Emergency contraception: The reproductive health innovation everyone should know about

Written by Elizabeth Westley, International Consortium for Emergency Contraception, and Monica Kerrigan. Originally posted on Devex’s website.

 

Unintended pregnancies take a harrowing toll on women, young people, families and nations. When women are unable to decide whether and when to have children, maternal and newborn deaths rise, educational and economic opportunities are lost, families, communities and countries suffer greatly.

Global data highlights the tremendous challenge we face: 213 million pregnancies occur annually and an astonishing 40 percent — about 85 million — of these are unintended. In the United States alone, there are approximately 3 million unintended pregnancies each year, and in India, a staggering 18 million. A woman’s ability to make informed decisions about her reproductive health is one of the most basic human rights. It is a decision that can determine what kind of future she will have — and whether she will have one at all.

Emergency contraception is a unique tool for women to space and time their pregnancies. It is grossly underutilized, underfunded, and not fully optimized globally. It is the only contraceptive method that can be taken after unprotected sex and is effective for several days to prevent pregnancy. It is especially needed by women who have been sexually assaulted, who are often desperate to avoid becoming pregnant by their rapist.

One thing to be clear about, since misinformation abounds: Emergency contraception is not abortion and should not be confused with medical abortion drugs. If a woman has already become pregnant, the EC pill will have no effect. It also will not prevent a fertilized egg from implanting into the uterus.

EC serves as a backup for broken condoms, unplanned sex, and mistakes made with fertility awareness birth control. It could meet the needs of millions of women postinor-box-multipackwho are not currently using contraception. The method is safe, suitable for all women, backed by a slew of evidence, and yet remains largely unheard of by millions of women and their partners. Positive disruption, support and creative thinking are urgently needed to ignite action on this issue.

More than 200 million women in developing countries currently have an unmet need for family planning; they want to avoid pregnancy but aren’t using a modern method of contraception. According to a recent report from the Guttmacher Institute, one of the most commonly cited reasons is infrequent sex.

For women whose husbands are away or whose sexual relationships are sporadic, a long-term contraceptive method may not make sense. Using EC on an as-needed basis gives these women another way to protect themselves. EC can fill an important gap, making more contraception options and choices available to more women.

So why doesn’t EC figure more prominently in family planning programs worldwide?

One reason may have to do with the way contraceptive methods are pigeonholed. EC is often regarded as a method provided by the private sector, in pharmacies, rather than through regular family planning programs. Another challenge is the concern that offering women the option of choosing less effective methods may deter them from using highly effective ones, such as IUDs or implants. Finally, EC is seen primarily as a part of sexual assault services, not family planning.

The World Health Organization’s guidelines include EC as an essential intervention after sexual assault. In crisis zones, with heightened levels of sexual violence, EC is routinely included in emergency supply kits. Many donors and public health professionals are accustomed to thinking of EC primarily in these contexts.

Brave advocates, family planning professionals, and some innovative foundation funders have worked hard to put EC on the map over the last two decades, bringing the product through the regulatory process, piloting EC in selected countries, and building up the scientific evidence and programmatic experience necessary to make this critical family planning method available worldwide.

Despite these good intentions and actions, the family planning community has failed to provide adequate support for and information about this game-changing contraceptive method. The majority of women and girls in developing countries don’t even know that emergency contraception exists.

In Africa, the percentage of women who have heard of EC ranges from 5.7 percent in Chad to 59.2 percent in Kenya. For those who have information about EC, they mauntitledy be prevented from access because it is cost prohibitive. Since EC is largely provided by the private sector, prices range widely: from $2 to $8 a dose in the Democratic Republic of the Congo to $50 in the United States, making it unaffordable and far from reach for large segments of the population, especially the most vulnerable and marginalized women and girls.

The government in the DRC strongly supports family planning and pledged to raise the country’s contraceptive prevalence rate to 19 percent by 2020. The pledge forms part of its commitment to Family Planning 2020, a global partnership to provide 120 million additional women and girls access to lifesaving contraceptives by the year 2020. There is strong domestic and international donor commitment to expand access to contraception. Emergency contraception has been on the DRC’s list of essential medicines since 2010, and is supposed to be available by prescription at public health centers.

Challenges abound; one study of 21 public health centers found that none of them had EC in stock. It is not widely integrated into family planning systems, and brochures created to explain contraceptive methods to women did not include any information on EC. Most of the country’s EC is shipped as part of emergency kits to the conflict zones in eastern Congo, where rape is endemic.

