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Many women who have a
need for emergency contraception do not use it. Usually, women simply do
not know that it exists or, if they know, they do not know where to get it
or how or when to use it.
Some mistakenly think it causes abortion. Others believe it can harm
them or -- if a woman is already pregnant -- her fetus. Misconceptions and
lack of knowledge about emergency contraception are common among family
planning providers, as well.
Efforts to familiarize both women and providers with the use of
emergency contraception include media and educational campaigns, telephone
hotlines, innovative marketing projects for women, and training for
providers.
That oral contraceptives can reduce the risk of pregnancy after
unprotected sexual intercourse has been recognized since the early 1970s.
In recent years, reproductive health experts have promoted emergency
contraception. The Consortium for Emergency Contraception, a group of more
than 20 organizations, has set a goal of making emergency contraceptive
pills a standard part of reproductive health care worldwide.
Consortium efforts to introduce emergency contraception in settings as
diverse as Kenya, Mexico, Indonesia and Sri Lanka have been comprehensive.
They include assessing user needs and service capabilities; building
support for the method; selecting and sometimes registering products;
developing distribution plans; informing prospective clients; training
providers; and monitoring and evaluating emergency contraception services.1
Why use is limited
Surveys conducted by the consortium shortly before it attempted to
introduce the method revealed that a majority of prospective users were
unfamiliar with the method.
"In Kenya, only about 10 percent of 282 female clients were aware
of emergency contraception when an introduction program began in
1996," says Dr. Esther Muia, program associate in Nairobi for the
Population Council, a consortium member. Pathfinder International
coordinated the Kenyan program, with assistance from the Population
Council.
Initially, only 18 percent and fewer than 5 percent of surveyed women
in Mexico and Indonesia, respectively, were familiar with emergency
contraception. In Sri Lanka, prospective user knowledge of the method was
also low even though the country’s contraceptive prevalence rate of 67
percent is one of the highest in South Asia.
A woman’s desire to prevent pregnancy may be particularly acute when
sex has been forced. In Kenyan refugee camps, the International Rescue
Committee (IRC) found that fewer than half of 825 women interviewed while
living in the camps knew they could prevent a potential pregnancy
following unprotected sex.2" Only 11 percent of surveyed
women who reported coerced sex in the camps said they had heard of
emergency contraception, despite its availability at a camp
hospital," says Dr. Fariyal Fikree, who with Dr. Muia and other
Population Council colleagues conducted the study in association with IRC.
"Furthermore, many health care providers were uninformed about how to
provide emergency contraception."
Researchers have found that younger women consistently know more about
the method than do older women, but their understanding is usually
superficial.3 Even well-informed women may not use emergency
contraception when they need it because they avoid thinking about the
possibility of pregnancy. The tendency to overlook or underestimate the
chance of becoming pregnant, particularly among younger women, can lead
some women to gamble with the possibility of pregnancy rather than to seek
emergency contraception quickly.4
Mistaken beliefs that emergency contraception will either cause
abortion or harm health may discourage women from using it. However, FHI
experts and others say emergency contraception does not terminate already
established pregnancies and, thus, is not an abortifacient. The method
prevents pregnancy in various ways. It can prevent or delay ovulation, the
process by which the egg is released from the ovary. If taken after
ovulation has occurred, it may prevent sperm from fertilizing the egg. It
may also interfere with implantation of the egg in the uterus.
Birth defects are no more common among babies born to women who
accidentally took oral contraceptives after conceiving than among babies
born to women who did not take these pills during pregnancy. An analysis
of 12 studies conducted since 1969 showed no association between oral
contraceptive pills and birth defects. Even use of high-dose oral
contraceptives containing up to 150 µg of estrogen per pill during
pregnancy (a dose of emergency contraceptive pills contains 100 µg of
estrogen) was not associated with defects.5
Routine use of emergency contraceptive pills, in place of regular
contraception, is not recommended due to concerns other than safety. The
pills are simply less effective than most other family planning methods.
Many users also experience nausea. Only in rare cases do emergency
contraceptive pills pose a health risk to woman taking them. Two studies
found that short-term use of the combined hormonal regimen of emergency
contraception did not increase risk of thromboembolism.6 There
is no evidence that repeated use of progestin-only emergency contraceptive
pills poses health risks under any circumstances. Routine and frequent use
may disrupt a woman’s menstrual cycle, which may be unacceptable to some
women.7
Informing women
For an increasing number of the world’s women, information about
emergency contraception is just a telephone call away. Several telephone
hotlines that provide key information about emergency contraception --
including information about service providers, correct use, potential side
effects and price -- have been established in the past five years.
