Unintended pregnancy, teenage pregnancy and induced abortive procedures with complications are some common reproductive health problems affecting millions of females worldwide. These issues are major causes of maternal mortality and morbidity in South Asia, posing a significant challenge to women’s sexual and reproductive health as well as social well-being and economic prospects.

In Nepal, nearly half of the pregnancies are unintended and 60 percent of them end up in abortion. This directly correlates with gender inequality, socio-economic status and restrictions on sexual and reproductive rights. Early and unintended pregnancies also pose a huge barrier to the achievement of Sustainable Development Goals (SDGs) 3.7, which ensure universal access to sexual and reproductive healthcare services, including family planning, information and education and integration of reproductive health into national strategies and programmes. Nepal's National Planning Commission 2020 states, "The government of Nepal’s target for SDG 3.7.1, is that 74% of allwomen age 15–49 have a met need for family planning with modern methods by 2022 and 80% by 2030."

Advancement of contraceptives

Over the past few decades, there have been tremendous advances in the development of new contraceptive technologies, and a wide variety of family planning methods have been introduced. According to the National Demographic Health Survey 2022 (NDHS), 57 percent of currently married women are using a method of contraception, 43 percent are using a modern technique, and 15 percent are using a traditional method. There has been a decline in the unmet need for family planning from 32 percent in 1996 to 21 percent in 2022, which is possibly due to contraceptives.

While different methods of contraception have prevented unintended pregnancies, emergency contraceptives are on the rise today. Emergency contraceptive pills (ECPs) are safe and effective drugs, recommended to be used within 72 hours after unprotected sexual intercourse, after accidents like condom rupture or missed pills, or if women are forced against their will to prevent pregnancy. ECPs help women avoid the adverse outcomes of unwanted pregnancies and reduce the risk of induced abortion. Offering emergency contraception is a crucial service delivery intervention for reducing this unmet need for contraception. As the name itself says, emergency contraceptives are intended only for occasional and emergency use. Counselling for the use of these pills should include options for regular contraception and advice on the correct methods in cases of perceived method failure.

Concerns regarding ECPs

Nepal first introduced emergency contraceptive pills (ECPs) through a social marketing programme in 2004. Since then, its use has risen, particularly in the last decade. The serious concerns regarding the potential use of ECP as a substitute for other contraceptives are similar to those voiced in response to the increased use of abortion in Nepal.

The increased availability of over-the-counter and easy accessibility of emergency contraceptives has raised concerns regarding their safe use, misuse and potential consequences. The trend of taking ECPs as an alternative method of contraception should be seriously considered, particularly among youth. The wide advertisements, banners and posters around street corners stating it is an “easy way to the difficult situation” have misled them to either abandon or consider not using the contraceptive method regularly. It provides easy options for women to avoid unwanted or unplanned births without having to face social stigmatisation.

Globally, the increasing use of ECPs has been described as an epidemic in which women are reportedly “eating contraceptives like chocolates” in Kenya and “popping them like candy” in India. The condition is similar in the context of Nepal today, where the pills are taken as a substitute for regular contraceptives. It might replace the regular use of oral combined pills, which in turn can lead to menstrual irregularities because of off-and-on withdrawal bleeding. This problem not only harms women but also potentially increases sexually transmitted diseases (STI) and HIV when condom use is replaced by repeated, indiscriminate use of emergency contraceptives. It will also deprive young women and girls of reaching out to the gynaecologist for appropriate counselling services and to consider various options regarding regular contraceptives.

There is no doubt that emergency contraceptives provide a woman with the opportunity to have unprotected intercourse and ensure that every pregnancy is wanted. However, repeated misuse of emergency contraceptives needs to be evaluated for a better understanding of the positive and negative impacts of ECPs, which is critical in guiding the discourse in the right direction.

Existing policies lack comprehensive implementation guidelines for the distribution of emergency contraceptive pills, necessitating integration. Comprehensive sexual health programmes and education campaigns through social media, workshops, community outreach initiatives on reproductive health and family planning methods and emergency contraceptives should be conducted. Health education on ECPs should be integrated into the curriculum to bridge the knowledge gap among youths.

Similarly, equipping teachers to offer detailed sex education in urban and rural schools, incorporating public education campaigns to raise awareness about ECPs and their importance as a backup method of contraception, integrating counselling services into healthcare settings, and enhancing the competencies of paramedics, community leaders and female community health volunteers to provide basic adolescent services are urgently needed. The media, programme implementors, service providers, decision-makers and policymakers should have the right and accurate information on ECPs.

There is an urgent need to disseminate information regarding family planning, pregnancy risks and contraceptive use to dispel myths and ensure the proper use of ECPs. An integrated approach is required to address the interrelated factors and create an enabling environment in which adolescents are fully aware, informed and equipped to properly utilise contraceptives and related services.

As Jeff Sheffield, chairman of FIGO’s Contraception and Family Planning Committee, said, “Globally, young people, especially adolescents, do not have access to reliable, up-to-date information related to sexual and reproductive health, including contraception. This information can help inform their decisions and potentially save lives.” Let’s ponder this issue seriously.