In support of community-based emergency contraception
Dawn S. Chin-Quee, John Stanback, Victoria Graham
Community-based family planning is a proven, high-impact practice for extending reproductive health services to women, particularly those in hard-to-reach places . Accordingly, many community-based family planning programs facilitate and support the provision of condoms, oral contraceptive pills and even injectable contraceptives by community health workers (CHWs). Emergency contraceptive pills (ECPs)—a method for which there are no contraindications and the user herself can determine need—are not routinely included among the contraceptive methods provided by community health workers. We think this is shortsighted, especially in light of the unique position that ECPs occupy in the method mix and the CHW's ability to meet the needs of potential clients in a way other providers often cannot or do not. The putative link between microcephaly and the Zika virus in the Americas that resulted in calls for women to avoid or delay pregnancy also serves to underscore the value of this proposition.
Emergency contraception, which includes dedicated emergency contraceptive pill products, combined oral contraceptive pills (Yuzpe method) and post-coital insertion of intrauterine devices (IUDs) provides women who have had unprotected sex with an opportunity, after the fact, to prevent an unintended pregnancy [3, 4]. IUDs are the most effective form of EC, and with continued use, can provide long-term protection from pregnancy . However, IUD insertions require a clinical procedure by a higher-level provider than a CHW, which make IUDs less convenient and more difficult to obtain than emergency contraceptive pills (ECPs) within five days of unprotected sex.
Initially, there was excitement at the prospect of offering women a post-coital method in the form of a pill. Reduced rates of unintended pregnancies and abortions were touted as likely outcomes with increased access to this method [6, 7]. However, subsequent studies–including randomized controlled trials–indicated that increased access, including advance provision of ECPs, had no public health impact on these rates [8, 9]. A call for CHW provision of ECPs may therefore be called into question for lack of proven widespread effect. Nevertheless, the method has proven effective for individual women who use it . Further, advocates have argued for a woman's individual right to this method [4, 11] and the World Health Organization (WHO) recommends that “comprehensive contraceptive information and services are provided to all segments of the population”, especially to “disadvantaged and marginalized populations,”  which are the populations that CHWs typically serve. As such, it would be remiss to disavow CHW-provision of ECPs and to single out CHW clients for denial of this service.
In spite of the wide availability of ECPs in many cities around the world, they are expensive and relatively under-utilized in most countries, particularly in rural areas where the poorest of the world's poor still live . A few countries, such as India, Bangladesh and Pakistan provide ECPs at the community level, but they remain exceptions. ECPs are little known and even less used among rural women in most poor countries. For example, rural women in the Democratic Republic of Congo, Madagascar, Niger, India, the Dominican Republic and Nicaragua were less likely to have heard of ECPs than their urban counterparts. Similarly, women in urban areas of Madagascar, Burkina Faso, and Ukraine  as well as Nepal  were more likely to have ever used ECPs than women living in rural areas of those countries.
We believe that now is the time for CHWs everywhere to provide ECPs in their communities. We know that in general unmet need for family planning is higher in rural than urban areas , and is largely due to lack of access to family planning services and methods. For that reason, we should double our efforts to achieve equity between urban and rural women and to use all the means at our disposal to do so. Community-based emergency contraception (CBEC) is an easily implemented public health initiative and would be timely given the need to help women avoid pregnancy in Zika-affected areas. Below, we briefly outline the Why, Who, andWhat, as well as the Where and How, of the way forward for CBEC.
1. Why CBEC?
The many reasons why emergency contraception should be provided in community-based programs range from the obvious to the relatively obscure: ECPs provided via CHWs would increase access to this method for rural women who have relatively poor access to pharmacies and clinics compared to urban women. Stockouts of regular family planning methods and the need to travel long distances to a health facility for service remain common occurrences in rural areas, thus many women may have unprotected sex while waiting to initiate or continue a regular contraceptive method. With CHWs living in the same villages as potential clients, ECPs (as well as condoms and pills) would be more readily and conveniently obtained. This is particularly important in cases where the CHW may be the only representative of the health care system available to provide post-rape care.