There is a tremendous opportunity in the DRC to emphasize EC more in the public and private sector. Partnerships with NGOS are critical to driving transformational change. DKT, a social marketing organization, has just introduced the Aleze brand of EC to be sold in drugstores and pharmacies. At the same time, government officials are interested in the integration of EC into family planning programs; informational materials on EC for family planning clients are under development, policies are being updated, and plans are underway for EC to be more consistently available in family planning clinics. The potential for impact is enormous: DRC has one of the lowest contraceptive prevalence rates in the world — just 8 percent of women are using modern contraception — yet women there express a strong desire to space their childbearing (45 percent of women) or have reached their desired family size (23 percent of women). However, the latest surveys show that only 18.8 percent of women have heard of EC. That is bound to change for the better as DKT markets its products and the government ramps up its efforts to make EC information and access more widely available.

So how can we collectively accelerate women’s access to this critical technology?

The family planning community must pick up the momentum and work to integrate EC into family planning services, discussions and country plans. Donors must consider funding programs that include EC as part of the contraceptive method mix. More research and testing are needed to understand whether community-based distribution systems can successfully and safely provide EC. Data collection also remains a challenge, though the community is beginning to address this with the inclusion of a question related to EC use in the Demographic and Health Surveys in 2014. New mobile data collection programs such as PMA2020 will also gather more frequent data about women’s contraceptive use.

We have a tremendous opportunity to elevate emergency contraception as a critical pathway to meet the needs of women and youth, promote informed choice, and support countries’ family planning goals, especially as we mark the midpoint of the Family Planning 2020 initiative, a significant milestone on the journey to realizing the Sustainable Development Goals, and contraceptive access for all, by 2030.

An important gathering of experts takes place on Sept. 21-22 in Washington, D.C., where conversations will be held on topics such as EC in community-based distribution, new channels of availability including in online access, and high prices in pharmacies. Co-sponsored by the International Consortium for Emergency Contraception and the American Society for Emergency Contraception, the EC Jamboree is an annual conference that brings together an international group of public health experts to share research and information on EC, discuss strategies and identify action plans for improving access.

EC is one of a kind. It remains the only contraceptive method that is effective after sexual intercourse, and is one of the most underutilized tools to broaden access and choice for women and youth globally. Governments, civil society, the private sector and NGOs all have a role to play in making sure that EC is widely accessible, integrated into the mainstream, and available to every woman and girl who wants and needs it.

Ultimately, women and girls deserve to have effective methods, full information, and affordable and quality products to plan their families and their futures. It’s up to all of us to ensure this “best-kept secret” doesn’t remain a secret any longer.

A script-writer walks into a pharmacy…

Written by Melissa Garcia and Elizabeth Westley, both of the International Consortium for Emergency Contraception. Originally posted on Management Sciences for Health’s website.

 

“What happened when you went to the pharmacy and asked for emergency contraception?” Melissa surveyed a room full of television and radio writers attending a workshop in the Democratic Republic of the Congo (DRC). The participants looked around, waiting for someone to speak up first.

“The pharmacist gave me a look, so I had to show him my PMC badge to prove I was there for research, not for myself!” said a woman from Population Media Center, an organization that produces educational soap operas to improve the health and well-being of people around the world. Writers in Nigeria had similar stories to tell. An older man in flowing traditional robes confessed “I walked up and down the street three times before I summoned the courage to enter the store.” A young family planning (FP) advocate joined the media training in Senegal, and wearing her hijab, reported that the pharmacist demanded to know who the pill was meant for.

 

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Over the past year, the International Consortium for Emergency Contraception (ICEC) has led workshops in the DRC, Senegal, and Nigeria with radio and television writers working on entertainment for education programming to create storylines that provide information on emergency contraception (EC)–sometimes called the “morning-after pill”–to their diverse audiences. EC can reduce the risk of pregnancy when taken after unprotected sex – the sooner the better. But most women don’t know that that there is an alternative to crossing fingers and hoping anxiously that menstruation will start on schedule. According to DHS data, over 80% of women in the DRC and Senegal do not know that this “post-coital” contraceptive method exists; in Nigeria, 70% of women are not aware of emergency contraception. Compounding the problem, EC is mainly accessed through private pharmacies. What’s more, EC is often left out of family planning counseling sessions and information materials, and it is not consistently offered to survivors of sexual assault. So just how can women learn about this second-chance method of birth control?

