC is suitable for many women, regardless of age or purpose. More information and education surrounding LARC methods is necessary for women to choose the method that is most suitable for them.
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Allison Yates received a B.A. from Indiana University in International Studies. She is interested in researching cross-cultural relationships, sexual education, and violence prevention.