June 4, 2014
KATHMANDU, NEPAL – Limbu, a 17-year-old student at British Gurkha College, began experiencing heavy vaginal bleeding just as classes began one morning in April.
She rushed to a pharmacy near her school in Kathmandu, Nepal’s capital, with her friend Gurung, 18.
The young women declined to publish their first names to avoid stigma for speaking openly about their sexual activities.
The pharmacist told Limbu he was unable to help her and advised her to go to the nearby Tribhuvan University Teaching Hospital, she says.
There, Limbu was treated for dehydration, given a blood transfusion to replace lost blood, and kept under observation for several hours, she says. The doctor told her the bleeding was most likely caused by her excessive use of the emergency contraception pill. Diagnosing her as anemic, the doctor also gave her iron supplements for free.
Limbu has not had a recurrence of bleeding or any other health complications since her treatment, she says.
Limbu first had intercourse at age 15, she says. She has since had many sexual partners and is currently having sex with three boys.
Acting on the advice of friends, Limbu has used the morning-after pill, known in Nepal as the emergency contraception pill, as her sole form of birth control, she says.
“It is almost three years since I started using emergency pills, as the boys do not like using the condom,” she says.
Limbu prefers the emergency pill to birth control pills because she can take it at the pharmacy, she says. This enables her to keep her contraceptive use a secret from her family.
Limbu takes the emergency pill after sex, three or four times a week, she says.
Her friend Gurung is concerned about the health risks posed by taking the emergency pill so frequently. But young people in Nepal have no other viable options for contraception, she says.
“For people like us, who are not married and need to hide our sexual life from society, the emergency contraceptive pill is the most reliable friend for us,” Gurung says.
Use of the emergency contraceptive pill has risen significantly in Nepal over the past five years, with young women choosing it as their principal form of contraception, say doctors, NGO workers, pharmacists and young women. Regular use of the pill poses serious health risks. In a culture in which discussion of premarital sex is taboo, many young Nepalese are unable to make informed choices about contraception. Government agencies and nongovernmental organizations are working to raise young people’s awareness of safe sex and contraception and to connect them with health care services.
Just over 4 percent of women ages 15 to 19 use modern contraception, according to the Nepal Demographic and Health Survey of 2011. The most popular forms of contraception in this age group are condoms – the survey does not distinguish between male and female condoms – and injectable contraceptives. The 2011 survey did not collect information on use of the emergency pill.
Nearly 18 percent of women ages 15 to 19 knew about the emergency contraceptive pill, according to the Nepal Adolescents and Youth Survey 2010-11, conducted by the Ministry of Health and Population.
There is no data available about the use of the emergency pill in Nepal because its popularity is a recent trend, says Dr. Khem Bahadur Karki, executive director of Society for Local Integrated Development Nepal, a nonprofit organization.
But doctors, pharmacists, NGO workers, and young women report that emergency contraceptives have increasingly become young women’s main form of birth control.
Emergency contraceptive pills were introduced to Nepal a decade ago, but use of the pills has increased significantly over the past five years, Karki says. He makes that observation based on his organization’s work in the field of sexual and reproductive health.
Ashok Shrestha Joshi, who has operated A.K. Medical Hall, a Kathmandu pharmacy, for 40 years, says that five years ago, only three or four young women bought the emergency pill in an average week. That number has gradually increased each year. The increase has corresponded with a drop in condom sales to men.
“Until 10 years ago, around 15 to 20 men came to my shop every day to buy condoms, but now the number has decreased to just two or three each day,” he says. “But now, around 15 to 20 young girls come in to buy the emergency contraceptive pill every day.”
The cost of the various brands ranges from 100 rupees ($1.05) to 160 rupees ($1.70) per pill.
Young customers tell Joshi they buy the pills with money their parents give them for food and other expenses.
“These days, the emergency pills have better sales,” Joshi says. “Women between 14 and 24 come to the shop and take the pill immediately, asking us for water.”
Any pharmacy registered with the Department of Drug Administration can sell emergency contraception pills, says Bhogendra Raj Dotel, the section officer of the Adolescent and Sexual Reproductive Health program under the Ministry of Health and Population. The nation’s Drugs Act states that medication, including the emergency pill, cannot be sold without a doctor’s prescription. But the law is not strictly enforced, and many people ask pharmacists for medication without prescriptions.
Joshi is aware of the law but defies it, he says. He is not concerned about possible ramifications of acknowledging his defiance because all Kathmandu pharmacies break the law.
