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.
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.
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.
FHI training for providers in Zambia.
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.
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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