In Sri Lanka, an emergency contraception hotline receives more than 75
calls daily from women throughout the country. Family Planning Association
of Sri Lanka (FPASL) launched the service supported by the Consortium for
Emergency Contraception, with assistance from the U.S.-based Program for
Appropriate Technology in Health (PATH) and the World Health Organization
in Geneva.
"One of the most valuable things we did as part of our emergency
contraception promotion plan was to set up the hotline," says Daya
Abeywickrema, FPASL executive director. "We did not think many people
would call, but we received 8,000 calls during the project’s first two
years." Phone attendants received a variety of questions,
illustrating a broad need for information. About a quarter of callers
wanted to know how to use emergency contraception; another quarter were
concerned about delayed menstrual periods; 18 percent asked where to buy
the pills; 11 percent requested the name of an emergency contraceptive
product; 9 percent asked about side effects, and 6 percent inquired about
price.
The promotion plan also included an extensive advertising campaign,
information dissemination through television talk shows, radio programs
and print media, and an educational campaign conducted by 50,000 field
volunteers.8
In Mexico, a similar telephone hotline established in 1999 is receiving
approximately 10,000 calls per month. The hotline is part of a larger
initiative that includes a Web site (http://www.en3dias.org.mx)
about emergency contraception. Information about emergency contraception
is distributed in a variety of other ways, including postcards in
restaurants and flyers at concerts and other large events for youth.
The Population Council conducted surveys before and after these and
other dissemination activities in Mexico to assess knowledge and opinions
about the method. "Perhaps partly as a result of dissemination
efforts in Mexico, nearly one-third of 806 female and male family planning
clients surveyed in the year 2000 knew about emergency contraception,
compared with fewer than a fifth of 1,127 clients surveyed in 1997,"
says the Population Council’s Angela Heimburger, who has spent the past
four years conducting emergency contraception research in Mexico.
Women in the United States can obtain information about emergency
contraceptive services by calling a national hotline or visiting a Web
site (http://www.not-2-late.com).
In the states of Connecticut, Georgia, Maryland and North Carolina, women
can obtain prescriptions for emergency contraceptive pills promptly by
calling hotlines. (In North Carolina, FHI is assisting Planned Parenthood
Federation of America affiliates that offer the telephone service.) In the
state of Washington, pharmacists are encouraged to provide emergency
contraception directly to clients by collaborating with physicians on
prescriptions.9
Taking information about emergency contraception to the workplace also
has increased awareness of the method. Some 400 workers in four assembly
plants in Tijuana, Mexico, have learned about emergency contraception and
have been offered kits containing emergency contraceptive pills for
pregnancy prevention and condoms for protection against sexually
transmitted infections. "The Population Council in collaboration with
Fronteras Unidas Pro Salud, a local nongovernmental organization, chose
this population, in part, because we anticipated a special need for
emergency contraception," says Dr. Sandra Garcia, a regional program
associate with the Population Council in Mexico. "Many workers are
young, and youth may be more likely than older people to have spontaneous,
unprotected sex. These workers also have long, irregular hours that make
seeking reproductive health services difficult."
About 50 of the workers (13 percent) took kits home. Notably, about
half of the people attending workplace training sessions in Tijuana were
men, and the council now plans to develop specific information about
emergency contraception for them.
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Leaflet for Asian-Pacific island men
|
Few campaigns to promote emergency contraception focus on men. However,
young Asian-Pacific island men in Seattle, WA, USA, have received
brochures about emergency contraception. This initiative by International
Community Health Services, in collaboration with PATH, is part of a larger
reproductive health program for the minority group.
"We encounter barriers that are unique to this group, such as
language, culture, acculturation levels, and lack of culturally relevant
educational materials," says Nhan Tran, program specialist for the
initiative. "This emergency contraception brochure was a response to
that." Unlike typical emergency contraception brochures for women,
the brochure for men contains little product information. But it strongly
encourages men to support their partners’ reproductive health decisions.
"Most of the men liked being targeted for something that is
traditionally seen as a woman’s issue," says Tran.
