Emergency Contraception: Have We Come Full Circle?


This article originally appeared in the journal Contraception.

Two decades ago, Dr. Felicia Stewart, then serving as
Medical Director of the Planned Parenthood affiliate in Sacramento California,
began her campaign to let out of the closet "America’s best-kept secret" –
emergency contraception. 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 emergency contraception 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 emergency contraception "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. The success of this twenty year effort is evident in the many
dedicated emergency contraception 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 emergency contraception by a
pharmaceutical company, not to mention the popularity of the method among
women.

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 emergency
contraception is not as effective in reducing unwanted pregnancy rates at a
population level as we once hoped seem to have put the brakes on funding
and have revived the original arguments that emergency contraception 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 emergency contraception 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 post-coitally, thus occupying a very critical
place in the array of currently available methods. The post-coital 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
emergency contraception in the United
States and around the world suggest that
significant numbers of women continue to need a post-coital method.

Some of the researchers who are concerned about the
"low-efficacy" of oral emergency contraceptives are now trying to promote
emergency IUD insertion as an alternative post-coital 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
emergency contraceptive pills through pharmacies, which are open long hours and
on weekends. The fact that women are willing to pay more for emergency
contraceptive 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 emergency
contraception 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
upwards by an early estimate that expanding access to emergency contraception
could dramatically reduce the incidence of unintended pregnancy and subsequent
abortion. 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 emergency contraception is ineffective in stopping pregnancy in
individual women who use it, but because women with enhanced access to
emergency contraception 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.

While the exact effectiveness of emergency
contraceptive pills is difficult to determine (estimates range from 59
percent to 94 percent
), we know that using emergency contraception is more
effective than doing nothing.  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 towards 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
emergency contraception 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 or 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. If individuals have accurate information about the pros and cons of various
methods, shouldn’t they be the ones
to decide which will best meet their current needs?

Effectiveness also has been the main driver behind the
push to use emergency contraception to "bridge" women to other methods.  The idea behind "bridging" is to use the lure
of emergency contraception to then get women hooked into a more effective
method. Again, we need to look at the numerous reasons 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, emergency contraception 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 post-coital 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 emergency contraception 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 emergency contraception 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 emergency contraception 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 emergency
contraception with other methods. We need to ask what we can do to help couples
use emergency contraception 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, emergency contraception 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.

References Consulted

  • Trussell J, Stewart F, Guest F, Hatcher R. Emergency contraception
    pills: a simple proposal to reduce unintended pregnancies. Family Planning Perspectives. 1992;
    24: 269-273.
  • Pillsbury B, Coeytaux F, Johnston
    A. From secret to shelf: how collaboration is bringing emergency
    contraception to women. Los
    Angeles: Pacific Institute for Women’s Health;
    1999; 32 p.
  • Blomberg R. Mainstreaming emergency contraception: a report to the
    board of the Compton Foundation on the Foundation’s Emergency
    Contraceptive Initiative, 2002-2007. Redwood
    City; 2008: 34 p.
  • Raymond EG,
    Trussell J, Polis C. Population effect of increased access to
    emergency contraceptive pills: a systematic review. Obstet Gynecol.
    2007; 109: 181-188.
  • 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; (2).
  • 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: 463-70.
  • Jain AK. Fertility reduction and the quality of family planning services.
    Studies in Family Planning.
    1989; 20:1-16.
  • Trussell J, Raymond E. Emergency contraception: a last chance to
    prevent pregnancy. October 2008. Accessed March 24, 2009 at.
  • Raymond E, Taylor D, Trussell J, Steiner MJ. Minimum
    effectiveness of the levonorgestrel regimen of emergency contraception.
    Contraception 2004;69:79-81.
  • Rosenfeld JA, Everett,
    K. Lifetime patterns of contraception and their relationship to unintended
    pregnancies. Journal of Family Practice. 2000; 49: 823-828.

 

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  • grayduck

    Why waste time writing about the morning-after pill when Implanon has been shown to be effective at reducing unwanted pregnancy rates at the population level?

    http://www.abortiondiscussion.com

  • frolicnaked

    Of all the types of contraception available, only 2 have been shown to be effective at postcoital contraception: emergency contraceptive pills and copper IUDs. A copper IUD requires a visit to a doctor/NP/PA — who may or may not be able or willing to insert the IUD — which means working with doctors’ office hours (M-F only for a lot of them). Since Plan B (in the U.S.) is available at a lot of 24-hour pharmacies, it may well be the most available poistcoital contraceptive option for a lot of women.

