Monday, 31 October 2011

What the poverty debate in India misses?

Devendra Kothari
Prof. Population program Management

The latest controversy over India’s poverty line argues that there is an urgent need to look at the issue from a pragmatic perspective.  The blog aims to provoke discussion and mobilize support for reproductive health services to expedite the process of alleviating poverty in India.

The Planning Commission,   an institution of Government of India, which formulates socio-economic policies including Five-Year Plans, filed an affidavit in the Supreme Court in the last week of September 2011 claiming that the "poverty line of Rs. 26[1]  and Rs. 32  for rural and urban areas respectively ensures the adequacy of private expenditure on food, health and education". According to this, a family of five spending less than Rs 4,824 (at June 2011 prices) in urban areas would come in the Below Poverty Line (BPL) category. The expenditure limit for a family in rural areas is being fixed at Rs 3,905. The affidavit could not have come at a worse time when food inflation is pushing poor households to the wall.

This created hue and cry throughout the country. Some prominent NGOs/experts including some members of the Indian ruling party’s think tank - National Advisory Council (NAC) - under the chairmanship of Mrs. Sonia Gandhi argued that the affidavit is a document, no less historically significant than the "India Shining" campaign that brought the downfall of a previous regime, because it reflected arrogance and contempt for the poor comparable to the views held by the Planning Commission.  In an open letter to Dr. Montek Singh Ahluwalia, Planning Commission Deputy Chairman, Mrs. Aruna Roy, member of NAC, demanded “withdraw the affidavit on the poverty line or resign”. The letter states that “If Rs 26 for rural areas and Rs. 32 for urban areas per capita expenditure was ‘adequate’ then it is not clear to us that why Planning Commission members are paid up to one hundred and fifteen times the amount (not counting the perks of free housing and health care and numerous other benefits that is enjoyed by you and members of the Planning Commission)”. It is interesting to note that in recent years, especially during the high economic growth, India has fallen further behind neighboring and poorer (in terms of per capita income) Bangladesh, in terms of most of the human development indicators.

It appears that the Planning Commission wanted to peg the number of beneficiaries of Centre's welfare schemes by reducing the number of poor people in India. The formal de-coupling of poverty and entitlements such as subsidized food, fuel and fertilizer is significant because of indications that a move was on to reduce the subsidy burden.  Seeking to counter the perception of insensitivity, the Government of India has agreed to remove caps on the number of poor an individual State can have and formally de-linked subsidies from the income threshold, but did not agree to change its definition of poverty, at least immediately. is argued that by relaxing the definition would open the floodgates for enumeration as poor, straining the exchequer in the process[2].  

One can also argue that by adopting proposed yardstick of poverty line, India will probably exceed the UN Millennium Development Goals (MDGs)[3] of halving poverty between 1991 and 2015. “Even so, argued economist Swaminathan Aiyar[4], “India will be a poor country for a long time. Forget statistics - just see the horrific workers’ hovels at construction sites. Workers nevertheless come because rural conditions are even worse”.

Is there any other way out to poverty alleviation? There is a need to take a pragmatic approach to poverty alleviation, which means addressing its root causes – including unplanned and unwanted fertility.  One should also build the capacity of women and men to move beyond poverty, training them in the skills, methods, knowledge and leadership needed to take self-reliant actions so they can meet their own basic needs, improve their communities and build better futures for themselves and their children. Available  data indicate that avoiding unwanted /unplanned fertility can be another but effective way to handle the poverty issue, as observed in many countries including Bangladesh and in some States of India. For this, one must empower people especially those belonging to the bottom of the pyramid to have children by choice not by chance.

One of the background characteristics used throughout the National Family Health Survey (NFHS–3) Report is an index of the economic status of households called the Wealth Index. The NFHS-3 economic status index was constructed using 33 household asset data and housing characteristics[5]. Accordingly, households have been divided into five categories[6]. To make point, I will   concentrate on three categories: Lowest, Middle and Highest.  The Table 1 provides some basic information about household by this index. The table reveals that differences by economic status are large for every selected variable. The proportion of men who have never attended school declines from  47% for men in the lowest wealth quintile to only 2% for men in the highest category; and the corresponding decrease in the proportion of women who never  attended school declines  sharply  from 77%  in the lowest category to only 8%  for women in the highest category.   Further, only 11% of women in the lowest economic strata have completed standard six and above of education, compared with 84% of women in the highest economic class.  Unless we focus on this segment, which constitutes around two-third of total population, achieving eradication of extreme poverty and hunger (MDG 1) within a reasonable time span will be a dream. Here the “Bottom of the Pyramid” approach, coined by Prahlad, could be of great help[7]. In other words, India needs class-specific measures to alleviate poverty.