Even where clinic services are available, CHWs may be less judgmental than clinicians and more willing to provide ECPs. Studies of providers and key opinion leaders in Senegal, Nigeria and India confirmed that clinic-based providers were reluctant to provide ECPs to young unmarried women and felt that ECPs should be dispensed by prescription and by medically-trained personnel only [16, 17, 18]. However, women, men and youth may feel more comfortable requesting ECPs from a CHW who is a member of their community and has earned their trust. A study in Rwanda that compared CHWs who added family planning services to their workload with counterparts who had not, showed that in both groups the overwhelming majority of clients reported that their CHW “spoke to them in a friendly way” (over 90%) and could be trusted to keep their privacy (over 95%). Moreover, when asked their preference for future health services, clients from both groups indicated that they much preferred to go to their CHW than the health clinic. The remainder indicated that it would depend on the nature of health services required .
ECPs may also be available from the private retail sector (e.g., in drug shops), but instructions and counseling are important elements of appropriate and successful use of ECPs, especially for illiterate women. Commercial sector providers may not be as willing to offer counseling and/or dedicate the time to provide education and instructions or address myths and misconceptions about the method as a CHW would. Moreover, ECPs may more readily fulfill its role as a bridge to more effective methods in the hands of CHWs (versus private commercial sector providers) [20, 21, 22] with whom client-provider interactions may prove more amenable to counseling and the provision or referral for regular, ongoing methods.
Finally, women who live most of the year without their partners can be found in both rural and urban areas. However, it is critical for women whose access to health care facilities is limited to have community-based distribution of ECPs when men return home unexpectedly. A consumer study conducted with three distinct groups of women in Nepal (never heard of ECPs; were aware of but never used ECPs; had ever used ECPs) underscored this point. About 16% of women in all three groups reported that, on average, their partners were home for only four months of the year and for that reason, were not currently using a contraceptive method. However, ever use of ECPs was reported mostly among urban women, while those who had never heard of ECPs were not only less likely to be currently using a contraceptive method than their counterparts, they were also more likely to live on the outskirts of urban or in rural areas .
2. Who can provide CBEC?
With minimum investments in time and resources, appropriately trained CHWs or CBD workers can provide ECPs. Whether male or female, paid or volunteer, literate or illiterate, any community health worker can be trained to safely provide ECPs, as they have no contraindications and women themselves are aware of when they may need ECPs. Training a CHW to provide ECPs is simple, particularly compared to other methods which require careful training about health screening, counseling for side effects, and techniques such as safe injection and waste disposal.
3. What kind of EC should be provided?
There are three options for ECPs: Yuzpe, which was described earlier and two options for dedicated ECPs—1.5 mg of levonorgestrel (LNG) or 30 mg. of ulipristal acetate (UPA)–both of which are indicated for use up to 120 h or five days after unprotected sex. However, UPA EC is more effective than LNG EC after the first 72 h . In spite of this, and research published in 2011 that suggested LNG EC was less effective than UPA EC for women weighing more than 165 lb , CBEC might be better served by the LNG formulation at this time for the following reasons:
- the cost of LNG is much lower than UPA;
- unlike UPA that is manufactured only by HRA Pharma in France, LNG EC is manufactured and distributed by many companies worldwide; has many generic formulations; and is a non-prescription product in many developing countries, which increases its availability for CBEC;
- a subsequent meta-analysis of ECP user data indicated that there was no evidence that LNG was less effective than UPA in women weighing more than 165 lb. .
- UPA is not yet widely available in less developed countries and requires a prescription everywhere except in the European Union.
4. Where should CBEC be provided?
It is imperative that the international community work together to increase women's access globally to emergency contraception through public and private sector programs that include community-based distribution, facility provision, social marketing programs, and private provider and clinics. ECPs do not require special handling or refrigeration, and clients in very remote areas, or areas that periodically become inaccessible (e.g., due to flooding) can be provided ECPs (dedicated products or Yuzpe method) in advance of need.
5. How should CBEC be provided?
As mentioned earlier, ECPs have no contraindications, and they are more effective if used as soon as possible after unprotected sex. As such, trained CHWs can provide the product and, more importantly, the necessary counseling on ECPs that sets it apart as a post-coital method of contraception. Training materials for this purpose already exist, such as WHO's family planning guide for community health workers and clients , which was adapted from WHO's Decision-Making Tool for Family Planning Clients and Providers . Since ECPs are not recommended as a regular method of contraception, CHWs should also assess the need for ongoing contraception and provide information and services accordingly. Care must be taken that clients who appear to be using ECPs as a routine method should be counseled about methods intended for ongoing use, including more effective ones such as OCPs and LARCs (long-acting reversible methods) for which CHWs are trained to provide referrals.
