Educating clients about
emergency contraceptive pills is an important step to the method’s
success in preventing unplanned pregnancies. However, keeping clients well
informed is only part of a good strategy for improving access to emergency
contraceptive pills. Clients must also be able to get the pills readily
and at a reasonable cost, within three days of unprotected intercourse.
Even if a client knows that emergency contraceptive pills are available,
there are often barriers to easy access. Among them are unnecessary
requirements for a prescription, reluctance among providers to offer help,
cost and inconvenient access.
One important way to improve access to emergency contraceptive pills is
to offer them over the counter rather than by prescription. Dr. David A.
Grimes of FHI is among those who advocate eliminating the prescription
requirement that exists in many countries, including the United States. He
recently submitted comments to the U.S. Food and Drug Administration in
favor of over-the-counter sales.
|
Planned Parenthood Federation of America information card.
|
"Prescription status is a major barrier to access," he says,
since women are often unable to consult a health care provider quickly to
obtain a prescription. "Removing the prescription requirement and
allowing women to purchase pills directly is the most expedient way to
ensure that women can obtain and use them whenever the need arises."
Many women are likely to need emergency contraception outside regular
clinic hours, particularly during weekends and holidays. The lack of time
to make and keep an appointment to get emergency contraception from a
health care provider can be a major obstacle to proper use.
Even where prescriptions are required, simply eliminating an office or
clinic visit can greatly reduce the time needed to obtain emergency
contraception. For example, in the state of Washington in the United
States, pharmacists can prescribe emergency contraceptive pills directly
to women, without the need for a visit to a physician. And in San
Francisco, a new program allows women to obtain pills without
prescriptions if their physicians or clinics have made previous
arrangements with the participating pharmacies.
Providing emergency contraceptive pills directly through pharmacists
can improve access because pharmacies are often conveniently located and
often open during evenings, weekends and holidays, when physicians and
clinic providers may not be available. Also, rural and other remote areas
that lack clinics or physicians may be served by pharmacies.
Family planning providers sometimes limit access to emergency
contraception unnecessarily due to unfounded concerns about health effects
from using the pills. Because of the short duration of the regimen,
emergency contraceptive pills are safe for most women to use. Other than
an existing pregnancy, World Health Organization guidelines do not list
any contraindications for the use of emergency contraceptive pills.1
And even if taken while pregnant, there is no known harm to the mother or
fetus.2
Studies have shown that emergency contraception does not encourage
adolescents to engage in sex, especially against their parents’ wishes,
if they were not otherwise inclined to do so. In the United States,
approximately 50 percent of adolescents become sexually active by the age
of 17 regardless of parental consent. Since sexually active adolescents
typically have unprotected sex, especially during the first six months of
sexual activity, easy access to emergency contraception would be important
for this population.3
Some providers are concerned about potential health risks to
adolescents if they have easy access to emergency contraception. However,
the very few contraindications for routine oral contraceptive use rarely
apply to adolescents.
Emergency contraception for adolescents can help prevent unplanned
pregnancy and might also serve as a young woman’s introduction to
regular contraception. Making access to emergency contraception easier,
such as providing emergency contraception through schools and other places
where youth congregate rather than only through a physician or clinic,
would help many adolescents avoid the trauma of an unplanned pregnancy and
perhaps a subsequent abortion.
Adolescents face many barriers to contraceptive services to begin with.
Lack of money to pay for outpatient visits, laboratory fees or
prescription medications is a problem for adolescents of all economic
backgrounds. Transportation to and from clinics can be a problem for
adolescents, as well as simply locating clinics with convenient hours,
given school and work schedules. Young adults also struggle with
embarrassment and the disapproval of older adults, such as parents and
teachers, making it difficult for them to seek help at clinics.
"Emergency contraceptive pills -- and the knowledge about their
use -- should be accessible to adolescents in school-based clinics,
pharmacies, convenience stores or other environments where youth are
comfortable seeking health care services and products," says Dr.
Charlotte Ellertson in Mexico City, the Population Council’s director of
reproductive health for Latin America and the Caribbean, who has written
extensively about emergency contraception.
"Also, having the pills available in packaging dedicated to
emergency contraception will make it simpler for women to get the right
dose every time, although if necessary, women can certainly also use pills
taken from ordinary oral contraceptive packs. Putting detailed emergency
contraception information about brands, doses and places to get help on
Web sites and hotlines can also point many young people in the right
direction when they need help."
Cost and convenience
Even though emergency contraceptive pills should only be used
occasionally, treatment may be relatively expensive for women with limited
income. Some experts suggest that providing free emergency contraceptive
pills for designated populations, as has been done with condoms, would
reduce this barrier.
Specially packaged emergency contraceptive pills are available in
several countries. Preparing the proper doses from supplies of regular
oral contraceptives is an option, but could be wasteful and is
inconvenient. Also, calculating the proper number of regular pills needed
increases the risk of dosage error. Depending on the brand, between two
and 25 regular oral contraceptive pills would be needed to equal one dose
of emergency contraceptive pills.
