A Hard Pill to Swallow: Why More Women Don’t Go for the Pill
Myths, misinformation, inaccessibility and judgment: what keeps urban Indian women from using birth control pills?
“I send my boyfriend out to get it because I find it too embarrassing,” says Ritika when asked about her experience buying birth control pills.
“The pharmacist doesn’t know the difference between the different types, and it’s too awkward to have the conversation with him to figure it out myself.”Payal, 23
Shame, embarrassment, sharam, whatever you call it, the reluctance to openly talk about sex keeps sexually active young adults in India from accessing the best-suited form of birth control for them and getting the proper guidance required to make informed decisions about their own health.
Today, on World Sexual and Reproductive Health Awareness Day, FIT explores birth control pills as a contraceptive choice, and what keeps women in India from choosing them.
Why Not the Pill?
While they may not be as hassle-free as some of the other contraception options in the market, birth control pills, or simply the pill, have a success rate of over 99%.
And unlike many others, it allows a woman control over her menstrual cycle, letting her choose when to ovulate.
Birth control pills work in two ways. They stop ovulation and thicken the cervical mucus preventing fertilization.
The most common type of birth control contains a combination of the hormones estrogen and progesterone, and are meant to be taken for 21 days followed by a gap of 7 days to allow menstruation.
What Is Keeping More Sexually Active Women From Reaching for the Pill?
The United Nations’ 2019 report shows that globally, oral birth control pills are the most popular form of contraceptive used.
That is, except in Asia, where female sterilization still remains the most widely practiced form of birth control.
In India, 4.5% of women in rural India use birth control pills for contraception, which is twice as much as in urban India which was around 2%. This data, furthermore consists only of married women.
One reason for the low number of South Asian women having access to birth control pills—and the complete lack of data on unmarried women on it—is due to the association of the pill with sexual promiscuity, and the idea of women enjoying sex still being an unpalatable concept.
Take, for instance, the contrast in the ads for contraceptives directed to men and those towards women.
While the tone of condom ads is often sensual and playful, promising uninhibited pleasure, women’s contraceptive ads are usually more serious, featuring ostensibly married women taking on the responsibility of family planning.
And this difference in attitude spills beyond the screen.
'Are You Married?'
“I remember the first time I went for a routine checkup. The doctor asked me, ‘are you married?’ and it took me a while to realise what she meant was if I was sexually active.”Jayshree, 27
In a country like India where sex is still treated like a clandestine operation, and even medical professionals aren’t always free of judgment, many young women, particularly unmarried women are reluctant to see a doctor for information on contraceptives.
“I find birth control pills a bit complicated. I’m afraid to take it on my own, and I’d rather just use condoms than have to see a doctor for the pill.”Jayshree, 27
Ritika talks about the first time she mustered up the courage to go to a gynecologist for advice on taking birth control pills, saying,“ It was awkward to begin with, and she didn’t make it any easier.”
“She started by asking me if I was married, when I said no, along with giving me the information I was seeking, she also gave me a not-so-subtle moral lesson on ‘abstinence’ and the virtues of having one partner. ”Ritika, 24
It was an uncomfortable experience filled with awkward silences and cryptic glances, she recalls. Enough to not want her to go back. “There were so many things I wanted to ask her, but I couldn't bring myself to. ”
According to the National Family Health Survey, only 47% of the total women on any form of contraceptive were properly informed about them.
The lack of accessibility to information on birth control without awkward encounters and moral policing in India led a group of Twitter users to come together to form a database of nonjudgemental gyneacologists who could be trusted.
This barrier to professional help not only perpetuates misinformation and myths about the pill and its effects, but also keeps women from making informed choices.
We speak to two renowned gynecologists, Dr Deepa Dewan, Associate Director & Head of Unit, Obstetrics And Gynaecology at MAX Hospital Gurugram, and Dr Anjila Aneja, Ob-gyn, Director and HOD, Fortis Memorial Research Institue, Gurugram, to get to the bottom of these myths, and address popular concerns that women are too afraid to ask their doctors.
What About the Side Affects?
Of all the women we spoke to about their choice of contraceptive, most preferred condoms, despite its lower success rate. When asked why, most answered that they were afraid of the side effects.
This fear isn’t entirely unfounded. Since most birth control pills contain hormones, they could cause some initial side effects like nausea, mood swings, and bloating.
But, says Dr Deepa Dewan, in most cases they settle within a couple of months. “Within a cycle or two, your body adjusts to the pill and you won’t really experience these symptoms,” she explains.
“One of the biggest apprehensions that women have with birth control pills is because it’s hormonal,” says Dr Anjila Aneja.