Provider knowledge
Some providers have long known about emergency contraception and have
offered it even when it meant dividing regular packets of oral
contraceptives to dispense as emergency contraception. This practice was
common at government and family planning clinics in Brazil before a
product designed specifically for emergency contraception became available
in 1998. The product dedicated to emergency contraception contains the
required dosages, as well as instructions.
Such resourcefulness and confidence in dispensing emergency
contraceptive pills is the exception to the rule. Numerous studies have
demonstrated that providers lack knowledge and have misconceptions about
the pills -- especially when they are not available as a dedicated
product. Even providers who know about the method often do not offer it to
eligible women.
A 1997 survey conducted in Ghana by FHI researchers in collaboration
with Research International, Ghana, evaluated health providers’
knowledge of emergency contraception. The survey found that about
one-third of 325 interviewed providers had heard of it but none knew how
to prescribe it correctly.10 As a result, FHI will help the
Planned Parenthood Association of Ghana train providers to deliver
emergency contraception in eight clinics.
Although the International Planned Parenthood Federation had strongly
endorsed emergency contraception for more than a decade, more than half of
72 federation affiliates that responded to a 1994 survey about the method
did not offer it. Lack of a dedicated product hindered at least some
family planning associations that were willing to offer it. Other
obstacles included lack of a perceived need, legal issues, a misconception
that the method causes abortion, and a lack of staff training and
guidelines for offering it.11
A recent survey of 775 U.S. family planning clinics found that 140 of
them did not dispense emergency contraceptive pills. The most frequent
reasons given for not doing so included lack of demand (46 percent) and
inadequate training for providing the method (22 percent).12
FHI assisted the National Family Planning and Reproductive Health
Association and the National Association of Nurse Practitioners in
Women’s Health Organizations in conducting the survey.
And, in a 1997 U.S. survey of physicians with expertise in adolescent
health, 40 percent of 112 respondents who prescribed emergency
contraception to adolescents restricted use to women who sought the method
within 24 or 48 hours after unprotected intercourse, rather than using the
standard of 72 hours. Two-thirds unnecessarily required pregnancy tests
before prescribing the method.13
In 1996, when the consortium-sponsored project to enhance the use of
emergency contraception in Kenya began, fewer than half of some 90
providers surveyed knew about the method. Few providers knew how to divide
regular packets of oral contraceptives to dispense as emergency
contraception. As part of the project, emergency contraceptive pills
packaged with the proper dosage became available. Some 200 providers were
trained about various regimens, effectiveness, modes of action,
indications and contraindications, side effects, and client screening and
counseling. After three years, the percentage of providers who knew about
emergency contraception had nearly doubled from 46 percent to 88 percent.
Those providing the method more than quadrupled from 15 percent to nearly
70 percent.14
In Mexico, a consortium-sponsored program to introduce emergency
contraception initially found that three of every four service providers
who were surveyed had heard of the method, but only about 30 percent knew
the correct dosages to prescribe, and only 7 percent offered the method.
An evaluation showed that training and providing better information helped
correct misinformation and reduce unnecessary concerns about the method.
Many providers had worried about the safety of emergency contraception and
whether it would be used incorrectly or overused.
About two-thirds of some 70 Sri Lankan doctors surveyed by the
consortium in 1997 before extensive provider training began were familiar
with emergency contraception, but could not confidently describe the
method’s advantages and disadvantages. A post-training survey found that
94 percent of participating doctors knew about emergency contraception and
three-fourths had provided it.
-- Kim Best
References
- Consortium for Emergency Contraception. Expanding
Global Access to Emergency Contraception. Seattle, WA:
Consolidated Printers, 2000.
- Muia E, Fikree F, Olenja J. Enhancing the Use of
Emergency Contraception in a Refugee Setting: Findings from a Baseline
Survey in Kakuma Refugee Camps, Kenya. New York: Population
Council, 2000.
- Ellertson C, Shochet T, Blanchard K, et al.
Emergency contraception: a review of the programmatic and social
science literature. Contraception 2000;61(3):145-86.
- Sorensen MB, Pedersen BL, Nyrnberg LE. Differences
between users and non-users of emergency contraception after a
recognized unprotected intercourse. Contraception
2000;62(1):1-3; Lewis C, Wood C, Randall S. Unplanned pregnancy: is
contraceptive failure predictable? Br J Fam Plann
1996;22(1):16-19.