ICEC is working to move the needle on awareness and to address misperceptions and misinformation about EC by mainstreaming it in popular media. If family planning clinics won’t talk about it, how about soap operas? Given that EC implies a sexual encounter, it already makes for compelling storytelling. American television shows such as ER and Boston Legal, and more recently East Los High and Master of None, have helped to raise the profile of EC in the United States, but EC has not, to our knowledge, been integrated into entertainment in Africa. ICEC is now working with the Population Media Center in the DRC and Nigeria and ONG-RAES (Réseau Africain pour l’éducation à la santé) in Senegal to ensure that writers and producers understand the basics of EC and to brainstorm scenarios that could be included in their radio and television programming.

To familiarize them with the topic, we gave the writers homework to complete in advance: to go into a pharmacy and ask for the emergency contraceptive pill. While this was a simple task for the writers in all three countries, who are experienced in creating content for radio and television and are used to talking openly about rather complicated and personal topics, many of them reported unease in entering a pharmacy to ask for EC. For them, learning about EC and how it works – as contraception, to delay ovulation—is almost always a revelation. One of the male writers even phoned his wife after the training to explain that they might have been able to prevent their last – unplanned – pregnancy, had they only known that they could. Amidst the ensuing laughter and warm, honest exchanges, the exercise reveals the underlying assumptions and some judgment—whether self-imposed or not—that come with an interaction around the purchase of a very safe pill.

Using the information from the EC workshop, PMC-DRC writers integrated EC into the dramas Vivra Verra (French) and Elembo (Lingala), which aired in 2015 and 2016. A large team of writers from PMC-Nigeria are working on including EC into two new radio dramas, one in Hausa and one in Pidgen, while in Senegal, writers are working on a television soap opera, C’est la vie, which focuses on a village health centre.

When awareness of EC is low, entertainment can be a powerful tool. But misinformation can spread easily and quickly as well. We are working to make sure that the people who create entertainment have accurate information about emergency contraception. We hope that as more programs feature storylines that mention EC as a second-chance option, more people will take it upon themselves to buy EC—even if it is embarrassing to ask for it in a pharmacy.

Emergency Contraception in National Essential Medicines Lists

Emergency Contraceptive Pills (ECPs) are an essential component of women’s reproductive health. They offer women an important second chance to prevent pregnancy when a regular method fails, no method was used, or sex was forced. Research over the past 30 years has shown that ECPs are safe and effective.

The most recent (April 2015) World Health Organization’s Essential Medicines List (EML) includes one form of ECP, containing levonorgestrel (LNG) as an active ingredient. While other drugs can be used for EC, only the LNG form is listed by the WHO at this time. The WHO list includes two regimen options for LNG ECPs: two tablets of 0.75 milligrams, or one tablet of 1.5 milligrams (mg). (These may also be written as 750 micrograms and 1500 micrograms (μg).) Either regimen can be used; although the two-pill regimen is labeled for the pills to be taken 12 hours apart, the current recommendation is for both pills to be taken together as a single 1.5 mg dose.

A new drug used for emergency contraception, called ulipristal acetate (UPA), is included in one country’s EML but is not included in the WHO EML at this time.

A number of countries have shared their national EMLs on the WHO website1; others have been shared via personal correspondence. Those that include ECPs are listed below, with the year of publication; two countries specify a different method of EC, based on taking a higher dose of regular oral contraceptives (called the “Yuzpe” regimen). The countries whose EMLs are available but do not include EC are also listed. However, the fact that a country does not include EC in its EMLs does not mean there is no product registered or on the market. For those countries with no EC listed in its EML, we have listed whether or not EC is available locally.

Of the 118 countries with available EMLs, 62 countries are known to list ECPs:

6 include only the 1.5 mg dose 38 include only the 0.75 mg dose  
12 include both the 1.5 and 0.75 mg doses 5 include LNG but do not specify the dose 
1 includes UPA EC
2 include the Yuzpe regimen (high dose of regular oral contraceptives as EC)

56 countries do not include ECPs. Of these, 7 do not include any contraceptives

6 National EMLs are known to include only the 1.5 mg LNG ECP regimen:

Brazil: 2010 Ghana: 2010 Sweden: 2011
Cook Islands: 2007 Peru: 2010 Tunisia: 2008

