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Emergency contraception: How far have we come? What's new? What's next?

March 2-16, 2011
http://my.ibpinitiative.org/ICEC/ECAccess

This two-week discussion explored evidence and issues related to the current global situation,
existing barriers, and innovative strategies for expanding access to emergency contraception
(EC).

Discussion Statistics


Number of participants: 1124
Number of participants' countries: 106
Number of contributions: 188 contributions from 102 participants
% of contributions from developing countries: About 35%
Number of countries contributing: 41 countries

Contributing countries: Argentina, Australia, Brazil, Cameroon, Canada, Colombia, Costa Rica, Democratic Republic of Congo, Ecuador, Ethiopia, France, Georgia, Ghana, Guatemala, Guyana, Jordan, India, Indonesia, Iran, Ireland, Kenya, Mexico, Malawi, Mali, Mozambique, Myanmar, Nepal, Netherlands, Nigeria, Pakistan, Papua New Guinea, Peru, Poland, Serbia, South Africa, Spain, Tanzania, Uganda, United Kingdom, United States of America, Zambia


Purpose and Objectives

Purpose:

This two-week discussion explored evidence and issues related to the current global
situation, existing barriers, and innovative strategies for expanding access to emergency
contraception (EC).

  • The discussion was guided by a series of guest experts, and participants had daily
    opportunities to share experiences, challenges and lessons learned with colleagues around
    the world
  • This forum sought to engage country-level advocates and health care providers, as well
    others in the international community who are working to ensure that EC is available to all
    women                                                                             

Objective:

  • Bring new members into the International Consortium for EC community
  • Learn about EC access challenges from various countries
  • Enable health professionals to learn more about EC; share up-to-date technical evidence
    and new science
  • Encourage questions and dialogue concerning EC access                                                                
Day 1.  Ensuring Access to Emergency Contraception: How Far Have We Come? 

Questions:

  • How widely is EC available in your country/region (and which brand, prescription/over- or behind-the-counter, dedicated product)? Do you have additions or changes to be made to the attached table? 
  • In which settings is EC available (pharmacies, clinics, community distribution agents, social marketing outlets, post-rape care)?
  •  Is EC included in national norms and guidelines (for family planning and sexual assault), and is it mainstreamed into services?
  • Is access restricted for any populations (e.g. unmarried women, adolescents)?                                                                             

Emerging themes and issues: Days 1 and 2

  • Rural vs. urban access: General knowledge and access remains low in many rural areas. In urban settings knowledge of EC pills (ECPs) is higher, and at the same time the population has more disposable income in order to be able to purchase ECPs, meaning pharmacies/drug shops are motivated to keep a stock of ECPs in urban settings
  • Yuzpe regimen: Many contributors noted that the Yuzpe regimen, which consists of ordinary estrogen/progestin contraceptive pills taken in a special dose (generally two doses of 2–5 pills each), is still widely used as EC in settings where there are no dedicated products or where barriers such as cost prohibit women from obtaining dedicated ECPs 
  • Cost is a barrier to access
  • Provider bias and misinformation: Despite many national or state guidelines, many pharmacies or clinics around the world refuse to stock EC because of personal or religious beliefs. Many providers are misinformed and still believe that taking EC is considered abortion
  • Lack of knowledge of EC, culture, stigma (about contraception and EC), and low literacy (including health literacy): These factors were mentioned by several contributors as playing a significant role in attitude towards contraception, fertility, and women’s roles, thus affecting access to and knowledge of EC 
  • Youth access: In many countries access to EC is limited by age, and younger girls do not have access. In addition, education on EC is generally not targeted at youth, and therefore knowledge is lacking 
  • Measuring “access” to EC: 1) DHS measures knowledge and use of EC. 2) CLAE is using a rights-based framework that focuses on free access within the public sector. 3) The USAID DELIVER project tracks several contraceptive security indicators. 4) The MEASURE Project conducts surveys of public sector clinics to determine whether EC is offered. 5) DKT International gathers and publishes sales data from social marketing NGOs working in developing countries 
Day 2. EC Accessibility

Questions:

  • How do we measure “access” to EC? In your opinion what are the right indicators?
  • In your setting which of the following factors do you feel affect women’s access to EC: Knowledge and awareness, price, over-the-counter/non-prescription access), and provider knowledge and attitude?
  • Why is EC widely used in some countries and not in others?
  • Is your program using any creative approaches to making EC accessible to women? To young women especially?

