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.
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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, and the customizable EC
PowerPoint Advocacy tool helps in making
presentations to decision-makers.
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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 117 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.
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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 ECPs are most effective when
used within the first 24 hours after
unprotected sex and must be used within
120 hours, preferably 72, 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.
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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); 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.
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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.
A provider training curriculum, Emergency
Contraceptive Pills, Module 5, A Comprehensive
Training Course, is available
in English and Spanish from Pathfinder
International. (To request a copy
contact Pathfinder International,
Medical Services, 9 Galen Street,
Suite 217, Watertown, MA 02172 USA,
or download them electronically).
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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.
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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.
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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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