By: Melissa Garcia, Technical Adviser, International Consortium for Emergency Contraception
For this year’s World Population Day on 11 July, our community celebrates and affirms the right to family planning. On this day, the United Nations Population Fund (UNFPA) is also calling attention to the many people around the world unable to realize this right. The Guttmacher Institute’s analysis, Adding it Up, estimates that 214 million women of reproductive age in developing regions want to avoid pregnancy but are not using a modern method of contraception. One hundred and fifty five million of these women are not using a contraceptive method. Some 59 million women use traditional practices and remedies for pregnancy prevention. UNFPA has listed some of these practices in this article and accompanying photo essay. They are cause for concern because the users of such “pseudo” contraceptive practices act in the belief that they are protecting themselves from the risk of unintended pregnancy. But in fact they are exposing themselves to that risk, and potentially to further health consequences.
This phenomenon affects emergency contraception (EC) as well. The majority of women are not aware that a contraceptive option after sex exists, in most countries that capture EC knowledge in their most recent Demographic and Health Survey (DHS) data. Most women have never heard of the dedicated, safe and effective pill, and copper- IUD, regimens that are the only effective post-cotial methods.
Yet, research in one country context reveals that the same phenomenon of folk or traditional contraceptive behaviors and practices also exist after sex. Although levels of awareness of dedicated ECPs in the Democratic Republic of the Congo (DRC) are low at 18.8% (DHS 2013-14), only about a third of respondents in ICEC’s recent qualitative study believed that nothing could be done to prevent pregnancy after sex. In structured focus groups, Kinshasa women and girl participants discussed in detail the arsenal of potential post-coital “emergency” behaviors and practices that they, and other women and girls in their communities, were familiar with. They described a range of folk remedy treatments, such as douching, drinking very salty water or sodas, using a herbal concoctions of avocado leaves, and “jumping really hard to make the sperm come out”. In other cases, they described the use of non-contraceptive drugs, such as antibiotics, deworming medications (Décaris, Tanzol) and antimalarial medications (quinine, tetracycline). Describing some of these behaviors, participants detailed very complex regimens and timeframes for use.
The focus group discussion participants offered several explanations for these practices. For one, they explained that most women had never benefited from a family planning counseling information session, and relied on the “handed-down” ingrained beliefs and practices that could be observed among their mothers, sisters, aunts, and others in their communities. Compounding that is their self-admitted generally poor knowledge of reproductive biology, including the fertile period.
In their calculation, the risks of these behaviors amounted to less than what they perceived to be the high and numerous “costs” of using modern contraceptive methods, citing their fears and concerns about these, including rumored health risks. Participants also explained the high financial cost of paying for a contraceptive method, saying that, in comparison, the relatively lower cost of non-contraceptive drugs made them more appealing. In addition, focus group participants referenced the anticipated “social” cost, in terms of embarrassment and stigma, of asking for a contraceptive out loud to a pharmacist or store clerk (potentially male, potentially older) at a pharmacy counter, for anyone to hear. For these and other reasons, women and girls in Kinshasa who participated in our research revealed that post-coital contraceptive behaviors were in fact being practiced within their communities, albeit using ineffective and unreliable treatments.
The recourse to unsafe behaviors and practices to prevent pregnancy highlights the great imperative of improving awareness, through training for providers and counseling for clients on the full and diverse range of high-quality, safe, effective contraceptive methods, including on EC. They must be made available, acceptable, accessible and affordable for all women and girls, then enabled and empowered to make free and informed choice and realize their rights to family planning.
To read the full article referenced above, please see “Awareness and Perceptions of Emergency Contraceptive Pills Among Women in Kinshasa, Democratic Republic of the Congo”, co-authored by Tulane University, the DRC Ministry of Health’s National Program for Adolescent Health and the National Program for Reproductive Health, and by the International Consortium for Emergency Contraception, hosted by Management Sciences for Health.
Recent Provider Training and Client Counselling Tools on Emergency Contraception
By: Melissa Garcia, Technical Adviser, & Sarah McKee, Technical Officer, International Consortium for Emergency Contraception
Emergency contraceptive pills (ECPs) are an important part of the family planning method mix and for post-rape care, being the only effective way to reduce the risk of pregnancy after sex, whether unprotected, insufficiently protected or coerced.