Emerging themes and issues: Days 1 and 2

  • Rural vs. urban access: General knowledge and access remains low in many rural areas. In urban settings knowledge of EC pills (ECPs) is higher, and at the same time the population has more disposable income in order to be able to purchase ECPs, meaning pharmacies/drug shops are motivated to keep a stock of ECPs in urban settings
  • Yuzpe regimen: Many contributors noted that the Yuzpe regimen, which consists of ordinary estrogen/progestin contraceptive pills taken in a special dose (generally two doses of 2–5 pills each), is still widely used as EC in settings where there are no dedicated products or where barriers such as cost prohibit women from obtaining dedicated ECPs 
  • Cost is a barrier to access
  • Provider bias and misinformation: Despite many national or state guidelines, many pharmacies or clinics around the world refuse to stock EC because of personal or religious beliefs. Many providers are misinformed and still believe that taking EC is considered abortion
  • Lack of knowledge of EC, culture, stigma (about contraception and EC), and low literacy (including health literacy): These factors were mentioned by several contributors as playing a significant role in attitude towards contraception, fertility, and women’s roles, thus affecting access to and knowledge of EC 
  • Youth access: In many countries access to EC is limited by age, and younger girls do not have access. In addition, education on EC is generally not targeted at youth, and therefore knowledge is lacking 
  • Measuring “access” to EC: 1) DHS measures knowledge and use of EC. 2) CLAE is using a rights-based framework that focuses on free access within the public sector. 3) The USAID DELIVER project tracks several contraceptive security indicators. 4) The MEASURE Project conducts surveys of public sector clinics to determine whether EC is offered. 5) DKT International gathers and publishes sales data from social marketing NGOs working in developing countries.   
Day 3. EC and Post-rape Care

Questions:

  • In your setting are women who have been sexually assaulted able to access EC? 
  • Are there laws and policies that shape sexual assault survivors’ access to EC
  • Where do women who have been sexually assaulted access EC?
  • In your setting what challenges exist to providing sexual assault survivors with timely access to EC?
  • Does misinformation pose a barrier to access?  
  • Where do women who have been sexually assaulted first present for services? Does the timeframe in which women present for services pose a barrier to access?   
  • Is EC integrated into the training of “first responders”? Into screening, services, and programs dedicated to addressing gender-based violence? 
  • What are priority areas for action with respect to better meeting survivors’ needs?
  • In your setting do women who have been sexually assaulted have different (or greater) access to EC than other women in the community?                                                  

Emerging themes and issues:

  • Laws and Policies: An important point raised in the discussion was that laws, policies, norms and guidelines are all highly variable
  • Delays in treatment are common, for a number of reasons including stigma and resulting delay in seeking treatment, lack of awareness of EC on the part of law enforcement, and barriers within health services, such as low provider awareness of EC, provider refusal or lack of supplies 
  • Religious opposition is also a factor. and several contributors mentioned that religiously-affiliated institutions are often exempted from national or state guidelines, or they do not adhere to or comply with standard post-rape protocols
Day 4. How Does EC Work? And How Well Does EC Work? (Mechanisms of Action and Effectiveness)

Questions:

  • Is the mechanism of action of EC widely understood in your setting? 
  • Do misunderstandings about how EC works cause barriers for your work?
  • Is there confusion between EC and medical abortion?
  • Is EC perceived to be effective where you work? 
  • How do you communicate about effectiveness

Emerging themes and issues:

  • Many respondents noted that the mechanism of action is poorly understood, or that EC is often confused with medical abortion in their setting. In response to questions about the safety and mechanisms of action for EC, ICEC provided in-depth information on both issues, as well as on the effectiveness of EC.
Days 5 and 6. Facing Opposition to EC

Questions:

  • Is your program experiencing religious opposition to EC? 
  • Is your program or country experiencing legal or policy challenges to EC?
  • What legal and advocacy strategies do conservative groups use in your country or region to restrict access to EC?
  • What strategies have you used to counter this opposition? 

Emerging themes and issues:

  • Religious opposition: Many contributors spoke about the Catholic Church and its opposition and campaign against EC worldwide. It was mentioned that in Latin America and Poland some members of the church occupy key positions in the government and are highly influential in policy making. At the same time, participants from the Catholic Health Association of the USA and Catholics for Choice remind us that many Catholics support family planning and a woman’s decision about whether or not to become pregnan. 
  • When does “life” begin: The issue of when a pregnancy begins has become important in the fight to ensure EC access. While medical experts consider that a pregnancy begins with the implantation of a fertilized egg in the uterine lining, many conservative religious groups believe that “life” begins at the moment of fertilization of an egg by a sperm, and this has major implications for EC access
Days 7 and 8. Beyond Levonorgestrel: What’s Next in Emergency Contraception?

