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Contraception Editorial May 2012

Emergency Contraception: Global Challenges, New Opportunities

Elizabeth Westley, Eleanor Bimla Schwarz

Emergency contraception (EC) is unique among modern contraceptive methods in its capacity to prevent pregnancy after sex. Perhaps for this reason, from the days of its earliest introduction, EC has engendered extraordinary anxiety and opposition in multiple settings around the world. This was most recently demonstrated by the US Secretary for Health and Human Services Kathleen Sibelius' unprecedented interference with US drug regulatory processes when she overruled the US Food and Drug Administration's approval of full over-the-counter status for all ages of a brand of levonorgestrel EC. Subsequently, President Obama added that he agreed with the decision, commenting that 11-year-olds should not be able to access EC as easily as “bubblegum and batteries”.1

Although dedicated EC products are now registered and available in most countries (and over the counter in more than 50), concerns continue to focus on three issues: emergency contraceptive pills' mechanism of action, impact on behavior, and safety.2 The fact that a growing body of evidence refutes each of these concerns seems to do little to quiet those committed to the broader agenda of restricting access to family planning services. The existing evidence demonstrates that levonorgestrel emergency contraceptive pills (ECPs) work primarily, and probably exclusively, by preventing ovulation and fertilization; despite this, the anti-choice movement continues to equate EC with abortion.3 Similarly, multiple studies have now shown that increased access to EC does not increase sexual risk-taking or lead couples to abandon use of condoms. Rather, women add EC to a range of short-term contraceptive methods and are as likely to switch to condoms after using EC as from condoms to EC.5, 6 The active ingredient in the most widely available EC product (levonorgestrel) has a robust safety profile after over 40 years on the market.6 Nonetheless, concerns about the safety and appropriateness of use of this medication continue to dominate the discourse on EC.

What is rarely discussed is the fact that few women anywhere in the world consistently have easy access to EC, although a global epidemic of unintended pregnancy and unsafe abortion rages on. In many developing countries, women continue to die from unsafe abortion, yet a large majority has simply never heard of EC.7 In Kenya, for example, where 80% of urban women interviewed in 2011 were unable to describe a method of postcoital contraception without prompting; in Nigeria, this increased to 90%, and rural women would be expected to have even less awareness.5

For those who are aware of EC, numerous challenges remain including concerns about privacy, cost and, in some settings, the ability to find a pharmacy with pills in stock. In the United States, the average cost of levonorgestrel EC is US$40–50, pricing this medication well out of reach for many teens and low-income women. In Europe, where EC is generally covered by national health insurance, cost is less of a barrier, but in developing countries, EC offered through the commercial sector may be unaffordable for younger and lower income women. Worldwide, young women face particular barriers to accessing EC; in the US, those under age 17 years cannot access EC without a prescription and some pharmacists, especially in low-income neighborhoods, may expand existing age restrictions.8 Additionally, not all pharmacies carry EC, citing either commercial or religious concerns.9 In developing countries, substantial anecdotal evidence suggests that young women frequently experience pharmacy refusals based on age.

Numerous policy and regulatory barriers also exist. Costa Rica has never allowed an EC product to be registered, and in Honduras, EC was banned by presidential decree following a coup in 2009. Similarly in the Philippines, EC's regulatory approval was reversed in 2001 and no additional EC product has entered the market.10 Even where there has been progress at the federal level (e.g., Mexico), some states have refused to implement Mexican federal law, which requires that EC be offered as part of post-rape care

New opportunities to expand access to EC 

All told, health care providers, women's health activists, advocates and researchers all have important roles to play in truly making EC available to the world's women. New strategies can be used to raise overall awareness of EC, including social media, text messages or mHealth, Internet, and the more traditional advertising and marketing approaches such as radio, television and other tools. Within health care settings, more can be done to provide women with accurate, user-friendly information about EC. Particular attention should be paid to women who may not know to ask for EC, including those seeking pregnancy testing, those seeking testing for sexually transmitted infections and women who have been raped. Women should be aware that the effectiveness of ECPs is limited and that a single dose will not protect against pregnancy if additional acts of unprotected intercourse occur. Given that unprotected sex is rarely a one-time occurrence, women need prompt access to ongoing methods of contraception, with the IUD being an excellent option for both highly effective EC and long-term contraception.

While the levonorgestrel regimen is currently the most widely available form of EC, other EC options may be more effective. Ulipristal acetate (brand name ella®) is now available by prescription in Europe and North America; given that it appears to be more effective than levonorgestrel for obese women and when EC is needed more than 3 days after unprotected intercourse, clinicians and patients should also become familiar with this option11 Although low-dose mifepristone is used for EC in a few countries (China, Russia and Vietnam) and has been found to be more effective than the levonorgestrel regimen, the fact that, unlike levonorgestrel, mifepristone (at a higher dose) can be used to induce abortion makes it unlikely that this method of EC will be marketed in regions where political opposition to abortion remains strong. The most effective form of EC is placement of a copper IUD within 5 days of unprotected sex.10, 12, 13, 14, 15, 16 Two recent studies estimated that 12–15% of US women seeking EC would have been interested in having a same-day placement of an IUD if the option was available to them.17, 18 In many countries, copper IUDs are relatively inexpensive; however, the shortage of clinicians able to place IUDs continues to limit this option. In addition, many women prefer the convenience and privacy offered by accessing EC through a pharmacy, as demonstrated by the increased use of EC that has been seen in countries that have allowed pharmacy access.19, 20, 21

Despite initial projections that widespread use of EC pills would dramatically reduce the number of unintended pregnancies and the consequent need for abortion services, none of the interventions designed to increase access to EC has been shown to significantly reduce rates of unintended pregnancy or abortion at the population level, even though EC has been shown to reduce an individual woman's chance of pregnancy when it is used.4, 22, 23 This discrepancy, which likely reflects a combination of both high rates of unprotected sex and disproportionately rare use of EC, highlights the need for new public health messages that effectively respond to women's unique calculus of risk. In addition, research is needed to help us understand more about women's use of short-term contraceptive methods and how EC can best help women meet their long-term reproductive goals and contraceptive needs.

From a global perspective, EC has yet to reach its full potential: many remain unaware the option exists, EC remains difficult for most women to access in a timely fashion and the most effective methods of EC are even harder to access. Much work remains for clinicians, lawyers, researchers, advocates and activists in ensuring that EC is available in all the world's countries and that unreasonable age and prescription requirements are overturned as rapidly as possible. We cannot allow women's fundamental rights to the full range of contraceptive methods to be traded away for short-term political gain

Elizabeth Westley
International Consortium for Emergency Contraception
New York, NY

Eleanor Bimla Schwarz
Obstetrics, Gynecology, and Reproductive Sciences
Center for Research on Health Care
University of Pittsburgh
Pittsburgh, PA

References

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Used with permission from Elsevier, Inc.