Table 1: Distribution of households by some selected indicators according to household economic status, 2005-06        
Economic Status
% of men never attended school
% of women never attended school
% if women completed standard 6 and above
Number of children per woman  (TFR)
Number of unwanted children/woman
% of births of  order  four or higher
% of couples having  unmet need for contraception
% of  couples  protected by modern contraceptives
% of  couples  protected by spacing methods
Source: National Family Health Survey- 3, 2005-06, IIPS, Mumbai 2007.

The level of unwanted or unplanned fertility can be measured by comparing the total wanted fertility with the total or actual fertility. The total wanted fertility rate represents the level of fertility that theoretically would result if all unwanted births were prevented.  The proportion of births that were unwanted was the highest for births to women from the “bottom of pyramid”. Table 1 reveals that in India, the total wanted fertility rate of 2.4 children per woman, belonging to the lowest economic strata is lower by 1.5 children (that is by 38 percent) than the actual or total fertility of 3.9 children per woman. This means the households belonging to low economic strata have more children than they actually want and this can be seen throughout the country. The table also indicates that the level of unwanted fertility decreases sharply among women from the lowest economic strata to the women in the wealthiest class from 1.5 children per woman to 0.3 children per woman.  One can argue that total fertility rate would drop substantially among women from the lower strata if their unwanted fertility could be eliminated, and this will help them to improve the quality of life. 

Unmet need for family planning[8] is an important indicator of assessing the potential demand for family planning services or contraceptive devices. In spite of poverty and illiteracy, the prevailing unmet need for family planning services is surprising.  Table 1 indicates that unmet need for family planning decreases with an increase in economic status of households from 18% to 8% among highest economic category. For the first time ever around, half of the currently married women in reproductive ages (15-49 years) in India are protected by modern contraception, however, its use is uneven. Economic status has a positive effect on contraceptive use, with use increasing from 35% among married women in households in the lowest economic strata to 58% among those in the highest strata. The use of any modern spacing methods (Pills, IUCD, and Condom increased sharply from 4 percent among couples in the lowest strata to 22 percent among in the highest one (Table 1).  This  indicates that the use of existing spacing methods  is not very popular among women and men belonging to lower economic strata mainly due to inconvenience to use. Such a situation leaves couples with no choice except sterilization. This choice is not widely preferred by couples in the light of prevailing of high infant and child mortality, especially among the lowest economic strata.

Based on findings of the National Family Health Surveys (NFHSs 1, 2 and 3), it is estimated that currently there are around 450 million people in India who are product of unwanted/unplanned  fertility[9], and most of them are from the lowest economic strata.  The consequences of unintended pregnancy are serious, imposing significant burden on women and families, and in turn slowing down the process of economic emancipation thus creates obstacles in the process of poverty alleviation. In short, in the changed situation most of the people, belonging to the lowest economic strata, do not want more children. But, they still have them, primarily due to lack of client centered reproductive healthcare.  The real need is to provide services in un-served and underserved areas by realigning the capacity of health system to deliver quality care to suit the needs of clients, especially those belonging to the “bottom of pyramid”. Therefore, reproductive healthcare is an essential plank in empowering the poor. We need creative policies to strengthen this foundation.

