Why Tamil Nadu Must Clarify Conflicting Signals About Reproductive Choices
Shortages of emergency contraceptive pills and the CM’s call for larger families – there is now a question mark over the state’s acclaimed reproductive health policies
A barrage of desperate queries inundates Chennai-based activist Archanaa Sekar’s social media every day. They are from men and women across Tamil Nadu in urgent need of levonorgestrel, an oral emergency contraceptive pill (ECP). The morning-after pill, approved by the World Health Organization – with brand names such as I-Pill and Unwanted 72 – is in acute short supply in the state. To be taken within 72 hours of unprotected sex, finding these pills is a race against time.
“I have held the hands of young women who have taken the pill in the carpark of my house; there was a woman, mother of two with one child on the autism spectrum, who said I cannot have other children. Another young man emailed me in broken English to ask me where in his remote district where he could find an ECP,” says Archanaa, a sexual and reproductive health activist.
From delivering over 250 ECPs during the pandemic to helping strangers find pharmacies with a stock of levonorgestrel, Archanaa is among the few reproductive and health rights activists in the state stepping up to help those in dire need of birth control, and advice on how to use it. And these desperate pleas, she says, come from people at intersections of caste, class, and region.
Why is there a shadow ban on ECPs in the state? Archanaa says it is a mix of taboo, stigma, and a popular misconception around the formulation, including among some pharmacists, that it is an abortion pill. This, she adds, can be traced to the absence of easy conversations around safe sex, contraception, consent, love, and pleasure.
“Given that this might be the (most popular) contraception method many are seeking, it is a shame it is not as available as it should be,” says the activist.
Introduced in 2002 by the Ministry of Health and Family Welfare (MoHFW), the ECP was made an over-the- counter (OTC) drug a decade ago. It is also included in the Accredited Social Health Activists’ (ASHA) drug kit. The World Health Organization has estimated the success rate of the ECP at 95%, declared it “safe for use by all women, including adolescents” and reported only mild and short-term side-effects, the most common being irregular menses, fatigue, abdominal discomfort, and nausea.
However, a section of gynaecologists in Tamil Nadu have been demanding that the sales of hormonal contraceptives be regulated because they believe they have more serious side effects. Trouble began when a six-member expert sub-committee was formed after the state government proposed a ban on the OTC sale of all hormonal contraceptives citing their “irrational usage” at the 62nd Drugs Consultative Committee meeting held in September 2023.
Then, a year later, news broke that the Central Drugs Standard Control Organisation (CDSCO) was likely to recommend a ban on the OTC sale of hormonal contraceptive drugs, including ECPs. The organisation later stated that the ECP would continue to be sold OTC, but issued no further clarifications.
This development is not the only reason why health activists in Tamil Nadu are dismayed by the state’s confused approach to sexual and reproductive health.
Earlier this month, chief minister MK Stalin exhorted young couples to have children “immediately” after marriage to deal with the proposed central delimitation exercise which would put Tamil Nadu at a disadvantage. This exercise will redraw parliamentary constituencies based on population and southern states – that have successfully controlled their population over the last few dates – now fear this would give more political clout to the populous northern states.
Activists say Stalin’s plea for more children could undo nearly a century of work progress on reproductive health in the state, as we detail later. “You are asking every woman of Tamil Nadu to play surrogate for future voters,” says Archanaa.
S Anandhi, professor at Madras Institute of Development, points to more problematic implications. “All of these anxieties are pinned onto women’s reproductive choice and they have a direct implication [for it] and are not to be taken only from the point of view of delimitation,” she says.
Tamil Nadu has a long and robust history of debating reproductive and sexual health. The social justice movement, which forms the ideological underpinning of the Dravidian parties, was progressive enough even in the 1930s and 1940s to advocate birth control and women’s autonomy in all spheres. Dravida Kazhagam leader EV Ramaswamy or Thanthai Periyar – the father of the Dravidian Movement – for instance argued that women should be the agents of their own liberation.
“Contraception is essential for women to be free and autonomous,” he wrote. Dismantling the idea of chastity, he argues in ‘Why were women enslaved?’ that “pregnancy is especially a cruel enemy to the independence of women”.
Essential But Not Available
According to the National List of Essential Medicines (NLEM), levonorgestrel must be stocked in all primary, secondary, and tertiary health centres, “at affordable costs and with assured quality”. However, as The News Minute reported, 22 out of 23 pharmacies the reporters visited in Chennai did not stock it.
