Blog Post on EC: EC is a simple part of post-rape care, why is it not routinely provided?

Melissa Garcia of ICEC and Sarah Rich of the Women’s Refugee Commission co-authored a blog post on the Sexual Violence Research Initiative’s website about EC and post-rape care, which can be read here. EC has particularly critical relevance for post-rape care since it can reduce the risk of pregnancy following unprotected sex, including forced sex, but it is not systematically provided to survivors, which violates their human rights. The blog piece discusses the most crucial barriers to EC access for sexual violence survivors, including policy, legal, and regulatory barriers; facility protocols and provider biases; and women’s low level of knowledge of EC and delayed care-seeking. As these barriers are often exacerbated in crisis settings, the blog piece calls for new approaches for ensuring that survivors receive EC.

Letter to the Editor: Pericoital Contraception and the Market

In August 2016, Stuart Derbyshire published an article in Conscience Magazine entitled “Does Big Pharma Believe in Autonomy?” In it, Derbyshire argues that pericoital contraception, contraception that women take just before or just after sex, could help dramatically decrease the rate of unintended pregnancies, but that pharmaceutical companies seem hesitant to fill this need because of moral implications. Specifically, pericoital contraception will facilitate women’s sexual autonomy, which is not welcome because such autonomy includes the possibility of unplanned sex.

In response to Derbyshire’s article, Elizabeth Westley and Elizabeth Raymond wrote a letter to the editor, entitled “Pericoital Contraception and the Market” and published in December 2016, in which they state that Derbyshire’s argument that “big pharma” is keeping EC pills out of the hands of women who want to use it as a regular method because of moral control is too simplistic. They argue that pharmaceutical companies are not investing in pericoital contraception because of markets, not morality. There are a number of challenges that pharmaceutical companies would have to overcome before the routine use of EC can become widespread, such as approval by a stringent regulatory authority and expensive clinical trials proving efficacy and safety. The authors do make the point, though, that in the absence of a dedicated pericoital pill, manufacturers and drug stores are starting to sell EC in multipacks, which encourages advance planning and makes it easier for women to use them more than once, destigmatizes repeat or routine use of emergency contraception, and may offer a price that allows some women to use this pill several times a month.

e-Book on EC in Brazil published by Brazilian Health Institute

The Brazilian Health Institute has recently published an e-Book about EC. While the book, called “Panorama da Contracepção de Emergência no Brasil” [Overview of Emergency Contraception in Brazil], touches on global issues relating to EC as well as issues specific to Latin America, its primary focus is on EC access issues in Brazil. The topics explored in the book are wide-ranging and include the knowledge and use of EC among adolescents in Brazil, EC and sexual violence, Brazilian pharmacists’ views on EC, and how EC is being portrayed in the Brazilian press. The first chapter, titled “A Global Assessment of Emergency Contraception Accessibility,” was written by Elizabeth Westley and Jamie Bass of ICEC and Cristina Puig of ECEC.

The book is in Portuguese, except for the first chapter, which is in English. The book can be viewed here, as well as on our Partner Publications page.

Launch of bpas campaign for affordable, accessible EC

The British Pregnancy Advisory Service (bpas) recently launched a campaign in the UK calling for LNG EC to be made available directly on pharmacy shelves at an affordable price. Currently in the UK, women can only obtain EC from behind the pharmacy counter after a consultation with a pharmacist, and LNG EC costs up to £30, which is more than anywhere else in Europe with the exception of Ireland. bpas’s campaign is calling for EC to be reclassified as a General Sales List medication so that it can be placed on pharmacy shelves for women to buy without a consultation. The organization is also calling for all those involved in the pricing of EC to consider how they can provide women with a much more affordable product.
                                                                                                                                            To launch the campaign, bpas created a tongue-in-cheek video highlighting that for some women in the UK it would be cheaper to fly to France to buy EC than purchase it in their local community. Click here to see the video, and for more information on the campaign, please visit http://www.justsaynon.org.uk/.