If over-the-counter access to emergency contraception is not available,
another strategy to improve access would be to provide the woman with a
supply of pills to keep at home. This would eliminate at least one trip to
a clinic or pharmacy with the resultant loss of time and money.4
Would women be more inclined to use emergency contraception promptly
and correctly if they could get the pills in a convenient, confidential
and timely way? Would women indulge in riskier behavior knowing that
emergency contraception would be easy to obtain?
To help answer these questions, researchers studied 1,083 women who
attended a family-planning clinic and a hospital in Edinburgh, Scotland,
for two years.5 The researchers gave about one-half of the
study participants a renewable supply of emergency contraceptive pills and
instructions to take home with them. The other half received no pills but
were informed about emergency contraception and told that, in the event of
a contraceptive failure such as a condom break or missed pills, they
should see a physician to obtain a prescription for emergency
contraception pills.
The study found that nearly half (47 percent) of the women who had
emergency contraception on hand used the method at least once and used it
correctly. This compares to 27 percent in the group that did not have
pills readily available. Neither group was more likely than the other to
repeat emergency contraception more than once. Furthermore, 89 percent of
the women who had pills said that their regular contraception remained
unchanged, and 8 percent reported that the availability of emergency
contraception gave them "peace of mind."
The study concluded that women are able to self-administer emergency
contraception correctly, at the appropriate time, without adverse effects,
and without abandoning regular contraception. The researchers believe that
making emergency contraception more accessible may reduce the rate of
unwanted pregnancies and abortions.
A study in Zambia sought to determine which emergency contraceptive
strategy was most effective at the lowest cost in a developing country
where resources are limited. About one-third of the 895 study participants
received a supply of emergency contraceptive pills to keep at home.
Another third received a prescription card that could be redeemed for
emergency contraceptive pills at local health centers 24 hours a day,
seven days a week, "no questions asked." Members of the last
group -- the control group -- were simply told about emergency
contraception and where to receive it, but did not receive either pills or
prescription cards. All participants were first-time users of regular
contraceptive methods -- either condoms or oral contraceptives.
Results revealed that 80 percent of the women who needed to use
emergency contraception and who had the pills on hand did use them within
24 hours after unprotected sex. However, women who had the prescription
card did not obtain emergency contraception any sooner than those with
neither pills nor a prescription card -- only about half in each of those
two groups used the pills within the first 24 hours. The authors suspect
that women with cards were reluctant to use them. Even with cards, these
young, unmarried women may find it difficult to visit health centers and
explain their need for emergency contraception.
The study also found a need for better emergency contraception
counseling. Some clients were inclined to substitute emergency
contraceptive pills in place of regular contraception because they thought
a regimen that required only two pills when needed rather than a pill
every day would be more "powerful," and therefore more
effective. Also, availability of emergency contraceptive pills sometimes
undermined a woman’s ability to negotiate condom use with her partner.6
Web sites and telephone hotlines offer advice on how to obtain
emergency contraceptive services. However, research raises questions about
how useful these services can be.
In one U.S. study, two college-educated investigators posing as women
who had a condom break the "previous night" -- the number of
elapsed hours were not specified -- called hundreds of providers listed
with an emergency contraception hotline and Web site.
The investigators made their phone calls during business hours in order
to maximize caller-provider interaction, giving the providers ample chance
to get emergency contraception into the hands of the caller within 72
hours. No calls were made on weekends or holidays, when many clinics and
private medical offices would be closed. The callers were native English
speakers and followed a script.
Despite these favorable conditions for a timely prescription, only 76
percent of the providers were able to provide prescriptions or
appointments within 72 hours. The authors believe that a more typical
hotline caller, perhaps a woman of limited education or one not fluent in
English, calling at night or during the weekend, would be far less likely
to obtain help in time.
The study concluded that, despite the availability of emergency
contraception information on Web sites and hotlines, access to emergency
contraception through these routes is poor.
Unless providers prescribe and dispense emergency contraception
promptly, the potential to prevent pregnancies through emergency
contraception cannot be fully realized.7
-- Ellen Devlin
References
- World Health Organization. Improving Access to
Quality Care in Family Planning, Medical Eligibility Criteria for
Contraceptive Use. Geneva: World Health Organization, 1996.
- Bracken MB. Oral contraception and congential
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 malformation. Adv Contracept 1990;6(3):141-67.
- Hewitt G. Should adolescents have over-the-counter
access to oral contraceptive pills and antibiotics? Adolesc Med 1997;8(3):443-48.
- Trussell J, Koenig J, Ellerston C, et al. Preventing
unintended pregnancy: the cost-effectiveness of three methods of
emergency contraception. Am J Public Health 1997;87(6):932-37.
- Glasier A, Baird D. The effects of
self-administering emergency contraception. N Engl J Med
1998;339(1):1-4.
- Skibiak JP, Ahmed Y, Ketata M. Testing Strategies
to Improve Access to Emergency Contraception Pills: Prescription vs.
Prophylactic Distribution. Nairobi: Population Council, 1999.
- Trussell J, Duran V, Shochet T, et al. Access to
emergency contraception. Obstet Gynecol 2000;95(2):267-70.
Copyright