The shortages and debates around the pill are not unprecedented. In 2006, the then-state government’s drug controller, N Selvaraju, imposed a ban on it, after protests from groups such as the Responsible Parents Forum and the Satvika Samuga Sevakar Sangam. Ten years later, filmmakers Vaishnavi Sundar and grassroots group Jhatkaa initiated an online petition to make the pills available in Tamil Nadu. The media took notice, there was some outrage and then the issue went off the news cycle, points out Archanaa.
“There is no official written documented ban on this pill and we are allowing this vagueness around it to continue. All we need to clarify this confusion is a simple notice to pharmacies put out by the CDSCO that it is an essential pill. This is there in the representation made to CDSCO, and there hasn’t been a response in 100 days,” adds Archanaa.
However, senior officials have maintained that OTC sales of the pill remain unaffected.
The Tamil Nadu State Policy for Women 2024 states that steps must be taken to ensure “women’s reproductive rights such as the right to exercise choices in contraception, family planning methods, right to bodily autonomy including the right to legal and safe abortion”.
However, senior gynecologist Jaishree Gajaraj argues that the ground reality is different. “We have always had difficulty prescribing ECP. Earlier, the formulation wasn’t there and we had to carve out a formulation from four tablets and explain how to take it,” she says. This formulation, including a mix of progesterone and estrogen, leads to side effects, she adds.
There has been an outcry against the “irrational use of ECPs” and misconceptions about its misuse but Jaishree maintains that “the onus is on us as health care professionals to create sufficient awareness”. According to the WHO fact sheet, levonorgestrel is “safe for use by all women, including adolescents” and may cause mild and short-term side-effects, the most common being irregular menses. fatigue, abdominal discomfort, and nausea. Side effects are not common, they are mild, and will normally resolve without further medications.”
Poor access to ECPs and an inability to negotiate safe sex may push women into searching for unsafe termination methods, and maternal deaths. BehanBox has reported on unsafe abortion, lack of rights and intersections with disability here and here.
In the 2010s, Archanaa recalls, the use of ECPs was something of a taboo but they were easily accessible, with women carrying the pills around like an emergency provision, exactly as they would menstrual pads. “Many of us were taking ECPs more than we should have [instead of opting for preventive contraception], and that was [because] information was not handed to us,” she says.
Dealing With Reality
Currently, in Chennai, a cursory search on Twitter or Instagram could yield a list of pharmacies that regularly stock these contraceptives, and it has been put together by city-based activists like Archanaa and Apoorva Mohan. “But [on a given day] there is no way of keeping track of whether the pill is stocked or not. Right now, for instance, two pharmacies on the list didn’t have the pills, but another does,” says an activist who chooses to remain anonymous.
So who are the people that approach these activists the most with demands for the pill? Archanaa says that, contrary to popular perception, they are not necessarily those engaging in premarital sex, or elite, English-speaking, urban and middle class.
“Our evidence reiterates our hypothesis that while the pill is a well-known method of contraception – and condoms are easily available and safer for the body – sex does not happen in a planned manner in people’s lives. If you have a large family, for example, you might be embarrassed to have condoms lying around,” says Archanaa. It is likely that abortion pills are more easily available in the market than ECPs, she adds, because they are sanctioned by every pharmacy attached to a hospital with a gynecology ward.
Many of these issues are rooted in the way women pander to male partners and what they think of pleasure without knowing the cost on their bodies, she adds.
The use of condoms as a means of contraception is below the national average of 9.5% in Tamil Nadu (1.8%), as per the National Family Health Survey (NFHS)-5 at 1.8% Female sterilisation stands at 57.8%, and vasectomies at 0.1%, and both Archanaa and Jaishree chalk this up to the inability to push for condom usage, and misconceptions that men lose “strength” if they undergo sterilisation.
The Delimitation Debate
Even as ECP shortages are being reported in the state, CM Stalin has exhorted young married couples to have more children to give the state a population advantage to maintain representation in the Lok Sabha, as we said earlier. Carried out by the Delimitation Commission, the exercise will redraw boundaries of parliamentary and assembly constituencies in states based on population. Given its high development index and highly successful family planning drive, the state’s population is 7.21 crore, as opposed to Bihar’s 10.4 crore or Uttar Pradesh’s 19.9 crore.