- Bracken MB. Oral contraception and congenital
malformations in offspring: a review and meta-analysis of the
prospective studies. Obstet Gynecol 1990;76(3, Pt 2):552-57;
Simpson JL, Phillips OP. Spermicides, hormonal contraception and
congenital malformations. Adv Contracept 1990;6(3):141-67.
- Vasilakis C, Jick SS, Jick H. The risk of venous
thromboembolism in users of postcoital contraceptive pills. Contraception
1999;59(2):79-83; Webb A, Taberner D. Clotting factors after emergency
contraception. Adv Contraception 1993;9(1):75-82.
- United Nations Development Programme/United Nations
Population Fund/World Health Organization/World Bank Special Programme
of Research, Development and Research Training in Human Reproduction,
Task Force on Post-Ovulatory Methods of Fertility Regulation. Efficacy
and side effects of immediate postcoital levonorgestrel used
repeatedly for contraception. Contraception 2000;61(5):303-8.
- Abeywickrema D, Basnayake S, Subasinghe C, et al.
An Evaluation Report of the Marketing of Postinor 2 in Sri Lanka.
Colombo, Sri Lanka: The Family Planning Association of Sri Lanka,
2000.
- Hutchings J, Winkler JL, Fuller TS, et al. When the
morning after is Sunday: pharmacist prescribing of emergency
contraceptive pills. J Am Med Wom Assoc 1998;53(5 Suppl
2):230-32; Wells ES, Hutchings J, Gardner JS, et al. Using pharmacies
in Washington state to expand access to emergency contraception. Fam
Plann Perspect 1998;30(6):288-90.
- Steiner M, Raymond E, Attafuah J, et al. Provider
knowledge about emergency contraception in Ghana. J Biosoc Sci
2000;32(1):99-106.
- Senanayake P. Emergency contraception: the
International Planned Parenthood Federation’s experience. Int Fam
Plann Perspect 1996;22(2):69-70.
- Spruyt A, Grey T, DeSarno J, et al. Provision of
emergency contraceptive pills in U.S. family planning clinics.
Unpublished paper. Family Health International, 2000.
- Gold MA, Schein A, Coupey SM. Emergency
contraception: a national survey of adolescent health experts. Fam
Plann Perspect 1997;29(1):15-19;24.
- Muia E, Blanchard K, Lukhando M, et al. Emergency
Contraception in Kenya: An Evaluation of a Project on Enhancing the
Use of Emergency Contraception in Kenya. New York: Population
Council, 2000.
| What Providers Need to Know |
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Providers of emergency contraceptive pills need to be
prepared to give clients specific information about use of this
backup contraceptive method. Most experts agree that providers
should do the following:
-
Emphasize that clients take the first dose of emergency
contraceptive pills as soon as possible, and the second dose
12 hours after the first. Women must understand the
importance of requesting emergency contraception within 72
hours after unprotected sex, especially in cultures where
women normally wait until their period is late before
seeking care. In Sri Lanka’s program to introduce
emergency contraception, more than 60 percent of women who
called the telephone hotline initially did so after they had
missed a period, at which time it was too late to use the
method. Likewise, in Indonesia’s introduction program,
about 20 percent of clients waited until a missed period to
seek the method.
-
Be able to identify the appropriate dosage of available
oral contraceptives for use as emergency contraceptive
pills, especially in settings where pills specifically
packaged for emergency contraception (dedicated products)
are not available.
- Be able to counsel clients about sexually transmitted
infections and to stress that emergency contraception
provides no protection against these infections.
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FHI training for providers in Zambia.
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-
Consider use of emergency contraception in relation to
different family planning methods. Providers must be able to
explain how to start or resume routine contraception after
use of emergency contraception, and offer clients ongoing
methods to prevent both pregnancy and disease. If routine
contraception cannot be provided during the visit to obtain
emergency contraception, providers should make follow-up
appointments for clients. If contraceptive method failure
leads to the need for emergency contraception, providers
should discuss the reasons for this failure and how other
failures can be prevented.
-
Explain that, following use of emergency contraception, a
woman should seek evaluation and care for possible pregnancy
if her menstrual period is more than a week later than
expected.
-
Be clear and courteous, and invite clients to ask
questions. Providers should maintain a respectful and
nonjudgmental attitude, offering emergency contraception to
any woman who needs it, regardless of her reasons.