New leaflets on EC in the Democratic Republic of the Congo

The Johns Hopkins Center for Communication Programs and ICEC, working closely with the National Reproductive Health Program, recently developed a leaflet on EC for health providers, community-based distribution agents, and pharmacists in the Democratic Republic of the Congo (DRC) to use when counseling their patients or clients. Knowledge and use of EC is very low in the DRC and the goal of this leaflet, which was produced in French, Swahili, Lingala, and Kikongo, is to bring an increased awareness and understanding of EC to the populations who most need it.
                                                                                                                                            Please visit our Partner Publications page under “Emergency Contraception Factsheets” to view the leaflets and for more information.

EC in Peru

In 2009, the provision of EC pills in public health facilities was banned by the Constitutional Court. Despite having more than 16 EC brands on the market, the public health system has not provided EC during all these years, not even in cases of rape, creating a clear inequality among women who can and cannot afford to buy EC and limiting the post-coital contraceptive choices for the lower-income population.

The troubled history of EC in Peru is well explained in the short film (in Spanish) “AOE: Bendita pildora” (“EC – Holy pill”).

In 2014, the Peruvian NGOs PROMSEX, DEMUS and Paz y Esperanza, and the Center for Reproductive Rights filed a lawsuit against the Ministry of Health based on the case of “Maria,” a young women who was denied EC in a public hospital after being raped. The case has also been brought up to the InterAmerican Commission of Human Rights, where it is awaiting to be seen.

However, this past August, and while the case is waiting to be heard at a local court, a judge order that EC pills be procured and provided in public health units, as a precautionary measure. This move prompted a heated public debate and, once again, those opposing the measure used the language on the FDA label for LNG products to claim that EC can interfere with implantation.

The trial is supposed to be held soon, but thanks to the precautionary measure, women who cannot afford EC can already receive it for free through the public health network.

Blog Post on EC: A script-writer walks into a pharmacy…

A new blog post, authored by Elizabeth Westley and Melissa Garcia, details ICEC’s recent strategy to increase awareness of EC by promoting EC-related storylines in “entertainment for education” media projects. These projects, which are produced by our partners Population Media Center and ONG RAES and include engaging television and radio soap operas, provide innovative and unique opportunities to reach wide audiences in the countries where ICEC has focused work (Democratic Republic of the Congo, Senegal, and Nigeria). Click here to read more.

Blog Post on EC: The Reproductive Health Innovation Everyone Should Know About

In an effort to draw more attention to emergency contraception access around the world, Elizabeth Westley and Monica Kerrigan authored a blog post on Devex’s website, available here. In it, the authors discuss the unfinished agenda for EC access and point out that although EC remains the only contraceptive method that is effective after sexual intercourse, it is one of the most underutilized, underfunded, and unheard of tools to broaden access and choice for millions of women and youth globally.

Preventing pregnancy after sexual assault

Global guidance clearly states that sexual assault survivors seeking treatment should be offered emergency contraception. Yet survivors do not routinely have access to EC. Why is a treatment that is so safe and effective not always provided? A recent blog post discusses this question:
rightsandrealities.org/2016/06/08/ec-after-sexual-assault

Preventing pregnancy after sexual assault: Do women and girls have access to emergency contraception?

By Sarah Rich

“Mapingure was raped and sought EC at a hospital. The provider told her that she needed a police report. But by the time she came back… she was told it was too late to assist her. She became pregnant as a result of the rape.”
–Zimbabwe case from 2014, presented by Godfrey Dalitso Kangaude in “Country overviews of legal grounds/policies related to health, rape, and safe abortion,” April 2016

Emergency contraception (EC) can prevent pregnancy after unprotected sex, including in cases of rape. Global guidance on EC access for sexual assault survivors is clear: EC should be offered to women and girls within 120 hours of the assault to prevent the traumatic consequences of pregnancy resulting from rape. The World Health Organization’s (WHO) clinical and policy guidelines for sexual assault and clinical handbook include strong recommendations to provide EC as part of comprehensive, woman-centered care.