 The next blog discusses the issue of creation of smaller States in India

[1] One American dollar is equal to Rs. (Rupees) 48.
[2] The number of poor entitled to BPL benefits, as per the affidavit, has been estimated at 407.4 million.
[3] The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the world's main development challenges. The MDGs are drawn from the actions and targets contained in the Millennium Declaration that was adopted by 191 nations - and signed by 147 heads of state and governments (including India) during the UN Millennium Summit in September 2000. Recognizing the urgency of poverty issue, world leaders have made poverty a top priority as a part of Millennium Development Goal 1.The Eight MDGs are:  1. Eradicate extreme poverty and hunger; 2. Achieve universal primary education; 3. Promote gender equality and empower women; 4. Reduce child mortality; 5. Improve maternal health; 6. Combat HIV/AIDs, malaria and other diseases; 7. Ensure environmental sustainability; and 8. Develop a global partnership for development.
[4] For details, see article: Middle Class hypocrisy on poverty line, Times of India, dated Oct.2, 2011. 
[6] The five Wealth Index categories are: Lowest, Second, Middle, Fourth and Highest. For details, see NFHS-3. 2007.  India: National Family Health Survey, 2005-06. International Institute for Population Sciences, Mumbai. 
[7] For details, see:  CK Prahlad.  The Fortune at the Bottom of Pyramid: Eradicating Poverty through Profit.  Pearson Education, Inc, 2006. 
[8] The standard definition of unmet need depends upon the apparent inconsistency between a woman’s contraceptive behavior and her stated reproductive preferences. The concept of unmet need was highlighted first time in India in a study conducted by the author in Rajasthan in 1988 on behalf of Ministry of Health and Family Welfare, Government of India. Based on the field data, the study revealed that there was sizable number of eligible couples that were not using contraceptive methods but did not want another child. According to the study, 15 per cent of currently married couple in Rajasthan had unmet need for family planning services in 1988-89. For details, see Devendra Kothari, Family Planning Programme in Rajasthan: Beyond the Existing Approach, Indian Institute of Health Management Research, Jaipur, 1989. 
[9] Kothari Devendra. 2011. Implications of emerging demographic scenario: Based on the provisional results of the census of India 2011.  A Brief.  Management Institute of Population and Development, New Delhi.

Monday, 10 October 2011

The revolutionary new birth control method for men and India’s lukewarm response

Dr. Devendra Kothari
Population and Development Analyst

Forum for Population Action
Currently men pretty much have three choices when it comes to avoiding pregnancy: Condom (which can break), Vasectomy (which is irreversible), and Withdrawal (not an effective method of contraceptive). But behold thanks to an Indian scientist world could be on the verge of a fourth option.

After a more than 30-year struggle, an unassuming Indian engineer from Indian Institute of Technology, New Delhi named Sujoy K. Giha is on the brink of what could well be the most revolutionary contraceptive technology since the pill – and this time it is for men. The 70 year- old Indian scientist has developed a form of male birth control that is non-hormonal, 100 percent effective and has no side effects. The procedure, called RISUG (reversible inhibition of sperm under guidance), involves injecting a positively charged, non-toxic polymer into the vas deferens that renders passing sperm useless. If the male decides he wants to reproduce, a second injection dissolves the polymer. This post discusses this new development and the Indian government machinery‘s lukewarm response to this revolutionary event.

The device does not inhibit sperm production; instead, it acts, to quote the May issue of Wired[1] , as "a tollbooth on the sperm superhighway”.   Not only is the technique would be an outpatient procedure completed within 15 minutes, does not have to done often, and does not have any side effects. So far all the trials done on Indian men since 1989 have been 100% effective.

If the research pans out, RISUG would represent the biggest advance in male birth control since a clever Polish entrepreneur dipped a phallic mold into liquid rubber and invented the modern condom some four hundred years ago. “It holds tremendous promise,” says Ronald Weiss, a leading Canadian vasectomy surgeon and a member of a World Health Organization team that visited India to look into RISUG. “If we can prove that RISUG is safe and effective and reversible, there is no reason why anybody would have a vasectomy.”

But here’s the thing: RISUG is not the product of some global pharmaceutical company or state-of-the-art government-funded research lab. It’s the brainchild of Prof. Guha, who has spent more than three decades refining the idea while battling bureaucrats in his own country and skeptics worldwide. He has prevailed because, in study after study, RISUG has been proven to work 100% of the time. Among the hundreds of men who have been successfully injected with the compound so far in three clinical trials, there has not been a single failure or serious adverse reaction. In May 2002, it was announced that RISUG was on track for approval in India and would be rolled out on a limited basis within six months. But it did not happen.  However, RISUG has faced a series of bureaucratic barriers.

RISUG has been in Phase III clinical trials in India since 2002. In October 2002, government officials aired concerns about RISUG in India's national press. Their concerns have since been resolved, but the controversy stalled the clinical trial for six months. The next delay was due to concerns about RISUG's initial toxicology tests. The Indian Council for Medical Research (ICMR) has reviewed the toxicology data three times and approved it each time. At around the same time, a World Health Organization team came to visit Guha’s lab in Delhi and examine his data. This it self was a triumph: It meant RISUG was finally on the international radar. In its report, the WHO team agreed that the concept of RISUG was intriguing. But they found fault with the homegrown production methods: Guha and his staff made the concoction themselves in his lab, and the WHO delegation found his facilities wanting by modern pharmaceutical manufacturing standards. Furthermore, they found that Guha’s studies did not meet “international regulatory requirements” for new drug approval. The team stated that the 25-year-old toxicology studies did not meet more recent international standards. RISUG was submitted for a new round of tests at a US lab, and approved in July 2005. In March 2006, the trial was slated to resume at 4 centers around India. Then a manufacturing delay halted progress. The pharmaceutical company making RISUG was finally able to deliver a batch produced to the World Health Organization’s Good Manufacturing Practice (GMP) standards in March 2007.  The trial resumed in earnest in April 2007.  The trial’s data collection, analysis and publication process will take several years to complete.

