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Contraception Editorial July 2009

Emergency Contraception: Have We Come Full Circle?

By: Francine Coeytaux, Elisa S. Wells, and Elizabeth Westley

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Two decades ago, Dr. Felicia Stewart, then serving as Medical Director of the Planned Parenthood affiliate in Sacramento, CA, began her campaign to let out of the closet “America's best-kept secret” — emergency contraception (EC).1 The method had been suppressed because many providers thought the method was “not effective enough” or would lead women to use it “too much” (in place of using other more effective methods). Advocates disagreed, believing that EC could help some women prevent pregnancy, that women could learn to use the method appropriately, and that women had the right to this important option. When Dr. Stewart and other women's health advocates pushed to move EC “from secret to shelf,” they had women's needs in mind — in particular the need for a method that, unlike others, could be used after sex and one that was safe enough to provide without the barrier of a medical interface.2 The success of this 20-year effort is evident in the many dedicated EC products now available worldwide, the increase in women's awareness and use of EC, and, in the United States, the full-on direct to consumer marketing of EC by a pharmaceutical company, not to mention the popularity of the method among women.3

Today, in the midst of this forward trajectory of increased access and awareness, we have encountered a curve ball that has us circling back to where we started. Recent analyses suggesting that EC is not as effective in reducing unwanted pregnancy rates at a population level as we once hoped4,5 seem to have put the brakes on funding and have revived the original arguments that EC is “not effective enough” to be promoted as an option and that women are “abusing” it, using it repeatedly instead of using other more effective methods. Some in the field have also again voiced concerns that by providing it directly to women we are missing opportunities to provide women with a full range of reproductive health services.

Our response to this recent round of questioning is that EC still fills a unique and important role in the mix of available contraceptive methods, that it is effective enough to be promoted as a contraceptive option and that women's use of the method does not constitute a problem (in terms of lower effectiveness) but rather contributes in a positive way to every woman's significant challenge of how to avoid unplanned pregnancies over her lengthy fertile years.

Emergency contraception is unique

Emergency contraception is unique and fills a much needed niche. It is the only method a woman can easily use postcoitally, thus occupying a very critical place in the array of currently available methods. The postcoital niche is important not only for women who have had no control over their exposure to sex, as in the case of sexual violence, but also for couples who find themselves in need of contraception after sex. The growing sales figures for EC in the United States and around the world suggest that significant numbers of women continue to need a postcoital method.

Some of the researchers who are concerned about the “low efficacy” of oral ECs are now trying to promote emergency IUD insertion as an alternative postcoital method. But the logistics and cost of obtaining it make it an unrealistic option for most women. And it ignores what many women tell us is the biggest appeal of emergency contraceptive pills — the convenience of being able to directly access the method without having to see a doctor or health care provider.

Emergency contraception is one of only a few methods that can be obtained without having to make an appointment for a medical office visit. Women value the privacy, confidentiality and convenience of accessing EC pills through pharmacies, which are open long hours and on weekends.6 The fact that women are willing to pay more for EC pills than for a month of oral contraceptive pills requiring a clinic visit and prescription should tell us a lot about what women want and how our current family planning services are failing them.

Emergency contraception is effective enough 

Asserting that EC is “not effective enough” begs two questions: what level of effectiveness is enough and who decides this — women or providers?

Our expectations for EC's effectiveness were biased upward by an early estimate that expanding access to EC could dramatically reduce the incidence of unintended pregnancy and subsequent abortion.1 This estimate made a compelling story and is likely a key reason why donors and others were willing to support efforts to expand access to EC. Now that we realize that this was an overly optimistic calculation—not because EC is ineffective in stopping pregnancy in individual women who use it, but because women with enhanced access to EC do not seem to always use it when they need it — we seem unable to acknowledge that individual women have a right to use the contraceptive method that best suits them, not the one that best contributes to overall demographic indicators. And we seem to have forgotten that an important way to increase contraceptive coverage and reduce fertility at the population level is by enhancing the choice of contraceptive methods available.7

While the exact effectiveness of EC pills is difficult to determine (estimates range from 59% to 94%), we know that using EC is more effective than doing nothing.8,9 Even a lower level of effectiveness is valuable, both to the individual and at the population level. When we realized that the typical effectiveness of condoms and pills was much lower than their theoretical effectiveness, did we tell women to stop using them in favor of more effective IUDs? Do we push everyone toward sterilization because it has the highest level of real effectiveness? We do not for two reasons: because at the individual level, we recognize this as coercive, and at the population level, we know that providing access to a wide variety of contraceptive methods is an effective approach to helping a diverse range of women meet their reproductive needs and desires. Why should EC be held to a higher standard with respect to effectiveness than other methods? And, why should any one method be held up as a key to reducing the incidence of unplanned pregnancy and abortion when numerous and complex factors influence these outcomes?