Yet women and girls around the world who have been sexually assaulted do not routinely have access to EC pills. Why is a treatment that is so safe, effective, and easy to administer not always provided? In April, I participated in a three-day meeting hosted by WHO and Population Council to discuss national pregnancy prevention and abortion policies for sexual assault survivors in Eastern and Southern Africa. The meeting brought together global experts with key stakeholders from six countries: Botswana, Ethiopia, Kenya, Malawi, Rwanda, and Zambia.

All six of the participating countries have sexual assault treatment policies in place, and all include EC as a core component of care. But the details in the policies and the ways the policies are implemented matter greatly in determining whether rape survivors can access EC. The Population Council conducted a review of post-rape care policies and programs in Sub-Saharan Africa that uncovered many barriers, and the meeting in April further illuminated the challenges.

National policies tend to be less detailed than global guidance on EC. For example, some are clearer than others that EC should be provided as soon as possible after the assault but that it can be offered up to 120 hours later. Gray areas in the policies can lead to lower access because front-line responders may be likely to err on the side of caution – not providing treatment – when the policy is unclear. Therefore, national policies must include detailed information aligned with global guidance on EC.

Clinics providing treatment do not always have supplies of EC pills. While the national sexual assault c policies focus on dedicated EC pills (those packaged and labeled for use as EC), in many clinics these pills are not actually available. Stocks vary by country; in Botswana, for example, the public sector does not procure dedicated EC pills at all. Ideally, countries should procure and distribute dedicated EC pills in their public sector systems; however, if they do not, or if stock outs are a problem, sexual assault treatment guidelines must include information about using regular oral contraceptive pills to make EC.

There is no clear global consensus on when to provide EC to child survivors of sexual assault. Unfortunately, many rape survivors are children and young adolescents. Should a 9-year-old girl who has been raped be offered EC? Some guidance suggests that girls who have not started menstruating should be offered EC if they have secondary sex characteristics, but there is not a global consensus on this suggestion. Forthcoming WHO guidance (expected in 2017) on treating child rape survivors will hopefully provide some clarification.

How can we ensure that survivors know about EC and can access it? Many sexual assault survivors never report the rape or seek clinical treatment. For these women and girls, knowing about EC and being able to obtain it elsewhere is critical. Yet in five of the six countries at the meeting, less than 40% of women have ever heard of EC. Moreover, barriers such as prescription requirements unnecessarily restrict EC access. Making EC widely known and available can help survivors, especially those who do not report or seek clinical care, obtain EC. Some countries have explored provision of EC through community health workers and even through police stations (see evidence from Zambia and Malawi)

These challenges suggest a need for further work to ensure that survivors can prevent pregnancy following rape. For more information about EC access as part of sexual assault care, see ICEC’s fact sheet or sign up for ICEC’s listserv.

EC in EMLs Fact Sheet 2016 Update

ICEC has updated its fact sheet on EC in Essential Medicines Lists (EMLs). Since our previous version in April 2014, eight countries have updated their national EMLs; of these, five countries have made changes to the way in which they list emergency contraception. One country (Colombia) added ECPs to its EML. Three countries (Belize, Tanzania, and Zimbabwe) now include LNG ECPs with no specified indication or dose from either only including the Yuzpe regimen (Tanzania and Zimbabwe) or from including the 1.5mg and 0.75mg ECP regimens (Belize). Also, one country (Ecuador) now includes both the 1.5mg and 0.75mg ECP regimens from only including the 0.75mg ECP regimen. Of the 118 countries with available EMLs, 61 include EC, while 57 do not, and seven of these do not include any contraceptives at all.
                                                                                                                                            You can access the updated fact sheet here, or by visiting the Publications section of our website.