38 National EMLs are known to include only the 0.75 mg LNG ECP regimen:

Algeria: 2007 Haiti: 2012 Senegal: 2008
Armenia: 2010 Iran: 2009 Seychelles: 2010
Bhutan: 2012 Jamaica: 2008 Solomon Islands: 2010
Bolivia: 2011-2013 Kenya: 2010 South Africa: 2008
Burkina Faso: 2014 Kyrgyzstan: 2009 Sri Lanka: 2009
Cape Verde: 2009 Malawi: 2015 Sudan: 2007
Chile: 2005 Mali: 2008 Suriname: 2014
Dem. Rep. of Congo: 2010 Mexico: 2009 Thailand: 2008
Dominican Republic: 2005 Nauru: 2010 Tuvalu: 2008
Ethiopia: 2015 Nicaragua: 2009 Uganda: 2012
Fiji: 2006 Niue: 2006 Zambia: 2013
Gabon: Year unknown Paraguay: 2009 Zimbabwe: 2011
Georgia: 2007 Rwanda: 2010

12 National EMLs are known to include both the 1.5 and 0.75 mg LNG ECP regimens:

Cameroon: 2009 Laos: Year unknown Pakistan: 2007
Colombia: 2011 Moldova: 2009 Russia: Year unknown
Congo: 2013 Myanmar: 2010 St. Vincent & the Grenadines: 2010
Ecuador: 2011 Nepal: 2009 Tajikistan: 2009

5 National EMLs are known to include LNG ECPs without specifying indication or dose:

Belize: 2009-2011 China: 2007 Ukraine: 2009
Central African Rep.: 2009 Syria: 2008

2 National EMLs are known to include the Yuzpe regimen (high dose of regular oral contraceptives as EC):

Tanzania: 2013 Zimbabwe: 2011

1 National EML is known to include UPA ECPs:

Sweden: 2011

56 National EMLs are known NOT to include ECPs:

Afghanistan: 2007 Guyana: 2009-2010 Nigeria: 2010 (EC product registered)
Angola: 2008 (no contraceptives in EML; no EC product registered, but allows for import with license) Honduras: 2009-2011 North Korea: 1999, list for international agencies (no contraceptives)
Argentina: 2005 (EC product registered) India: 2011 (no contraceptives in EML, but EC product registered) Oman: 2009
Bahrain: 2009 Indonesia: 2008 (Listed as removed since 2005 edition) (EC product registered) Palau: 2006
Bangladesh: 2008 (EC product registered) Iraq: 2010 Papua New Guinea: 2002
Barbados: 2011-2012 (EC product registered) Jordan: 2009 Philippines: 2008
Botswana: 2012 (EC product registered) Kiribati: 2009 Poland: 2009 (EC product registered)
Bulgaria: 2009 (EC product registered) Lesotho: 2005 (no contraceptives in EML, but EC product registered) Serbia: 2010 (EC product registered)
Burundi: 2012 (no EC product registered, but allows for import with license) Macedonia: 2010 (no contraceptives in EML, but EC product registered) Slovakia: 2010 (EC product registered)
Cambodia: 2003 (EC product registered) Madagascar: 2008 (EC product registered) Slovenia: 2010 (EC product registered)
Chad: 2007 (no EC product registered, but allows for import with license) Malaysia: 2008 (EC product registered) Somalia: 2006 (no contraceptives in EML)
Cote d’Ivoire: Year unknown (EC product registered) Maldives: 2009 Timor Leste: 2004
Croatia: 2010 (EC product registered) Malta: 2008 Togo: 2012 (EC product registered)
Djibouti: 2007 (EC product registered) Marshall Islands: 2007 (no contraceptives in EML) Tonga: 2007
Egypt: 2006 (EC product registered) Mauritania: 2007 (EC product registered) Trinidad and Tobago: 2010 (EC product registered)
El Salvador: 2009 (EC product registered) Montenegro: 2011 (EC product registered) Uruguay: 2011 (EC product registered)
Eritrea: 2010 Morocco: 2008 (no contraceptives in EML, but EC product registered) Vanuatu: 2007
Guinea-Conakry: 2013 (EC product registered) Namibia: 2008 (EC product registered) Venezuela: 2004 (EC product registered)
Vietnam: 2008 (EC product registered) Yemen: 2007 (EC product registered)

 

 

1 World Health Organization. “National Medicines List/Formulary/Standard Treatment Guidelines.” Website: www.who.int/selection_medicines/country_lists/en/index.html.

A note on methodology: ICEC downloaded all the available EMLs from the WHO website in October 2015 and used the “find” function to search for the following key words: levonorgestrel, ulipristal acetate, norgestrel, contraception, and emergency contraception.