-
Routinely educate clients about the availability and use
of emergency contraception.
-- Kim Best
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| Counseling
about Regular Methods Needed |
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No one contraceptive method is considered better or more
appropriate than any other as a routine method to use following
emergency contraception.
Like most other situations in a client’s life, starting or
resuming regular contraception after emergency contraception
should involve a range of choices and should address the needs
and preferences of the client.
After using emergency contraception, even women who have
previously used a method may need follow-up counseling. For
example, if a woman had been using oral contraceptives as a
regular method and sought emergency contraception due to missed
pills, her physician or provider should discuss the reason why
she did not use her regular pills.
Advice on when to resume or initiate a regular method depends
on the method involved:
-
Barrier and other nonhormonal methods may be initiated
immediately after using emergency contraceptive pills.
-
Hormonal methods such as oral contraceptive pills,
injectables and Norplant can begin immediately as long as
the woman is not pregnant. If a client waits for her next
menstrual cycle before initiating a reliable hormonal
method, she should use condoms or other barrier methods as a
backup.
-
If a woman chooses an intrauterine device (IUD) as her
regular contraceptive method, the provider can insert the
device as long as the woman is not pregnant.1
An IUD can also be used for emergency contraception up to
five days after unprotected intercourse, and could be continued
as a regular contraceptive method. However, an IUD should not be
inserted if the woman suffers from a sexually transmitted
infection (STI).
After using emergency contraceptive pills, a woman’s
menstruation may be delayed for up to a week. If it is more than
a week late, she should be tested to ensure that she is not
pregnant.
Routine use?
Some providers worry that telling clients about emergency
contraceptive pills may encourage women to use emergency
contraception routinely.
Most studies indicate that knowledge about and use of
emergency contraceptive pills do not discourage women from using
regular contraception. A primary reason is that some side
effects of emergency contraceptive pills -- specifically nausea,
menstrual disruption and vomiting -- discourage women from using
this method routinely.
However, interviews with 29 young, unmarried Nigerian women
indicated some of them were using emergency contraception as
their routine method choice. For example, some of the women only
have occasional sex with their boyfriends, and felt emergency
contraceptive pills suited their situation. The study also noted
that women in some cultures believe modern contraceptives are
dangerous or social stigmas may discourage using regular
methods. "Whether these beliefs and social restrictions
have substance in fact, they contribute to young, unmarried
women’s preference for a one-shot contraceptive, immediately
after intercourse," concluded Elisha P. Renne of Princeton
University’s Office of Population, author of the study.2
Emergency contraceptive use can be an opportunity to counsel
women who have never used regular contraception or who have used
it inconsistently. In the United Kingdom, young women who come
to clinics for emergency contraception are routinely counseled
about regular methods. A study found that some British women,
particularly those in late adolescence, initiate regular
contraception after using emergency contraceptive pills.
In a survey of British women ages 14-29 registered in a
general practice research database, only 4 percent (608) of
15,200 women who had received emergency contraception received
it more than twice in any year, suggesting that few women rely
solely on emergency contraception.3
For couples using condoms or other barrier methods for dual
protection -- against pregnancy and sexually transmitted
infections -- emergency contraceptive pills can be offered as a
backup against pregnancy when the barrier method fails or is not
used.
In a study conducted in Ghana, emergency contraception
counseling was given to women using one of two spermicides
(nonoxynol-9 or menfegol). Some women were also given emergency
contraceptive pills in case of unprotected sex. Among women who
used emergency contraceptive pills, none reported using their
spermicide less frequently than they would have if pills had not
been available. Most women said they would like to have
emergency contraception only as a backup to spermicide.4
-- Ellen Devlin
References
- The Technical Guidance/Competence Working
Group. Recommendations for Updating Selected Practices in
Contraceptive Use, Volume II. Chapel Hill, NC: Program
for International Training in Health, 1997.
- Renne EP. Postinor use among young women
in southwestern Nigeria: a research note. Reprod Health
Matters 1998;6(11):107-14.
- Rowlands S, Devalia H, Lawrenson R.
Repeated use of hormonal emergency contraception by younger
women in the UK. Br J Fam Plan 2000;26(3):138-43.
- Lovvorn A, Nerquaye-Tetteh J, Glover EK,
et al. Provision of emergency contraceptive pills to
spermicide users in Ghana. Contraception
2000;61(4):287-93.
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