Guha looked around for a corporate partner for improving the facilities but found no takers. Unlike birth control pills, which must be used daily, sometimes for years, RISUG is a long-lasting, low-cost treatment (the syringe could end up costing more than the material it injects). “Pharmaceutical companies are not interested in one-offs,” Weiss says. “They’re interested in things they can sell repeatedly, like the birth control pill or Viagra.” In other words, “It was not a problem of science,” says A. R. Nanda, an early supporter of RISUG and former secretary of the department of family welfare. “It was a problem of politics and ego.”

In both the East and the West, the need for better contraceptives couldn’t be clearer. India will soon surpass China as the world’s most populous nation; in the poorest Indian state, women bear an average of nearly four children. Cheap to produce and relatively easy to administer, RISUG could help poor couples limit their families—increasing their chances of escaping poverty. The impact could be huge for India, where sterilization is still the most often used method of birth control. The numbers say it all. Today, only 3% of women are on the pill and 5%t of couples use condoms. Meanwhile, some 37% of women undergo the comparatively dangerous tubectomy operation, while only 1% of men get vasectomies.  In the developed countries, RISUG would help relieve women of the risks of long-term birth-control-pill use and give men a more reliable; less annoying option than condoms, and at the same time reduce the number of abortions significantly.

RISUG is garnering interest beyond India.  Thanks to a novel collaboration between Guha and a San Francisco reproductive health activist- Elaine Lissner, RISUG could soon be on the road to FDA approval in the US.  By 2001, she had concluded that RISUG was the most promising new development out there and began tracking its ups and downs closely. By 2009, though, she had grown frustrated with the lack of progress on RISUG in India. Luckily, she was in a position to do something about it. At the beginning of the real estate boom, she’d invested a small amount of money in her father’s construction company, which had become wildly successful building houses around Reno, Nevada. She parked the profits in a small private foundation called Parsemus and set about putting money behind RISUG.

In February 2010, Parsemus bought the international rights to the RISUG technology from Guha and IIT Kharagpur for $100,000. The plan was to get RISUG OK’d in the US, perhaps even before it hit the market in India.  Whether our policy makers are listening?

The next blog discusses what the poverty debate misses in India.  

[1] This post is mainly based on an article:   The Injectable Vasectomy by Bill Gifford appeared in Wired magazine of May 2011, 170-186.

Tuesday, 4 October 2011

Controversy over Injectable contraceptives in India: How to resolve it?

Dr. Devendra Kothari
Population and Development Analyst

Forum for Population Action

Are injectable contraceptives suitable for the Indian women? This blog weighs the pros and cons, so the policy makers could make an informed decision.

The contraception is anything that prevents a woman from becoming pregnant. Medical technology allows contraception through various means like sterilization, Pill, intrauterine device (IUD), condom, implants, injectables among others so that those not practicing abstinence can control conception. Injectable Contraceptives (ICs) are the fourth most popular method worldwide, after female sterilization, intrauterine device and oral contraceptives. Currently two brands of ICs are very popular: Depo-Provera and Noristerat. Of these, Depo-Provera also known as depot medroxyprogesterone acetate (DMPA) is by far the more widely-used.

The Depo-Provera is a reversible contraceptive and it can prevent pregnancy for three months. It decreases chances of benign breast disease. Also protects against endometrial cancer. Any nurse or trained non-medical staff can administer the injection. There is no need to book an appointment with gynecologist or doctor every time for a shot. However, there are a few disadvantages as well. Changes in menstrual bleeding are likely, including light spotting or bleeding. In fact, amenorrhea is a normal effect especially after the first year of use. These injections may also cause some weight gain. Severe headache, nausea, abdominal pain, hair loss, lack of sex drive and acne in some women has also been recorded. In addition, recent studies indicate that the drug may contribute to osteoporosis. Despite potential drawbacks, the available research indicates that the contraceptive's benefits appeared to outweigh its risks[1].

