Introducing EC: A Framework

Designing an Emergency Contraception Program

Consortium members developed a 9-step framework for introducing EC into national programs. This framework offers a carefully planned process, designed to be participatory and responsive to client needs. EC introduction should ideally be situated within a strong family planning program that offers a range of methods.

The 9 steps are:

Step 1 – Assess user needs and service capabilities

An initial assessment of client information and service needs, regulatory requirements, and service delivery capabilities can provide useful information about the need for ECP services as well as help guide the development of an introductory plan. The assessment can be done locally, regionally, or nationally and should focus on Client Needs and Perspectives, Regulatory Systems Requirements, and Service Delivery Capabilities. To view a list of questions that should be addressed by this pre-introduction assessment, download the PDF here.

If the assessment results indicate that introduction of ECPs is warranted, the next steps are to build community and policy maker support and select a product for introduction.

Step 2 – Build support for emergency contraception introduction at appropriate levels

Gaining the support of key government officials and community leaders early on in the introduction process can help to ensure initial acceptance of the method and facilitate the introduction process. It is important to listen to the concerns of these groups and take them into consideration when making decisions about how to introduce ECPs. Involving a broad range of individuals and groups in the assessment process is a first step. In addition, providing clear, scientifically based information (such as that available from ICEC) to government and community groups can help address any concerns they may have. The Questions and Answers for Decision-Makers and the Talking Points for Spokespersons Responding to Opposition provide useful language for responding to challenging questions about ECPs.

Step 3 – Select a product

Dedicated EC products– pills packaged and labeled specifically for emergency use– should be the first choice when selecting a product. Dedicated products are currently registered in 140 countries. They have advantages for service delivery in that they are specifically identified for emergency contraception and contain appropriate instructions as well as the required number of pills for their correct use. Specific packaging makes them easier to supply through pharmacies and social marketing programs. For information on providing EC doses of regular oral contraceptives, click here.

Step 4 – Develop a distribution plan

In addition to the normal family planning program service delivery points (including maternal and child health clinics, family planning clinics, and community-based distribution systems), the distribution of ECPs should be considered through a variety of other channels. These include private health practitioners of many types, hospital emergency rooms, pharmacies, social marketing programs, school-based clinics, and sexual assault crisis centers. The results of the assessment
(Step 1) of potential user needs and perceptions, provider perceptions, local regulations, and existing distribution channels for hormonal contraceptives can help define which channels are most appropriate in a given setting. Once distribution channels have been selected, systems must be put in place to ensure that these channels have a consistent supply of the product. (This typically can be done through the existing contraceptive logistics system.) In addition, record-keeping systems must be updated to include ECPs.

Given that some types of ECPs are most effective when used as soon as possible within 120 hours, every effort should be made to ensure that ECP distribution channels are convenient and acceptable to clients. Factors influencing acceptability include location, hours of service, and efficiency of service. Providing an advance supply of pills helps to ensure that women know about the method and have easy access to it when they need it. Requiring women to come to the clinic and request pills each time they need them ensures a high degree of medical oversight, but may present barriers. Sources such as pharmacies may be more convenient for many women.

Step 5 – Identify and meet clients’ information needs

In order for ECPs to have an impact on reducing unplanned pregnancy, women must know about their availability before they need to use them. Women need to know that ECPs are safe and most effective the sooner they are used, and that they can be used up to five days after unprotected sex. Programs that provide emergency contraceptive IUD insertion should also include information about it in their messages.

A key way to inform women about emergency contraception is to provide basic facts about EC at the time of regular family planning or health care visits – especially for women choosing family planning methods that are dependent upon correct use, such as condoms and other barrier methods, oral contraceptives, or natural family planning. Information can be provided verbally during counseling, or in writing through the use of information brochures or waiting room posters.

Because many of the women who need ECPs are not regular family planning clients, alternative mechanisms for informing women about ECPs also are needed. These can include use of the mass media (such as television, radio, newspaper, and magazines); internet and social networking websites; advertising campaigns; traditional folk media (such as songs, local theater); or discussions at local community organizations, schools, or women’s groups. Information from the Step 1 assessment about where clients get information can be helpful in identifying appropriate communication strategies.

Women who request ECPs need more specific information about the method, including its effectiveness, safety, common side effects, instructions for use, and follow-up requirements. Ideally, this information should be provided verbally to all ECP clients during counseling as well as in simple written materials that the client can take home. Prototype client informational sheets in multiple languages are available here.

Step 6 – Train providers

Before a product is introduced to clients, providers will need training in the issues related to providing ECPs, including the special counseling needs of ECP clients. Of key importance is ensuring that providers treat women respectfully and maintain a nonjudgmental attitude while providing services. ECP service delivery training provides an opportunity to strengthen provider knowledge and skills concerning other contraceptive methods as well; the importance of their routine use; and sexually transmitted infection risk assessment, diagnosis, and management. It must be stressed that ECPs do not protect against sexually transmitted infections or subsequent unprotected intercourse.

Information on ECPs also must be incorporated as part of overall training on family planning, including all basic and refresher training for service providers. Including information about emergency contraception in the curricula of medical, nursing, and pharmacy schools can help to ensure that new health care providers are knowledgeable about the method. In addition to service providers, staff who interact with clients (including receptionists and other non-clinical staff) should receive basic information about ECPs so that they can answer inquiries about availability of the method and help clients obtain services in a timely way.

ICEC’s Medical and Service Delivery Guidelines are available online in English, Spanish, Russian, and Portuguese or in hard copy in English only by contacting the current host organization here. An updated version of the Medical and Service Delivery Guidelines will be released in 2011. A provider training curriculum, Emergency Contraceptive Pills, Second Edition, is available online in English from Pathfinder International or in hard copy by contacting the organization here.

Step 7 – Introduce the product

Once Steps 1 through 6 have been completed, the designated ECPs can be introduced through a variety of established mechanisms for the distribution of contraceptives and emergency health services. Publicizing the product “launch” through local media can be an effective way of increasing the visibility of the method among both potential clients and the medical community.

Step 8 – Monitor and evaluate emergency contraception services

Ongoing monitoring and supervision of method provision and further research into user perspectives and service delivery can identify necessary adaptations to service management, educational materials, and other aspects of providing ECPs before the method is introduced more widely within a country. Evaluation activities should include assessments of user and provider perceptions and experiences with ECPs, as well as the service delivery channels through which they are provided. Evaluation activities can assist in ensuring that ECPs are used appropriately and that they serve as a bridge to regular contraception for clients who require it.

Step 9 – Disseminate evaluation results

The results of the monitoring and evaluation activities included in Step 8 are most useful if they are disseminated to and discussed by a broad group of constituencies, and subsequently used in the development of strategies for the broader provision of ECPs within the country. As with the previous elements of the introductory process, this activity should be participatory in nature and should be aimed at ensuring that expansion of services is done in a way that ensures appropriate quality and acceptability of services.

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