At the global level, women have low levels of awareness of ECPs as a contraceptive option. This could be due in part that ECPs are not consistently included in contraceptive counselling, and/or because the right tools and information are lacking to dispel myths and misinformation. As ICEC’s mission is to ensure the safe and locally-appropriate use of EC in all reproductive health programming, we have made recent investments to support the global health care workforce by improving provider training and client counselling and awareness of ECPs at global, regional and national levels. In partnership with several other organisations, materials were created to provide up-to-date guidance on EC. While the focus is on levonorgestrel (LNG) ECPs–the most commonly available type of EC globally–select resources provide detail on the expanded post-coital contraceptive method mix.
ICEC has provided technical review to several global-level provider training materials, including EC training modules on FPTraining.org for providers (in English and in French) and for pharmacists (in English and in French). The latest edition of Family Planning: A Global Handbook for Providers has updated guidance as well; see the EC chapter here.
Our colleagues at the European Consortium for Emergency Contraception have developed the EC Wheel, based on the recommendations for EC use from WHO and the UK Faculty of Sexual and Reproductive Healthcare. It is a counseling tool for health providers, including pharmacists, intended to strengthen the quality of counselling and thus promote women’s choice in post-coital contraception. The wheel guides providers and their clients in the choice of EC methods among levonorgestrel ECPs, ulipristal acetate ECPs and the copper IUD as EC (available in English and French).
EC Wheel (electronic version)
There have been important initiatives at national levels as well. In the Democratic Republic of the Congo (DRC), the Ministry of Health’s National Program for Reproductive Health (PNSR) is committed to ensuring a range of contraceptive methods, and had created a suite of counselling brochures, one on each contraceptive method, for providers to guide their clients on contraceptive methods. Since those resources did not include EC, ICEC partnered with the PNSR and Centre for Communications Programs-DRC to add new resources into the series: one brochure on LNG ECP available in French, Lingala, Kikongo and Swahili, and one updated all-methods brochure.
ECP counselling brochures (DRC, French; Nigeria, Hausa; Tanzania, Swahili)
In Nigeria, we partnered with the Federal Ministry of Health and Centre for Communications Programs—Nigeria to create a similar series of brochures for the Nigerian health system, which has now resulted in LNG ECP brochures available in English, Hausa, Ibo, and Yoruba.
Our partners also adapted their resources to create regional, unbranded prototype brochures that can be adapted and used in any programme, in English (developed in Nigeria), French (developed in DRC) and in Swahili (developed in Tanzania, by Tanzania Communication and Development Center). In all countries, the brochures went through an extensive period of stakeholder review and pre-test, in order to ensure that it provided clear, accurate, and easily comprehensible information to any potential clients.
Additional materials were developed in Nigeria, following the country’s adoption of several policies favourable to mainstreaming EC access throughout the health system, namely the inclusion of LNG ECPs in their National Essential Medicines List (2016) and the National Guidelines for Emergency Contraception (2017).
National training modules on ECPs were developed by the Association for Reproductive and Family Health (ARFH), with one manual for trainers and one for participants, and these complement the national family planning training curriculum. Also, to support the pharmacy sector, given the prominence of commercial sector pharmacies, drug shops, and social marketing for rapid and anonymous access to ECPs, unbranded prototype materials were created by Society for Family Health for pharmacy detailing. Materials include a detailing folder, a leaflet and a hanging dangler, and these prototypes can be adapted for use in any programme. Other partners have created their own EC counselling materials as well, including this handout produced by NURHI II (Nigerian Urban Reproductive Health Initiative).
Association for Reproductive and Family Health (ARFH), Nigeria
ECPs are also safe and appropriate for community-based distribution. They are included in WHO’s Guide to Family Planning for Community Health Workers and Their Clients. In addition, the Advancing Partners & Communities (APC) project has developed an EC fact sheet for village health teams (VHTs), a job aid for community health workers, and other related resources.
We hope these resources may be of use to you in your family planning and post-rape care programming, to support providers and to improve counselling and awareness of ECPs for all women and girls in all settings–urban and rural, development and humanitarian.