Background

The family planning programme has percolated in India down to the grassroot level. Already, there exists a full-fledged distribution and monitoring system. Emergency Contraception can, therefore, be made available to the masses through the same infrastructure.

It has been widely accepted that judicious use of EC is safe for women even in self–administered cases. Nonetheless, counselling by medical personnel plays an important role in helping women decide about the future mode of contraception and prevention of sexually transmitted diseases.

Questions to be answered

A. Is there a need for monitoring?

B. Who should be monitored and how?

C. What should be the framework for monitoring including the need for a National Monitoring Cell?

Need for monitoring was also felt for defining the eligibility criteria, efficacy, side-effects, failures and need to have a follow-up form for each client.

Views of the Group

A. Need for monitoring

The National programme for EC distribution in India needs monitoring in its initial phase because of the following special reasons:

I It is a new concept in India where there is a lack of public awareness about EC, which makes it mandatory for the distribution staff to be discreet and cautious, as well as to ensure that the client has understood the correct dosage schedule and side-effects.

II Injudicious and repeated use needs to be monitored.

III The negative impact on society as well as spread of STI/AIDS is to be monitored.

The Group suggested the following :

• Collecting and assessing base-line information through documented information, such as, registries and other materials that give insight into the characteristics of the target population and its surrounding environment.

• Monitoring to set the priorities. This is based on assessment of the needs and of what is feasible and what is acceptable to the client.

• Monitoring the factors which facilitate or inhibit the programme success through feed- back from all levels of the pyramid and through local community leaders.

• Direct co-ordination of all the centres from subcentre level to district level in collecting data and computation under proper competent supervision.

B. Who is to be monitored

It was decided by the Group that monitoring would be required at all levels. There is need to monitor the

I Provider

II Client and

III Effect on women’s health

I. Provider-monitoring would include

• Provider profile –medical / para medical

• Training of provider – need for refresher training

• Place of providing EC services

• Facility for other RCH services (FP, STI screening)

II. Client-monitoring would include

• Client-profile including age, residence, marital status, parity, literacy, economic status, previous use of contraception, indication for use, interval between intercourse and EC use, LMP, evidence of STI and source of information

• Follow-up of client for information on further intercourse, side-effects, date of menstruation, change in menstrual pattern, failure, etc.

III. Monitoring for effect on woman’s health will include information on

• Effect on regular contraceptive use

• Misuse, repeated or injudicious use

• Monitoring of pregnancies resulting from failure

For monitoring data need to be compiled by all providers. An exhaustive form for doing so was presented by the discussion Group.

C. framework of monitoring

All providers will be required to provide information for monitoring by appropriate record keeping at village, sub-centre, PHC, district hospital as well as private clinic level. The information thus gathered will be compiled and sent to district EC control cell each month, which, in turn, will send quarterly information to a National Monitoring Cell.

The national monitoring of this programme will be under the following areas

• To find out the number of women in the reproductive age group who need Emergency Contraception in a population of a particular zone. This will help monitor the demand and supply ratio of this particular zone.

• To monitor how good and how effective is our counselling. After a certain regular period, survey of population is to be made to find out how much awareness regarding EC has developed and how knowledgeable they are regarding EC.

• To monitor how effective is one specific regime of EC in terms of preventing pregnancy. This needs continuous follow-up of all the clients.

• Monitoring the compliance of the clients in terms of reporting for drugs in time, follow- up visits and acceptance of the drug.

• Monitoring for side-effects of the drug along with monitoring of pregnancy resulting from failure.

• To monitor how much coverage of EC can be done for a said demand in a defined population. This will indirectly measure the effectiveness of our information, media campaign and distribution system and will help in setting the priorities.

• Very important long-term monitoring to find out whether women who are aware of EC gradually use a regular contraceptive method.

• For proper monitoring, a National Monitoring Cell needs to be created with its chairperson acting as “National Advisor to the Government of India on Emergency Contraception”.

Discussion

The Expert Forum felt that such detailed recording as suggested by the Group is not possible even during research protocols, and will not be feasible. Though it is a good idea to record the client and the provider profile, but most will not accept it and nobody will be willing to fill out such elaborate forms. Monitoring should be as simple as possible. A simplified monitoring form is proposed, which will be inserted in the packet as a stamped card or pre-paid inland letter, to be posted to National Monitoring Cell / Consortium Secretariat.

The simplified follow-up form is as follows :

- Pack No.

- Age

- Married/Unmarried

- No. of living children

- MTP/abortions if any

- LMP

- Date of ECP use

- Reason for use : Condom failure/forgotten pill/no contraception used/sexual assault/ others.

- Date of periods after taking ECP

• Each pack of ECP will have a pack no. assigned to it. It is proposed that each state will have its own alphabetical code followed by a numerical code, something similar to the licence plate on vehicles. This will aid in having a rough idea about client location and will help in monitoring the progress of the programme. Client’s name or address is not required for monitoring.

• Besides the monitoring form and the pills, the pack will also contain product information and instructions for use in English/Hindi/local language. For illiterate clients, the form can be filled by the provider during the follow-up visit.

• It was also felt that though monitoring may be possible in the clinical-setting, it will not be feasible in community-setting. At village level, instead of individual monitoring, a catchment area survey may be more useful.

• The preceived risks of EC are largely inaccurate and exaggerated. The ability to reduce these concerns and to inform the clients about the actual risks in comparion with documented risks from unintended pregnancy is crucial for realizing the potential of EC in preventing unwanted pregancies and unsafe abortions in India. It should be appreciated that the risk off pregnancyy and/or induced abotion is greater than the risk of using ec. After elaborate discussions on the issue, the Expert Forum agreed that a simplified monitoring is desirable. Monitoring is needed specifically during the initial years of pilot introduction so that the programme can be modified appropriately.

• It was also considered vital during discussions that both national and regional problems be given due consideration as service-delivery conditions may not be optimal in all parts of India. In India, sometimes, family planning and contraception have been introduced in a coercive manner. Though current family planning policy is a target-free approach, yet counting the number of users continues.

Emergency Contraception is one method where there is no scope for coercion and user number means nothing. A high number of users may reflect increasing awareness, whereas, in contrast, a low number may be due to poor awareness or greater use of regular contraceptive methods, limiting EC requirement.

Unresolved issue/action required

To constitute a National Monitoring Cell.

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