By 2026, it is expected the southern states will lose some Lok Sabha seats, its share declining from 23.7% to 19%. The southern states, particularly Tamil Nadu, have demanded a freeze on delimitation until 2056, until northern states deal with their population figures.
“If Tamil Nadu needs to be an important state in the Union, you need more representation which means ‘dear woman of Tamil Nadu, bear us children’ and you are putting the onus on the woman. It is ironic that this statement is made by a man from a party that is meant to uphold social justice values. If we don’t nip this in the bud, it will pave the way to archaic expectations of women’s use of their uterus,” says Archanaa.
In the 1930s and 40s, India saw a flurry of debates (here, here and here) regarding birth control initiatives, and anxiety over population. As Sarah Hodges, a researcher and professor of Global Health and Social Medicine at King’s College, London writes in Contraception, Colonialism and Commerce, there were proposals for birth control clinics and counselling facilities at dispensaries in Bombay City, Karachi, Mysore, Madras, and Ahmedabad.
“These arguments for birth control developed in the context of the economic crisis, specifically the global economic depression that began in 1929 and intensified during the early 1930s,” she writes. International birth control pioneers like Margaret Anger and Maria Stopes assisted extensive networks of birth control correspondents in India.
Early Debates
In the early 1880s, a Hindu-Malthusian League was formed in Madras consisting of upper caste Hindu elites. It pushed for population control and was inspired by theosophist Annie Besant’s campaign for birth control in London, writes Ohio University scholar Mytheli Sreenivas in her book Reproductive Politics and Making of Modern India. In the 1930s, the first debates on birth control in Madras presidency were rooted in ideas of nation-building. The Madras Legislative Council passed a resolution on setting up birth control clinics.
As scholar Anandhi writes in the essay in her book A question of silence? The sexual economies of modern India, the Malthusians and Neo-Malthusians “claimed that a check on population growth through birth control would help improve the standard of living of the poor, and hence argued for the use of contraceptive methods.”
This drive, she argues, was rooted in ideas of racial purity and eugenics. She cites this statement of Murari S Krishnamurthi Ayyar, medical counsel to the league: “As birth control among the well-to-do and the intelligent has come to stay, it is the duty of the politician and the statesman to spread the knowledge of birth-control among the lower classes and afford them facilities for its adoption. It is eugenic to raise people from the lower to the higher state by spreading knowledge among the poor, and dysgenic to bring down the intelligent classes by preventing birth-control among them, though it is an impossible task.”
She also flags the statements of Justice V Ramesam, the vice-president of the league, who believed that Indian women were not aware of the rationale for birth control and that only men were qualified to discuss the issue; and how industrialist Thiru Vi Ka declared that “a woman who does not procreate or is unwilling to accept the role of mother is not a woman”.
“They thought the poor reproduced and that led to a eugenic crisis, and that the upper caste should grow consciously and the lower caste must come down in terms of population. Administrating control and family planning became a part of Tamil Nadu,” she says, in an interview with Behanbox.
According to Census documents, the family planning programme was initiated in Madras State as a health measure as early as 1945. Advice on family planning and suitable means of birth control were made available to married women, if in the opinion of the medical officers such advice and facilities were required.
“As an alternative, simple, safe and reliable method, the Madras Government began to propagate in 1958 sterilisation, particularly vasectomy to fathers of three living children and more,” says a document titled ‘Family Planning Attitude in Madras City’, published by the government in 1966. But now, medical institutions are pushing the idea that female sterilisation is the official norm for birth control, says Anandhi. And as Archanaa adds, India’s health system styles birth control measures for women who they think are “right” for them – married, within caste lines, and a mother of two.
In 2022, the world witnessed the United States’ Supreme Court’s abrogation of Roe vs. Wade ruled, ending the right to abortion, and protests continued as Donald Trump returned to the White House. Globally, there is a fear that reproductive rights will be affected. But the fight for access, autonomy and rights must continue.
“Like any system that does a copy-paste template of another country’s policies, we should be aware that we haven’t borrowed from the West the right for abortions and bodily autonomy. When we have to be taking many strides in the direction ahead, we should not look to backtrack like US. and we should be able to build a critique on how religion has controlled women’s bodies. It shouldn’t be about cultural legacies, it needs to be about citizen agency,” says Archanaa.
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