Questions:

  • Are any of these regimens in use in your setting? Which ones?
  • If so, what are some programmatic benefits you have noted? Are there any drawbacks
  • If not, do you think they would be suitable in your setting?
  • What type of information or technical support regarding these methods would you need in order to make them accessible in your setting?

Emerging themes and issues:

  • IUDs for EC: Many participants had questions and concerns about the use of IUDs for EC. Most said that it was not very common in their setting except when the woman would continue to use the IUD as a long-term method of contraception. Many participants also spoke of the issue of STIs and IUDs and recommended testing or treating for possible infections before inserting an IU. 
  • Other new and underutilized EC methods: Several participants were enthusiastic about the potential of newer methods of EC that may be effective over a longer period of time 
  • The issue of prescription versus non-prescription access: Policy and health issues were raised on the use of ulipristal acetate and mifepristone and what the implications will be if they are offered over the counter 
  • Population-level effectiveness of EC and the use of more effective contraceptive methods: Many questions arose in this section: Does EC use have any effect on abortion rates? What research, if any, is being done currently on how to boost the use-effectiveness of already established EC methods at either the individual or the population level?
Days 9 and 10. Repeat Use

Questions:

  • How common is repeat EC use in your setting? How do you assess that?
  • Why are women using EC repeatedly?
  • What are the patterns of repeat EC use? For example, how often are repeat users using EC?
  • Are they using it as backup to or along with another contraceptive, or are they using it instead of another method?
  • What concerns do you or other providers/program managers have about repeat use of EC?
  • 1. Do you think that repeat or routine EC use might have any benefits to women?

Emerging themes and issues:

  • How common is repeat use? Several contributors from Latin America observed that women in their settings frequently rely on EC and use it repeatedly. Repeat use is not as common in other settings (Africa, the Middle East, etc.) due to the low awareness and access of EC in general 
  • Patterns leading to repeat EC use: Contributors noted several possible factors that may lead women to use EC repeatedly, ranging from misinformation, convenience, privacy, reluctance to use hormones or dislike of condoms, and infrequent sex (long-distance relationships/husband works in another city) to weakened health systems and concerns about other contraceptive methods
  • Concerns of program managers and providers: Several participants share the common concern among providers regarding adverse effects for repeated users. Literature shows that repeated use of ECPs is safe, but providers do not know how safe is repeated use within the same menstrual cycle
  • Benefits of routine EC use: Most agree that ideally EC use should only be for emergency situations, but in situations where women have no alternative, EC use is better than using nothing to prevent unwanted pregnancies 
Program Examples

Post-Rape Care:

  • In Zambia a model was piloted in which police effectively and safely provided EC to post rape victims. The report also recommended that EC be included in national post-rape care protocols. Many contributors referred to this Zambian study and are interested in trying to pilot a similar program in their own communities 
  • Teenage mothers training workshops on the prevention of early and unwanted pregnancy, whether due to rape, unprotected sexual intercourse or where the condom was not properly used, are being conducted in Cameroon. These teenage mothers, who are designated AUNTIES after this five-day training, go into their homes and communities to create awareness on EC, too. They sensitize the general public in neighborhoods during campaigns and sensitizations against rape and incest 
  • Lenore Tsikitas from the Massachusetts Department of Public Health Family Planning Program in the US reports on a multi-year compliance monitoring and technical assistance initiative to help hospitals in Massachusetts remove barriers to providing sexual assault survivors with timely access to EC
  • In the urban area of Argentina, reports Lia Arribas, there are “rape kits” available in the pharmacy that include prophylaxis for HIV, hepatitis B vaccine, antibiotics for syphilis, gonorrhea, and Chlamydia, as well as levonorgestrel for EC

Increasing Accessibility:

