Improving Access to Emergency Contraception

2003
Publication type: What's Next for EC?

Prompt, easy and affordable access to emergency contraception within 120 hours of unprotected sex can reduce the rate of unwanted pregnancies and abortions.1 Despite endorsement of emergency contraception by major health organizations such as the World Health Organization, and greater availability of dedicated Emergency Contraceptive Pills (ECPs), access remains limited for most women throughout the world.

Why do Women Need Improved Access to Emergency Contraception?

  • Studies have shown that the earlier an emergency contraception regimen is taken, the more effective it is at preventing unwanted pregnancies.1 If access is easy and without a prescription, women can begin to use the regimen without consulting a physician and may begin to use ECPs earlier.2 
  • In Scotland, women who were provided advance supplies of ECPs were nearly twice as likely to use them as those who sought emergency contraception from a physician. Women with advance supplies of ECPs also experienced lower rates of pregnancy than those who did not have easy access.3 Another study showed that women provided with ECPs in advance were no more likely than those without advance provision to engage in unprotected intercourse.4
  • In the United States, increased access to emergency contraception was instrumental in averting 51,000 abortions in 2000 and accounted for an estimated 43% decline in abortions between 1994 and 2000.5
  • The World Health Organization has called emergency contraception safe and effective and has called for greater access to ECPs as well as inclusion of the method in country health programs.

Where is Emergency Contraception Available?

  • Several brands of dedicated ECPs are now marketed in the United States, Europe and other countries. Health advocates and private ECPs manufacturers are actively working to achieve broader registration and over-the-counter status for ECPs in both developed and developing countries. At this writing, ECPs are registered in a total of 97 countries worldwide.6 Twenty-seven countries in Europe, Asia, and Africa, and two states in the U.S. offer ECPs directly through pharmacies.7

What Are Some of the Barriers to Improving Access to Emergency Contraception?

  • In many countries, lack of government policy about the method leaves providers unclear about its legal status and insufficiently informed to recommend it to women when needed. Clear policy to promote provision of emergency contraception ensures that it is available in situations such as when contraception has failed as well as among vulnerable groups such as young women and rape survivors.
  • Some policy makers and providers are misinformed about how ECPs work and believe that they may be an abortifacient. ECPs, like other hormonal contraceptives act in a variety of ways by inhibiting ovulation and preventing sperm and egg from uniting.8 While the exact mechanism of action is not fully understood, it is not likely that ECPs prevent implantation of a fertilized egg.9 Once implantation of the egg has begun, ECPs are ineffective and will not interfere with an established pregnancy or harm a developing embryo.10,11
  • Most women are unaware of the existence of emergency contraception, thus resulting in little demand for the product. Women must be sufficiently aware of the method before it is needed in order to initiate use within the required time frame. Improvements in awareness may come through health care providers, public service communication campaigns as well as through the availability of dedicated ECPs in pharmaceutical outlets.
  • Unclear service delivery protocols may impede women’s access to emergency contraception by requiring unnecessary medical screening to receive the product. While counseling may be desirable when recommending emergency contraception, it is not indispensable to its correct use.12
  • Prescription requirements may result in women needlessly delaying use of ECPs beyond the recommended time frame for its use. Past studies have shown that women understand labeling on emergency contraception13 and have used it safely and effectively suggesting that involvement of a medical provider is not essential. The established safety record of ECPs and the public health benefits from improved access at the point of sale justify a change in its regulatory status.14

Recommendation

Improved access to emergency contraception has the potential to avert unwanted pregnancies and abortions worldwide. To achieve this public health benefit, policy makers should include the method in medical and legal protocols, providers should inform women about emergency contraception and women should have the ability to obtain the method without a medical prescription.

References

1 Piaggio G, von Hertzen H, Grimes DA, Van Look PF; “Timing of Emergency Contraception with Levonorgestrel or the Yuzpe Regimen”; Lancet, 1998; 353; 721.

2 Trussell J, Duran V, Schochet T, Moore K; “Access to Emergency Contraception”; Obstetrics & Gynecology, 2000; 95; 267-70.

3 Glasier A, Baird D; “The Effects of Self-Administering Emergency Contraception”; New England Journal of Medicine, 1998; 339; 1.

4 Ellertson C, Ambardekar S, Hedley A, et al. “Emergency Contraception: Randomized Comparison of Advance Provision and Information Only”; Obstetrics & Gynecology; October 2001(4): 570-575.

5 Jones R, Darroch J, Henshaw S; “Contraceptive Use Among U.S. Women Having Abortions in 2000-2001”; Perspectives on Sexual and Reproductive Health; February 2003.

6 International Consortium for Emergency Contraception; Meeting Report, November 2002.

7 American Society for Emergency Contraception; Meeting Report, November 2002.

8 Marions L, Hultenby K, Lindell I, Sun X, Stabi B, Danilesson K; “Emergency Contraception with Mifepristone and Levonorgestrel: Mechanism of Action”; American College of Obstetricians and Gynecologists, 2002; 100; 1: 65-71.

9 IPPF Medical Bulletin; December 2002.

10 Bacic M, Wesselius de Casparis A, Diczfalusy E. “Failure of large doses of ethinyl estradiol to interfere with early embryonic development in the human species.” Amer J Obstet Gynecol 1970;107(4):531-534.

11 FDA. Prescription Drug Products; Certain Combined Oral Contraceptives for Use as Postcoital Emergency Contraception: Notice; Federal Register, February 1997; 62(37):8610-8612.

12 Raymond E, Chen P, Dalebout S. “Actual use” study of emergency contraceptive pills provided in a simulated over-the-counter manner. Obstetrics and Gynecology, in press.

13 Raymond E, Dalebout S, Camp S; “Comprehension of a Prototype Over-the-Counter Label for an Emergency Contraceptive Pill Product.” Obstetrics and Gynecology 2002; 100:342-9.

14 Ellertson C, Trussell J, Stewart F, Winikoff B; “Should Emergency Contraceptive Pills Be Available Without Prescription?”; Journal of American Women’s Medical Association; 1998; 56; 5: 226-229.