As a product not intended for routine use and—even now—poorly known among providers and potential clients, ECP demand is difficult to forecast. However, as ECPs are mainstreamed into public sector family planning programs via inclusion in a country's National Essential Medicines List, supportive policies, greater awareness of the method, integration into routine logistics data and procurement, supply can be tailored to approximate demand. A guide recently developed by the Institute for Reproductive Health, John Snow Inc. and Population Services International for the Reproductive Health Supplies Coalition was designed to forecast demand for new and underused methods like ECPs .
6. Challenges to CBEC
We anticipate that CHW provision of ECPs would create some challenges. We reiterate some, alluded to earlier, and raise others below. However, we think that with the exception of lack of public health impact on unintended pregnancy and abortion rates, these can be addressed.
Concerns about increased ECP access in general are also raised by CBEC. Predictions have and continue to be made of rampant promiscuity and unprotected sex (especially among adolescents), as well as a concomitant increase in sexually transmitted diseases. Studies have not substantiated these predictions [29, 30, 31]. Moreover, women who obtained ECPs without a prescription do recognize that there are better ways to prevent pregnancy and that the method does not protect against STIs [14, 32]. Routine or repeated use of ECPs is also seen as a harmful byproduct of increased access to the method, but the risk lies in its lower effectiveness than regular contraceptive methods . The medication per se is not harmful to the woman nor to the fetus should the woman become pregnant . Two independent studies conducted in Kenya and Nigeria, where charges of repeat use of ECPs have been leveled, indicated that the phenomenon was not a common one [29, 32].
One challenge specific to CBEC is the possible diversion of resources to accommodate its addition to community health workers' basket of services—whether through overburdening the CHW and/or taxing the health system. Unless and until research is conducted to investigate this, we will not know whether and in what ways this is true. We do believe that adding ECP provision to community-based family planning would prove much less disruptive than other methods already provided by CHWs (i.e., pills and injectables) that require more training in counseling, administration, and logistics as discussed earlier. A January 2015 technical consultation hosted by WHO and USAID on the classification of contraceptive methods acknowledged that ECPs ranked low on need for program support (J. Kiarie, personal communication, February 15, 2016).
Many of these challenges and concerns were voiced by participants in a formative assessment of the feasibility of CHW-provision of ECPs in Uganda . Still, these government officials along with men and women from four districts considered CHW-provision of ECPs to be feasible and acceptable. Further, both district and national level officials felt that any negative aspects associated with increased access and availability of ECPs via CHWs would be outweighed by the positive (avoidance of unintended/unwanted pregnancy and abortion). On these issues of feasibility, acceptability and the greater weight of benefits over harm, we are in agreement with assessment participants.
The Why, Who, What, Where, and How of CBEC provide ample justification for adding emergency contraception to community-based family planning programs. Moreover, advent of the post-2015 family planning agenda, with the added importance of a rights-based focus, underscores health and ethical obligations. Just as lack of public health impact has not hindered efforts to increase individual women's access to ECPs in general, it should not be used to justify disallowing CBEC specifically. Community-based emergency contraception should be considered an integral part of community-based family planning services, because unintended pregnancy is generally higher in rural than urban settings, as is unmet need for contraception more broadly. Provision of ECPs through CHWs would help individual women in largely marginalized, underserved areas to decrease their chances of having unintended pregnancies. Thus, in areas like the impoverished northeast of Brazil where the Zika virus is endemic, CBEC and other community-based services can be drawn on to address this health emergency.
CBEC should also be considered ethical, because the provision of comprehensive contraceptive information and services is a human right. To ensure the right to the highest attainable standard of health for all, the World Health Organization (WHO) recommends the “integration of contraceptive commodities, supplies and equipment, covering a range of methods, including emergency contraception, within the essential medicine supply chain to increase availability” . As a practice that can be readily implemented, CHW-provision of ECPs is low-hanging fruit for preventing unintended pregnancy, increasing access to family planning, expanding the method mix and advancing equity in reproductive health.
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