“Selling medicines without a prescription is a common practice, though it’s illegal,” Joshi says. “But it’s impossible to sell medicines only if the customer comes with a doctor’s prescription because doctors are not easily available everywhere. So if only a few of us follow this law, then we would lose business because customers want an easy and fast way and will go to another shop which does not ask for a prescription.”
There is also a cultural reason why pharmacists do not question young customers who request the emergency pill, Dotel says.
“When it comes to sex and sexuality, it is considered a matter of privacy,” he says. “As it is a private matter, the pharmacist does not question why young people want to purchase contraceptives.”
Young people are reluctant to carry condoms or birth control pills in their pockets for fear of their families discovering their sexual activities, Karki says. Many girls feel secure about avoiding pregnancy so long as they take the emergency pill within 72 hours after intercourse.
The contraceptives that Nepalese women use most commonly are intrauterine devices, small devices inserted into the uterus that prevent insemination of eggs; injectable contraceptives that release progestin, which keeps the ovaries from releasing eggs; and subdermal implants, tiny capsules that are inserted beneath the skin and release progestin for about three years, says Pramij Thapa, focal person of the abortion program at the Family Planning Association of Nepal.
Thapa bases his information on the organization’s local research and surveys. But teenagers often use the emergency contraceptive pill without considering safer forms of everyday contraception because it is more discreet, he says.
“For other means of contraception, such as for Norplant and IUDs, the women need to visit a clinic,” Thapa says. “To maintain their privacy, the young people use emergency contraceptive pills, which can be easily taken in the same pharmacy where it is bought.”
(The maker of Norplant, a long-acting contraceptive implant, has replaced it with a safer product called Norplant II, marketed as Jadelle. Doctors and patients often refer to the product by its predecessor’s name.)
Priti Bhandari, 19, a student at Padma Kanya Multiple Campus in Kathmandu, says one can easily buy an emergency pill at a pharmacy without disclosing personal information.
“To use any other type of pill, you need to get advice from a doctor, and he will ask why I want contraception when I am still unmarried and also advise me to wait and have children first,” she says.
Bhandari conceived two years ago while relying on coitus interruptus, a birth control method in which the man withdraws his penis before ejaculating, she says. She started taking the emergency pill after having an abortion, which has been legal in Nepal since 2002.
“The doctor who carried out my abortion told me not to repeat the same mistake,” Bhandari says. “I was very ashamed when he said that. Since then, I regularly take the emergency pill after having sex.”
Bhandari uses the emergency pill about twice a week, she says. She purchases it from pharmacies. Because it is a single tablet, she feels confident she can even take it at home without anyone knowing.
“The emergency pill is a safe and faithful contraceptive for unmarried women like us,” she says.
But young women do not realize that taking emergency pills regularly as one’s main form of contraception poses serious health risks, Karki says.
The high level of progestin in the pills can cause an imbalance in a woman’s hormone levels, impairing her mental development, Karki says. If taken regularly for seven or eight years, the pill can lead to hormonal disorders; diabetes; hypertension; bone degeneration; excessive bleeding and irregularity in periods; uterine cancer; and even sterility.
“There is no risk on health if it is used one or two times a month,” Karki says. “But taking pills after every intercourse will certainly put the reproductive health of young women at risk.”
Dr. Geeta Gurung, a professor and senior gynecologist at Tribhuvan University Teaching Hospital, confirms Karki’s warning. The number of young women seeking treatment at the hospital because they have overused emergency pills has increased over the past four or five years, she says.
“Every day, we get about two or three teenage girls who come for treatment after using the emergency pill,” Geeta Gurung says. “Most of these girls complain of heavy bleeding, headaches and nausea.”
They are treated with saline and, if necessary, blood transfusions to replace the blood they have lost, she says. They are kept in the hospital for a few hours, until their condition stabilizes. Often, they are given iron supplements to help them increase their hemoglobin levels.
She attributes the rising popularity of emergency pills to the increasing freedom with which young people talk about sex and share sexual information and feelings via mobile phones and the Internet.
“We can only advise them not to use the emergency pill as a contraceptive,” Geeta Gurung says.
On a busy day, however, members of the hospital’s medical staff do not have time to advise patients before discharging them, she says.
Narbada Karki, 28, is beginning to understand the devastating impacts of long-term use of the emergency pill. She took the pill about twice a week for seven years.
Since she got married three years ago, she has been trying unsuccessfully to conceive. After many doctor visits and medical tests, she learned she is infertile.
“The doctor said that consumption of emergency pills was the reason for infertility,” Narbada Karki says.
This was the first time she learned of the pill’s risks, she says. She had never read the packaging of the pill.