There was a long, controversial history regarding the approval of Depo-Provera in many countries including USA. The original manufacturer, Upjohn, applied repeatedly for approval to the U.S. Food and Drug Administration in 1973, 1975 and 1992, but the FDA repeatedly denied approval. Ultimately, on October 29, 1992, the FDA approved Depo-Provera, which had by then been used by over 30 million women since 1969[2]. FDA discussed thoroughly the side effects before approving it and also consulted experts within and outside USA including WHO.

Is it effective? Depo-Provera is as effective as sterilization and more effective at preventing pregnancy than several other spacing methods, including birth control pills, condoms and diaphragms or IUDs. A field based study, conducted by the Johns Hopkins Bloomberg School of Public Health[3] in 2006 states that “More than twice as many women are using injectable contraceptives today as a decade ago, and the numbers keep growing. Injectables appeal to the many women, especially young and poor who seek a family planning method that is effective and long-acting and can be used privately”. Injectable contraceptives are widely accepted in America, Europe, Africa and parts of Asia, especially in Bangladesh, Nepal, Thailand, Indonesia and even Pakistan (Table 1). Between 1995 and 2005 the number of women worldwide using ICs more than doubled. In 2005 over 32 million were using injectables. By 2015 worldwide use is projected to reach nearly 40 million - more than triple the 1995 level.

      Table 1 Estimated use of Injectables among married women ages 15–49, 2006
Per cent currently using
Per cent of modern method users using Injectables
Any method
Any modern method

Kenya (2003)
Egypt (2005)
South Africa (2003)
Bangladesh 2004
Cambodia 2005
Indonesia 2002–03
Nepal 2006
Source: Series K, Number 6. Injectables and Implants, Knowledge for Health Project, the Johns Hopkins Bloomberg School of Public Health, USA, 2006.

India and Injectable contraceptives:
ICs are available in more than 106 countries; however they are not the part of the public sector family planning program in India even after nearly two decades of discussions and scientific trials. It is interesting to note that ICs were approved for marketing by Government of India in 1993, and later they were introduced in the official family planning program. However, some women’s groups[4] led by politicians launched an intensive campaign against the introduction of injectables and succeeded in filing a petition in the Supreme Court, seeking a ban on such contraceptives. After much lobbying and pressure from women’s groups, the Ministry of Health and Family Welfare (MoHFW) finally dropped its plan to introduce injectables in the program. It was argued that the public sector wasn't equipped well enough to handle its use in a large-scale manner, and also manage its side effects, however approved the use in the private sector. ICs are easily available over the counter, even without a doctor’s prescription. But they are expensive.

After more than 15 years of scientific trials and experiments as well as widespread use of ICs in the neighboring countries as well as its easy availability in the open market, there was a hope that in order to increase the basket of choice of contraceptives for women, India may introduce ICs in its official program soon."Lot of work has been done on injectable contraceptives and we have come to the final stage where the Joint Technical Advisory Board will meet shortly and hopefully clear it,[5]" the  Health and Family Welfare Secretary Sujatha Rao told at the the First Asian Population Association Conference held in New Delhi on November 16, 2010. But, the Government later came under criticism for the proposed move, and wilting under pressure from some public interest groups and politicians dropped the idea of introducing injectable contraceptives in its program.[6]

The announcement was a big shock especially to those belonging to the lowest economic strata as well as followers of Islam who are having serious problem of unwanted fertility. They were looking forward to have ICs as part of a package of public sector reproductive or primary   health care services since these are expensive but convenient and very-very private. Available studies indicate that women in India by and large, no matter how poor or subjugated they may be, have a strong desire to control their fertility. However, as per the latest National Family Health Survey (NFHS-3), every fifth birth has been classified as unplanned or unintended (that is mistimed or unwanted at the time the women became pregnant).  It is estimated that more than 26 million children are born in India every year and out of this about 6 million births have been classified as unplanned. Approximately two-thirds of the unintended pregnancies resulted from non-use of contraceptives; clearly indicating the need for revamping the program. In addition, around one-third of unintended pregnancies resulted from the ineffective use of contraceptives, which suggests the need for improved counseling and follow-up of couples that adopt the method (Kothari, 2010)[7].

