Introduction
According to the National Family Health Survey (NFHS) 42 percent of married Indian women use modern methods of contraception; less than 7 percent of currently married women use one of the three major spacing methods (oral contraceptives, condoms, intra- uterine devices). Another estimate by NFHS 2 reports that 21 percent of all pregnancies contraception can prevent unwanted pregnancy following unprotected intercourse.

In this context the importance of increasing awareness and utilisation of Emergency Contraceptive Services is evident. An important method of Emergency Contraception (EC) is the progesterone only pill, levonorgestrel (LNG). In Bangladesh, emergency contraception is dispensed even by field level extension workers. However, in India, this was hitherto available only on a doctor’s prescription.

There data is not available on the feasibility of training Auxiliary Nurse Midwives and other paramedical staff in rural In dia for distribution of EC pills through the public health network. This study was carried out to determine whether Indian nurses and paramedical workers could be trained to dispense EC pills.

Objective This paper evaluates the impact of training about Emergency Contraceptive Pills on Auxiliary Nurse Midwives, Lady Health Visitors, Health Assistants, Multi Purpose Workers and Pharmacists in order to assess whether dispensing of E pills by them is feasible.

A multicentric study on “Utilisation of EC service through paramedics in India” was planned by Indian Council of Medical Research (ICMR) in collaboration with Population Council. ICMR’s Regional Centre for Clinical Research in Human Reproduction (RCCHR) in the Department of Obstetrics and Gynecology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai is one of the participating centres in collaboration with Department of

Health, Government of Maharashtra. Methods Trainees: 102 Auxiliary Nurse Midwives, Lady Health Visitors, Health Assistants, Multi Purpose

Workers and Pharmacists from Palghar taluka were given a day-long training (6 hour-session) in 5 batches. Trainers: The training was imparted by faculty from Seth GS Medical College and KEM Hospital, officers from ICMR Headquarters and Population Council, Representative of DHO, Thane, District training faculty, RCCHR (KEM) and EC project staff. Training was mainly under the following heads : Need for the research, Training of trainers, Counselling skills, A role play in which trainees acted as provider and client for E pills.

Instruments: Identical, prestructured pre- and post-training questionnaires in Marathi (local language) were administered just before and after the training session, to assess the existing knowledge regarding emergency contraception services and the impact of the training on them. Disclosure of identity was optional. Questions were provided with multiple choice answers; some had more than one correct answer. This was clearly

explained to the participants. Marks were allotted as follows: (i) 1 for a correct answer, and (ii) 0 for no answer or wrong answer Marks obtained per question were added and the difference in pre- and post-training scores was statistically analysed. Results: 68.13% trainees were

aware about Emergency Contraceptive pills before training, this awareness increased to 95 percent post-training. The time of taking EC pills was identified correctly by 75.49 percent post-training as compared to only 32.6 percent pre-training; 95 percent trainees correctly mentioned 2 doses post-training as compared to 58.76 percent pretraining. Post training increase in knowledge was statistically significant.

Discussion Emergency contraception prevents an unwanted pregnancy in the event of unprotected sexual intercourse. Combination pills containing LNG and ethinylestradiol have now made way for the progesterone only pill containing LNG. LNG was first introduced as an EC pill in the National Health Care Programme by Ministry of Health and Family Welfare in 2001, to be dispensed only by doctors. In India the unmet need for family planning (a situation of wanting to avoid or postpone child bearing but not using any contraception) is 16 percent. The WHO estimates that annually unintended pregnancies lead to nearly 20 million unsafe abortions worldwide, resulting in 80,000 maternal deaths. In India, 6.7 million abortions are performed every year in unrecognised centres, often by untrained persons in unhygienic conditions. The unmet need for emergency contraception is evident. EC is available without prescription in 26 countries (Source: The American Society for Emergency
Contraception, current as on November 7, 2002). Emergency

contraception has significantly reduced the US abortion rate. In 2000- 2001, the Alan Guttmacher Institute surveyed all US abortion providers and more than 10,000 women who had undergone abortion.

An estimated 51,000 abortions were averted by use of emergency contraceptives in 2000; emergency contraceptives accounted for upto 43% of the decrease in total abortions between 1994 and 2000. E pills are available in US only on prescription but are easily accessible. The abortion rate in France (which is half the US rate) is one of the lowest in the world at 12 per 1,000 women aged 14-44.

The French Government in June 1999 granted EC pills a nonprescription status and also made them available free of cost at family planning clinics; 97 percent of the 1.5 million pills were sold without a prescription with no reported adverse effects. In Netherlands, where emergency contraception is easily available to women, abortion rates are one of the lowest (8.4 per 1000 women of 15-44 age group).

Levonorgestrel was made available without prescription in Netherlands from January 2005. The South Africa Medicines Control Council in 2000 allowed pharmacies to sell levonorgestrel (Norlevo) without prescription. Emergency contraceptives are also available free of charge at public health facilities in South Africa, where

staff provide pills along with regularoral contraceptive packets. In the current study, knowledge about Emergency Contraceptive pills (ECP) of the ANMs and other paramedics was 33.33 percent prior to training and 66.12 percent post-training. The results show that the paramedical staff ’s knowledge and concepts regarding Emergency Contraception improved considerably after the training session. The increase was found to be statistically significant.

In the rural healthcare setup Primary Health Centres (PHC) are very often manned by male doctors. For example, of the 13 doctors from 8 PHCs in the intervention areas (Palghar), 12 were males. It is unlikely that rural Indian women would approach a male doctor for EC pills. Tribal women usually stay far away from the PHC; they would not spend money and time travelling for an emergency pill. Involvement of Auxiliary Nurses and other paramedical staff who are close by and well known to the women, will certainly improve the utilisation of E pills. Our study shows that the ANMs had increased knowledge after training was adequate for safe dispensing of E pills by them.

The inference therefore strengthens the view that paramedical staff services can be utilised to dispense E pills. This is the research question that will be studied in depth during the project “Studying the Utilisation of Emergency Contraceptive Services through Paramedics in India”. It would be useful to know if the experience in China and Bangladesh

(which report that abortion rates have fallen by 50 percent and 32 percent respectively after introduction of dispensing E pills by paramedical staff) can be duplicated in India. An easy access to E pills will help in avoiding unwanted pregnancies and unsafe abortions.

Acknowledgements We are indebted to ICMR, Population Council, Department of Health, Government of Maharashtra, District Health Officer and staff of Thane District for making the study possible and to Mr Shrinivas Gurav for statistical analysis.

References
1.http://www.unQ)a.org.in/ country_profile.htm. accessed