The packaging warns users that the pill should not be used as a substitute for condoms and other regular contraceptive methods. One package lists the possible side effects as irregular bleeding, nausea, abdominal pain, headaches, vomiting and dizziness.
Narbada Karki regrets her excessive use of the emergency pill in college, she says. Now she is deeply worried about the future of her marriage.
“If I do not bear children, my husband will bring another wife,” she says.
Nepal is in transition, Khem Bahadur Karki says. Long a closed society in which discussion of sex was taboo, it is becoming more open. Education and technology empower young people to change with the times, but their parents resist such changes.
Khem Bahadur Karki believes the increased use of emergency pills as everyday contraception stems from this generational conflict.
“If parents would understand that when their children reach a certain age they are likely to have girlfriend and boyfriends, and there is a possibility of sexual activities between them, the youngsters would not use emergency pills but would rather use condoms and other contraceptives,” Khem Bahadur Karki says. “Emergency pill usage is higher because it is hidden.”
Gyanu Chhetri, a lecturer in the sociology department at Patan Samyukta Campus in Kathmandu, which is affiliated with Tribhuvan University, agrees.
Family discussion of sex is virtually impossible in Nepal, she says. Nepalese culture, which is heavily influenced by Hinduism’s strong conservative attitude toward sex, discourages premarital sex. But over the past 15 years, young people have been breaking traditional norms and adopting a more liberal attitude.
Modernization, globalization, mobile technology and Internet access have encouraged young people to engage in unprotected sex and rely on emergency contraceptive pills, Chhetri says.
Charitra Oli, a Kathmandu homemaker and mother of two teenagers, typifies her generation’s attitude toward adolescent sexuality.
“I never talk about sex with my children,” Oli says. “I feel ashamed to talk about it, and I prefer to not think about whether they are sexually active.”
Oli knows that teenagers engage in sexual activities, she says. She is scared for her children because they can easily be influenced by their friends.
Oli sometimes wants to talk to her children about sexual behavior but is ashamed to bring up the topic, she says. She does not know how to begin or guide such a conversation.
“My daughter often visits her friend’s house and spends a lot of time in the evening and during holidays,” she says, referring to a male friend of her daughter’s. “I have fears regarding her safety, but I have never asked anything from her.”
Such reticence is not limited to parents. Even some schoolteachers are embarrassed to teach the curriculum on sex education because the names of some sex organs sound like indecent words, Dotel says. In his visits to schools around the country, he has met many teachers who avoid teaching the chapter on sex education.
“It is urgent to address this issue, as adolescents are misusing the emergency pill and their health is at risk due to the pill’s side effects,” Dotel says.
Government agencies and nongovernmental organizations are working to educate young people about sexuality and contraception.
The Ministry of Health and Population is implementing a peer educator program among young people ages 10 to 19, Dotel says. The program, launched in 2009-2010, seeks to make 1,100 primary health care centers, health posts and sub-health posts in 60 districts more youth-friendly by educating youth leaders about sexual health, reproduction and contraception. The youth leaders share the information with their friends and acquaintances.
“The government is also planning to create awareness on sexual health among adolescents by sending SMS [text messages] on their mobile phones,” Dotel says.
Working with local telephone operators, the government plans to disseminate educational messages about sexual health, Dotel says. These programs raise awareness of safe contraceptive methods and give young people opportunities to seek advice and information.
Since 2010, the Ministry of Health and Population has published eight textbooks on sexual and reproductive health for 10- to 19-year-olds, Dotel says. The government has distributed the textbooks to all government schools in 49 districts and plans to increase the coverage to 60 districts in the coming year.
For the past five years, SOLID Nepal has been producing a radio program called “Khulduli.com” to educate young people about reproductive health, including the correct use of emergency contraceptive pills, Khem Bahadur Karki says. The program, whose name incorporates the Nepali word for curiosity, is broadcast over 54 FM stations across the country.
The Family Planning Association of Nepal has 84 youth-friendly service delivery centers and 82 youth information centers in 42 districts, Thapa says.
“Awareness about side effects of excessive use of the emergency contraceptive pill, unsafe sexual practices and sexually transmitted diseases are most necessary to reduce the misuse of the emergency contraceptive pills by adolescents,” he says.
In spite of the available information and her bleeding episode, Limbu remains unconvinced that regular use of the emergency pill is unsafe.
“My first priority is to prevent pregnancy,” Limbu says. “I have not thought about other problems yet.”
GPJ translated this article from Nepali.
No sources in this article are related.
Tara Bhattarai contributed to the reporting of this article.