This document was co-developed with the Inter-Agency Working Group on Reproductive Health in Crises (IAWG)
Emergency contraception (EC) provides women and girls with the opportunity to avoid unplanned pregnancy when a regular method is seen to have failed, no method was used, or sex was forced.
EC is a vital option for women and girls in crisis-affected settings. Women living in crisis settings, such as countries or regions affected by conflicts and natural disasters, face particular challenges that make access to EC essential. Regular contraceptive supplies can be disrupted when a crisis strikes, while sexual assault and transactional sex can often rise; both of these factors result in an increased need for EC. Moreover, the especially harsh living conditions in most crisis-affected settings make pregnancy and childbirth even more difficult and life-threatening. Women’s ability to access a full range of contraceptive methods, including EC pills (ECPs), is critical to preventing unintended pregnancy and its consequences. ECPs are extremely safe and should therefore be available to women directly from health facilities, including pharmacies, without a prescription.
Types of ECPs: Several types of pills are packaged and labeled specifically for use as emergency contraceptive pills (referred to as “dedicated” ECPs). Levonorgestrel ECPs are the most commonly available method.1
Where dedicated EC products are not available, as is often the case in crisis settings, oral contraceptives – regular birth control pills – can be used as EC. While less effective and more likely to cause side effects, this regimen offers critical EC access for women without access to dedicated ECPs. It is generally considered legally acceptable to take a drug, such as daily oral contraceptive pills, “off-label” (in other words, in a way other than the product’s offers label specifies). Any brand of combined oral contraceptives can be used as long as it provides the correct dosage of hormones.2
Safety of ECPs: Research shows that ECPs are safe for all women and girls of reproductive age, even for women who are advised not to use combined oral contraceptives for ongoing contraception. ECPs have been found to be safe for adolescents, with no contraindications and no lasting side effects. They have no medically serious complications, do not affect future fertility, and are not harmful if taken inadvertently during pregnancy. Side effects, such as menstrual irregularities and nausea, are not serious and last only a short time. For these reasons, women should be able to obtain ECPs without a doctor’s prescription.
How ECPs work: ECPs work by preventing pregnancy before it begins. They delay or prevent the release of an egg (ovulation) or stop the egg and sperm from meeting. ECPs do not have any effects after fertilization and cannot terminate or interfere with an established pregnancy.
Timeframe for using ECPs: ECPs can be used to prevent pregnancy for up to 120 hours (five days) after unprotected sex. ECPs are more effective the sooner they are taken, so prompt access is critical.
Repeated use of ECPs: ECPs remain safe and effective in preventing pregnancy if taken more than once, even in the same menstrual cycle (although using a regular, ongoing method is the most effective way to prevent pregnancy and only condoms can prevent the spread of sexually transmitted infections). The World Health Organization’s 2015 Medical Eligibility Criteria states that “there are no restrictions on repeated use” of ECPs.
Post-rape care: EC should routinely be offered as part of comprehensive care to sexual assault survivors to prevent the traumatic psychological and physical consequences of a pregnancy from rape. EC should be provided along with post-exposure prophylaxis and other health, psychological, and social supports.
What do international health organizations say about ECPs? The World Health Organization’s Essential Medicines List includes levonorgestrel ECPs. The International Federation of Gynecology and Obstetrics (FIGO) recommends that “emergency contraception be easily available and accessible at all times to all women.” Leading global health organizations’ endorsements of EC reflect confidence not only in EC’s safety and efficacy, but also in the belief that greater access to EC is vital.
How to ensure that women in crisis-affected settings have access to EC
EC was identified as a critical need in crisis settings in the early 1990s and ECPs have since been integrated into the Inter-agency Field Manual on Reproductive Health in Humanitarian Settings and the Inter-agency Reproductive Health Kits, as well as other emergency health kits. However, assessments show that women still have little access to EC in crisis situations. There is an urgent need to make EC available at the outset of humanitarian crises as well as in long-term crisis settings.
Are ECPs available in my country? Dedicated ECPs are legal and approved for sales and distribution in most countries. However, a number of crisis-affected countries do not have a dedicated ECP product registered. To find out which dedicated ECPs are available in your country, see www.cecinfo.org/country-by-country-information/status-availability-database/.
What if my country does not have a dedicated EC product? If a dedicated EC product is not available, ECPs may be brought into your country in RH Kits or through special licensing agreements. In addition, EC can be provided using regular oral contraceptive pills. Any brand of oral contraceptive pills can be used as long as the correct dose of hormones is provided. To find out the correct regimen of oral contraceptive pills that should be taken for EC, see ec.princeton.edu/worldwide/ to search by brand name or country.
How can my country or my program access ECPs? There are a number of ways to procure ECPs depending on your setting. In many crisis settings, RH Kits are available. Dedicated ECPs are included in Kit 3 (post-rape treatment) and Kit 4 (oral and injectable contraception), and regular oral contraceptive pills (which can also be used as EC) are also included in Kit 4. Dedicated ECPs can also be purchased from UNFPA through the AccessRH catalog, accessible at myaccessrh.org. For more information about forecasting for ECPs, see the resources footnoted below.3,4 Depending on the country, ECPs may be accessed through the public sector, social marketing organizations, and/or directly from private commercial outlets; see www.cecinfo.org/country-by-country-information/status-availability-database/.
How can decision-makers increase women’s access to EC in crisis settings?
- Register at least one dedicated ECP product through the national regulatory system.
- Include EC in family planning guidelines, guidance on post-rape care, and national essential medicines lists.
- Include EC in public, private, and NGO procurement and supply systems. EC should also be incorporated into national contraceptive security strategies and their corresponding tools, such as the national FP register.
- Reduce barriers to obtaining EC; for instance, make ECPs available without a prescription from pharmacies and health facilities and incorporate community-based distribution of EC into national and organizational protocols.
- Ensure that all EC methods are included in pre-service provider training and ongoing professional development for pharmacists, doctors, nurses, and midwives. EC training can be provided in short formats, such as slide decks.
- Promote public education of EC to increase community-level knowledge. Behavior change communication (BCC) to raise awareness about EC use and availability can include interpersonal communication, community sensitization, mass media campaigns, and new communications technologies and social media efforts.
- Track and reduce provider stock-outs of EC.
- Address poor quality and counterfeit EC products where they exist.
Reproductive health care, including emergency contraception, is an essential component of any humanitarian response. Women and girls in crisis settings have particular needs and it is important to make programs and services acceptable, accessible and appropriate for those in emergency situations.
Notes and References
1 Most levonorgestrel ECPs available in crisis settings include 2 tablets of LNG 0.75. They are labeled to be taken 12 hours apart but can be safely taken together as soon after unprotected sex as possible. Regimens with the full dose combined into a single pill are also available.
2 This regimen includes estrogen (100-120mcg ethinyl estradiol (EE)) and progestin (0.50-0.60mg levonorgestrel (LNG) or 1.0-1.2 mg norgestrel (NG)) followed by the same dose 12 hours later. Alternatively, progestin-only pills labeled for daily oral contraceptive use can be used to make EC. The dose is 1.5 mg of levonorgestrel (40 or 50 pills). See ec.princeton.edu/worldwide for more information.
3 Contraceptive Security Brief. Emergency Contraceptive Pills: Supply Chain Considerations USAID | Deliver Project. May 2012. Web site: http://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=17548&lid=3.
4 “A Forecasting Guide for New & Underused Methods of Family Planning: What to Do When There Is No Trend Data?” Web site: http://irh.org/projects/new_underused_methods/.
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