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.
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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.
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Internet Offers Information about Emergency Contraception |
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Several Web sites around the world offer emergency contraception information, including where to obtain pills. Here are some of them, available in English only unless otherwise specified:
http://www.not-2-late.com
This Web site, operated by the Office of Population Research at Princeton University in the United States, gives general information, a bibliography of research and recent news accounts about emergency contraception. From a directory of more than 2,900 providers, women in the United States can find providers in their communities who prescribe the pills. The site is offered in English, Spanish and French.
http://www.plannedparenthood.org/ec/
Planned Parenthood Federation of America provides a description of emergency contraception, how and when it should be used and the locations of Planned Parenthood clinics throughout the United States. This site also lists a telephone hotline.
http://www.en3dias.org.mx
The Consortium for Emergency Contraception offers general information in English and Spanish. The site also includes materials for providers and policy-makers, such as advice on how to operate local emergency contraception programs.
http://www.jhuccp.org/mmc/
The Media/Materials Clearinghouse at Johns Hopkins University allows health professionals to see samples of pamphlets, posters, photographs, videos, and other materials involving reproductive health and family planning topics, including emergency contraception. Some materials are available in Spanish and French, in addition to English.
http://www.fda.gov/
The U.S. Food and Drug Administration offers a database of health documents, including materials on emergency contraception.
http://www.jamwa.org/vol53/toc53_5.html
The Journal of the American Medical Women's Association provides articles from its fall 1998 issue, Vol. 53, No. 5, on emergency contraception.
http://www.fhi.org
Our Web site includes a fact sheet, articles from Network, training materials and other resources on emergency contraception. Some materials are available in Spanish and French, in addition to English. |
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