“Hormonal doesn’t equal bad. In fact, if taken properly, under proper medical supervision, birth control pills can have added benefits like lightening period flow, regulating irregular periods, and even help with hormonal acne.”Dr Anjila Aneja, Ob-gyn, Director and HOD, Fortis Memorial Research Institute, Gurugram
Dr Deepa adds that apart from fixing irregular periods, they can also help with certain conditions caused due to hormonal imbalance such as hyperandrogenism in those suffering from PCOD.
“I had really bad PCOS, growing up. My periods would be all over the place. I would have heavy bleeding for 10 days and then nothing for months, ” says Devina.
She goes on to tell us about how she was prescribed oral contraceptives to regulate her periods. “It's been really helpful in fixing my cycle. And I’ve been lucky in that I haven't had any side effects either.”
Will It Affect My Fertility in the Long Run?
“Many women come to me with the fear that birth control pills will keep them from conceiving later in life. This is just not true,”Dr Anjila Aneja, Ob-gyn, Director and HOD, Fortis Memorial Research Institue, Gurugram
Dr Deepa Dewan agrees. “Birth control pills only work as long as you take them. Once you stop taking the pills, your periods will go back to normal, this is because when you stop taking the pill, you start ovulating again.”
Do Birth Control Pills Cause Weight Gain?
About the popular notion, Dr Deepa Dewan has this to say: “While some high dose birth control pills could sometimes lead to bloating and weight gain, these can easily be managed with a proper diet and regular exercise.”
“That being said, birth control pills with a low dosage of hormones won’t, in themselves, make you gain weight,” she added.
Check With a Doctor
While it is true that in most cases the side effects resolve themselves, there is also a chance of them persisting or causing other complications.
This is why, Dr Anjila Aneja explains, it is important to consult a gynaecologist to know what suits you best.
"A medical history of high blood pressure, heart diseases, and other conditions must be considered before one takes any hormone based birth control. This is why it is advisable to see a doctor so they can do some preliminary tests before prescribing a suitable pill.”Dr Anjila Aneja
But What About the Judgment From Doctors?
Sometimes it can just be a matter of finding the right doctor.
“I haven't faced a lot of judgment. It could be because I live in a big city like Mumbai, and possibly also because I’ve been prescribed it since I was 16, to treat my PCOS,” says Devina.
“Although, some doctors I went to initially wouldn’t prescribe it to me. But then I went to a gynaecologist who is a family friend. She turned out to be super helpful.”Devina, 26
Dr Deepa Dewan also suggests that although it is advised that you go to a gynaecologist, there are over-the-counter pills that you can safely take. Provided you don't have any medical history of heart disease, obesity, blood pressure, and aren't a smoker, it's okay to go for them.
However, if you do so, make sure to follow the instructions on the label to the T and reach out to a doctor if you notice any persistent discomfort.
“Many hospitals and clinics also provide telephonic and online consultations. If you're uncomfortable with a physical appointment, speaking to a doctor over the phone may make it easier for you to ask your questions freely,” she also adds.
I Pill: In Case of Emergency Only
Although sexual behaviour is changing, talking about sex, especially premarital sex is still marred with taboo. And so it is no wonder that although classic birth control pills aren’t widely used, over-the-counter emergency pills are worryingly popular among Indian urban youth.
When Payal, 23, became sexually active she was in college. “Back then I didn’t feel comfortable talking to anyone about it. I did some googling of course but I wanted to avoid going to a doctor to talk about birth control options.”
“We stuck to condoms, but I would get paranoid and often take the morning-after pill,” she says. “Until it started completely messing with my periods.”
“They would be extremely unpredictable and when they did come, they were painful and sometimes lasted for longer than two weeks.”Payal, 23
For this very reason, Dr Deepa Dewan warns against using the ‘morning after’ pill or (the emergency pill) as a regular method of contraception.
“Emergency pills are called ‘emergency’ for a reason. They have a very high dose of hormones and are only meant to be used as a backup in cases of emergency.”Dr Deepa Dewan, Associate Director & Head of Unit, Obstetrics And Gynaecology
Besides leading to irregular periods and other possible complications, emergency pills also have a failure rate of over 8%, which makes it even less preferable as the primary form of contraception.
This trend of relying on emergency pills further prods at the larger issue of the reluctance of young women to reach out for help, highlighting the need for open and honest conversations around sex and sexual health, especially from medical professionals.
It must also be noted that most contraceptives, except male and female condoms, do not prevent STIs, so if you’re sexually active, it is advisable to use a condom irrespective of your choice of contraception as well as get regular checkups.
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