  • Esther Oyewo of Nigeria says that her program has increased accessibility by targeting youth and promoting youth-friendly clinics. Kemi Olatomi of Nigeria echoes Esther’s comments and adds that the use of mobile clinics has improved access as well  
  • The program that Dennis Raterno of Kenya works with offers a special STI room where clients are screened and family planning, including education on EC, is provided for fre. 
  • Sue Kettner, with Family Planning Health Services in Wisconsin, in the US, describes a unique system her organization has developed to help distribute EC to women after hours and over weekends, when their clinics are closed. “We have partnered with family planning providers and medical clinics… and a car wash in one small rural community… and installed EC lockboxes on their buildings.” She explains that when people call for services, their information is gathered, if possible they are enrolled in a program to cover costs, and they are then directed to the lockbox, with the combination for the lock, to retrieve the EC. FPHS distributed 15,151 cycles of Plan B One-Step in 2010 
  • In the UK, Ali Kubba writes that in South London, pharmacies are located at the heart of the community and typically serve a younger clientele and more ethnic minorities than clinics. Therefore, subsidized or free access in pharmacies, possibly alongside condoms, Chlamydia testing, and quickstart oral contraception, would be a good strategy to increase EC access and use 
  • Mohammad Eslami of Iran notes that EC education has been “integrated in the routine contraception and family planning programs and also in the obligatory pre-marriage training classes with about 2,000,000 marital clients annually
  • Some programs in New York City and elsewhere have innovated with “Quickstart,” providing women who have come in to clinics for EC with both EC and an on-going FP method starting immediately. Both OCs and injectable contraception such as Depo-Provera can be started on the same day as EC, according to Family Planning: A Global Handbook for Providers (available at http://info.k4health.org/globalhandbook/#msword in multiple languages). IUDs for EC are a “self-bridging” method as they may be left in place to provide many years of highly effective contraceptive coverage. We encourage participants to share their strategies
Additional important points/ questions

Questions:

  • What are the best practices in terms of shaping demand for ECP among the population?
  • What are the best practices for integrating ECP into insurance packages?
  • Follow-up on EC and Depo-Provera studies is needed
  • More information on non-medical personnel providing EC following rape is needed

Emerging themes and issues:

  • Religious opposition: Many contributors spoke about the Catholic Church and its opposition and campaign against EC worldwide. It was mentioned that in Latin America and Poland some members of the church occupy key positions in the government and are highly influential in policy making. At the same time, participants from the Catholic Health Association of the USA and Catholics for Choice remind us that many Catholics support family planning and a woman’s decision about whether or not to become pregnant 
  • When does “life” begin: The issue of when a pregnancy begins has become important in the fight to ensure EC access. While medical experts consider that a pregnancy begins with the implantation of a fertilized egg in the uterine lining, many conservative religious groups believe that “life” begins at the moment of fertilization of an egg by a sperm, and this has major implications for EC access
Post-forum survey results

N of surveys completed - 122

% who have passed content to others - 63.8%

% who have or will use in their work - 95.6%

% very satisfied with forum content - 60.3%

Suggestions for improvement:

Many participants offered valuable ideas for the forum. The majority of comments included the following:

  • It was difficult to participate fully since discussions were daily and many people have very busy schedules. Many participants would rather it be spread out over a few weeks or even a month to allow more time to respond 
  • Many participants would like translations to be available
  • The format in which the digests comes in is not very reader-friendly. Formatting the messages would make them easier and more appealing to read. Also, have all messages come from the same person                                                                    

Additional  quotes/comments

  • “This was an excellent balance of e-mail and online information, allowing users to access as much information as they wanted but not overload them"
  • “This is a great opportunity to share knowledge and understanding amongst academics and practitioners at a global level. Thank you!”
  • “It was very interesting and enjoyable, and great to take part in an international community of people with shared concerns”
  • “I commend the efforts of the moderators and other team members, looking forward for more [such] fruitful deliberation in the nearest future”                                                               
References and resources

Click here to see community library/list of references

Organizing groups

The International Consortium for Emergency Contraception (www.emergencycontraception.org), World Health Organization Department of Reproductive Health and Research (WHO/RHR) and the Partners of the Implementing Best Practices (IBP) Initiative, with assistance from The American Society for Emergency Contraception (ASEC)

Contributing experts/facilitators 

Martha Brady, M.S., Senior Associate, Population Council

Dawn Chin-Quee, PhD, MPH, scientist, FHI

Kelly Cleland, MPH, MPA, Princeton

Angel Foster, MD, PhD, Senior Associate, Ibis Reproductive Health

David Nolan, Director of Communication, Catholics for Choice Cristina Puig, MS, ICEC

Elizabeth Raymond, MD, MPH, gynecologist/ scientist, Gynuity Health Projects

David Turok, MD, University of Utah

Maggie Usher-Patel, Scientist, WHO/RHR, IBP Secretariat

Steering committee

Dawn Chin-Quee

Kelly Cleland

Angel Foster

Cristina Puig

Kathleen Schaffer

Elizabeth Westley

Other acknowledgements

American Society for Emergency Contraception

Catholics for Choice

CLAE (Latin American Consortium for EC)

ECAfrique

Family Violence Prevention Fund

Gynuity Health Projects

FHI

Population Council

Princeton University

Sexual Violence Research Initiative

FIGO

Ibis Reproductive Health

Moderators

Christina Fusco, RN, MSN, FNP-BC, MPH: WHO consultant

Deepa Ramchandran, MHS: WHO consultant

Katie Richey, MPH: Technical Officer, WHO/RHR