An even more important question is who should be deciding what is “effective enough”? We tend to hear from policy makers and providers that the best choices are always methods that are most effective and have the smallest chance of user error. Yet, even though avoiding pregnancy is the motivation behind using contraception, it is clear from the wide variety of methods in use that women (and men) consider many factors when choosing a method. While some may prioritize effectiveness, many consider other factors, including convenience, privacy, insurance coverage, avoiding hormones and the reputation — accurate or not — of the method.

Furthermore, the interplay of these factors changes over the course of a woman's life, explaining why the average woman uses between three and four different contraceptive methods during her lifetime.10 If individuals have accurate information about the pros and cons of various methods, should they not be the ones to decide which will best meet their current needs?

Effectiveness also has been the main driver behind the push to use EC to “bridge” women to other methods. The idea behind “bridging” is to use the lure of EC to then get women hooked into a more effective method. Again, we need to look at the numerous factors that affect contraceptive choice (in addition to effectiveness) and let women determine which methods best meet their needs rather than reinforce the policy maker and provider-driven perspective that bridging should lead to a more “effective” method. We also need to remember that effectiveness of methods depends on their correct use and that in some instances, EC is the best method.

Women need and want this option 

Women's health advocates have fought long and hard to make “choice,” not demographic indicators, the foundation of reproductive health services. Emergency contraception is a prime example of a method that expands choice, not only because it provides a unique postcoital opportunity, but also because women can access it for themselves with minimal medical supervision, an added value that is clearly recognized by many.

We urge the reproductive health and donor communities to not give up on EC just because it is not proving to be as effective at the population level as we had once hoped. Instead, we need to protect women's access to this important choice and ensure that they have the information they need about where it fits in the array of available contraceptive methods. With information and access, women can decide for themselves how EC fits into their plans to avoid an unintended pregnancy.

We also urge the reproductive health community to continue to learn from the experience of promoting EC. We need to find out more about what women like about EC and why they are willing to accept its lower effectiveness and high cost compared with other methods. We need to better understand women's perceptions about EC's effectiveness and what information is helpful to women in comparing the choice of EC with other methods. We need to ask what we can do to help couples use EC most effectively and, possibly, avoid the cost of using it when it will not be effective. The way forward is clear — we need to continue to ease women's informed access to this unique and important method while doing a better job of assisting them in using it effectively.

Fortunately for women, EC is no longer a secret. While it is far from perfect, it remains an important option for the many women who may have occasion to need it. Let us continue to work together to ensure that all women who need a “second chance” get it.

Francine Coeytaux
Compton Foundation Emergency Contraception Initiative
Redwood City, CA

Elisa S. Wells
Association of Reproductive Health Professionals
Washington, DC

Elizabeth Westley
International Consortium for Emergency Contraception
New York, NY

References

  1. Trussell J, Stewart F, Guest F, Hatcher R. Emergency contraception pills: a simple proposal to reduce unintended pregnancies. Fam Plann Perspect. 1992; 24: 269–273.
  2. Pillsbury B, Coeytaux F, Johnston A. In: From secret to shelf: how collaboration is bringing emergency contraception to women. Los Angeles: Pacific Institute for Women's Health; 1999; p. 32.
  3. Blomberg R. In: Mainstreaming emergency contraception: a report to the board of the Compton Foundation on the Foundation's Emergency Contraceptive Initiative, 2002–2007. 2008; p. 34; Redwood City (Calif).
  4. Raymond EG, Trussell J, Polis C. Population effect of increased access to emergency contraceptive pills: a systematic review. Obstet Gynecol. 2007; 109: 181–188.
  5. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention. Cochrane Database Syst Rev. 2007; Issue 2. Available at http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005497/frame.html..
  6. Landau   SC, Tapias MP, McGhee BT. Birth control within reach: a national survey on women's attitudes toward and interest in pharmacy access to hormonal contraception. Contraception. 2006; 74: 463–470.
  7. Jain   AK. Fertility reduction and the quality of family planning services. Stud Fam Plann. 1989; 20: 1–16.
  8. Trussell J, Raymond E. Emergency contraception: a last chance to prevent pregnancy. October 2008. Accessed March 24, 2009 at http://ec.princeton.edu/questions/ec-review.pdf.
  9. Raymond E, Taylor D, Trussell J, Steiner MJ. Minimum effectiveness of the levonorgestrel regimen of emergency contraception. Contraception. 2004; 69: 79–81.
  10. Rosenfeld JA, Everett K. Lifetime patterns of contraception and their relationship to unintended pregnancies. J Fam Pract. 2000; 49: 823–828.

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Used with permission from Elsevier, Inc.