The level of unwanted fertility can also be measured by comparing the total wanted fertility rate with the total or actual fertility rate. The total wanted fertility rate represents the level of fertility that theoretically would result if all unwanted births were prevented.  The proportion of births that were unwanted was the highest for births to women from the “bottom of pyramid”. NFHS-3 data  reveals that in India, the total wanted fertility rate of 2.4 children per woman, belonging to the lowest economic strata is lower by 1.5 children (that is by 38 percent) than the actual or total fertility of 3.9 children per woman. This means the women belonging to low economic strata have more children than they actually want and this can be seen throughout the country (NFHS-3, 2007)[8]. The data also indicates that the level of unwanted fertility decreases sharply among women from the lowest economic strata to the women in the wealthiest strata from 1.5 children per woman to 0.3 children per woman. Further, among various religious groups, the level of unwanted fertility was highest among Muslims (1.1 children per woman).   It means total fertility would drop substantially if their unwanted fertility could be eliminated. And here modern contraceptive methods especially effective spacing methods could  play an important role. 

The findings of the group discussions indicate that women in the Kacchi Basti (slums)[9]  want wider choice of methods like injectables to be part of the official Family Welfare Programme to improve ‘choice’ and ‘convenience’. Although injectable contraceptives have been kept out of the public sector program, they are available in the private health sector. In our study area a large number of women knew about injectable contraceptives and some of them were using Depo-Provera, though they found it expensive. However they considered it more convenient in comparison with taking pills every day, or inserting an IUD or telling their husbands to use condom. The women of the study area were convinced that an injectable is actually a more convenient means of contraception than the existing ones. One of the women told in the group discussion:

I was not keen on the third child since I was already having two children - a boy and a girl. I had a lot of arguments with my husband because of this.  I tried to convince him, but in vain.  I came to know about injection from my friend and took it from the local clinic Aadhar (a clinic run by the Parivar Seva in the slum). I had some health problems like bleeding, back pain, nausea, joint pain and headache.  Despite these problems, for me the injection was a blessing, as I was relieved from conceiving again and again”. 

Although injectable contraceptives are not included in the Family Welfare Programme of India, it is surprising that more than half of the currently married women are aware of this spacing method. And in some poor performing States like Uttar Pradesh, the awareness was more than 80 per cent among women. Further, the proportion of women in India who know about injectables increased from 19% in NFHS-1 (1992-93) to 52%t in NFHS-3 (2005-06). And the level of awareness is relatively high among women belonging to lower strata.  Although the use of injectables is extremely low in India, it is relatively more popular among the women belonging to lowest strata (NFHS-3).

The right to decide freely and responsibly the number and spacing of children and to have the information, education and means to do so is well recognized as an important component of reproductive rights. Contraceptives enable men and women to exercise these rights. Modern technology has provided us with a range of contraceptive choices. The distribution pattern of usage of various methods to prevent pregnancies is called "method mix". India is unique in that female sterilization is the predominant method, since it is aggressively promoted by the program. India's family planning program has largely failed to encourage the use of reversible methods, particularly among young women (age 15-25) who are in the most fertile years of their reproductive period. And there is urgent need to promote convenient and effective spacing methods like ICs. Here mass media campaigns have the potential to provide visibility to this product, spread information, build interest and influence public opinion.  Such campaign will change the mindset of the policy makers.

The next blog discusses how a maverick Indian scientist developed a revolutionary, easily reversible birth control method for man but how the system discouraged it.

[1] For details, see: Lande, R. and Richey, C. “Expanding Services for Injectables,” Population Reports, Series K, No. 6. Baltimore, INFO Project, Johns Hopkins Bloomberg School of Public Health, December 2006.

[2]See, Leary, Warren E. (October 30, 1992). "U.S. Approves Injectable Drug As Birth Control"The New York Times.

[3]  For reference, see footnote 2.

[4]  For details, see: Sarojini NB and Laxmi Murthy. 2005. Why women's groups oppose injectable contraceptives, Indian Journal of Medical Ethics. 2(1)
[5] See Times of India dated November, 17, 2010
[6] See, Times of India dated March 28, 2011

[7] For details, see: Kothari, Devendra. 2010.  “Empowering Women in India through better Reproductive Healthcare”, FPA Working Paper No 5, Jaipur: Forum for Population Action.

[8] IIPS.  2007.  India: National Family Health Survey, 2005-06. Mumbai:  International Institute for Population Sciences.

[9] [9] For details, see; The Status of Reproductive Health in Jawahar Nagar Kacchi  Basti (Slums), Jaipur, India. Forum for Population Action, Jaipur, 2010.