     

    Implanon — like an IUD — can be expensive (without insurance that covers the bulk of it) and needs to be inserted by a specially trained health care provider. Not everyone has ready access to this kind of money (or insurance) or health care. 

     

    While Implanon (or other hormonal options) can be very good methods of contraception for people, they only work if they’re used/inserted before sex. Pre-coital options are fabulous when they’re utilized, but they’re contingent on knowing when you’re going to be sexually active (and, in the case of Implanon, being able to get to a health care provider and being able to pay as much as $800 or $900 for the device plus exam plus insertion). Yes, that’s true for a lot of people — which is why almost 90% of women who are at risk of pregnancy use a method of contraception before or during intercourse. 

     

    However, not every woman knows when she will be sexually active. The first time I had sex was due to an assault. I wasn’t using contraception at the time because I had no intention of having sex. As such, I was at risk for pregnancy at a time when my only options were postcoital methods. Certainly not everyone had the same experience I did, but I’m not alone in what I did experience — nor is my situation the only one in which someone might not already be using a hormonal method of contraception. 

     

    Methods like Implanon — ones that are very effective and especially ones that are longer-term and have a lower rate of user error — are absolutely valuable methods of contraception and should be promoted, yes. However, emergency contraceptive pills are unique in when they can be used and how easily they can be accessed. In that respect, EC is crucial. 

  • therealistmom

    and Implanon may not be a good alternative for all women. I had the Norplants not long after they came out, and while I understand Implanon is supposed to be better overall it still seems like some of the risks could be there. I had bleeding daily for a year and a half with the Norplants as well as weight gain and mood swings. When they went to remove them the implants had "drifted" and ultrasound had to be used to find the rods for removal. So with the expense and the potential problems with long-term hormonal methods its not always the best option- though I surely would love to see ALL contraception made more accessible.

  • lon-newman

    Thank you for this article.  We have seen the number of positive pregnancy tests among our 6000-8000 contracepting patients/year drop by 1/2 (from 2002 baseline 5.5% to 2%) since we thoroughly implemented free EC-in- advance-of-need protocols in 2005.

    EC works if a woman takes it when she needs to.

    We have to work very hard to encourage our academic population researchers to 1) find a reliable way to measure unintended pregnancy rates among patients and, 2) resist the temptation to define success so broadly or so narrowly that our policy-makers miss the connection that each unwanted pregnancy prevented matters.

  • isol93

    GreyDuck, Implanon is a very effective contraceptive method, but like IUDs, the cost can be prohibitive, particularly for women in developing countries. Also, you missed the point of the article, because the article is not about reducing unwanted pregnancy rates at the population level but about giving women a choice.

  • grayduck

    "Implanon — like an IUD — can be expensive…"

     

    According to the National Institute for Health and Clinical Excellence in the United Kingdom, reversible long-acting contraceptives are more cost effective than the combined oral contraceptive pill at a year or more of use.

     

    http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10974

     

    "EC is crucial."

     

    But if the morning-after pill is not effective at the population level, how can you be sure that it is effective at the individual level? It seems to me that we should be stopping rapes from occurring, not waiting until they happen and then expecting the victims to use a highly faulty pregnancy prevention method.

     

    http://www.abortiondiscussion.com

  • grayduck

    "Implanon is a very effective contraceptive method, but like IUDs, the cost can be prohibitive…"

     

    See my post above. Implanon has been shown to be very cost-effective because, while the up-front costs are high, the ongoing maintenance is much less expensive than buying pills or condoms continuously.

     

    "…the article is not about reducing unwanted pregnancy rates at the population level but about giving women a choice.

     

    But if the morning-after pill is not effective at the population level, the benefits of it at the individual level are too immaterial to be worth expending valuable resources to gain.

     

    http://www.abortiondiscussion.com

  • frolicnaked

    GrayDuck, it seems to me that there’s a pretty serious flaw in your logic.

     

    While it’s true that long-acting contraceptives are more cost effective in the long run, they can still cost a patient up to $900 upfront. Which means that unless she has the funds at that time, she can’t get the device. 

     

    As for stopping rapes from occurring, I absolutely agree. However, that’a a monumental task that probably involves changing the way much of society approaches and processes the concept of consent. We should still be doing that, yes, but it’s going to take substantial time for society to get there. EC is available now, so now is a good time to promote its use. 

  • frolicnaked

    … the benefits of it at the individual level are too immaterial…

     

     Unless, you know, you’re one of the people for whom emergency contraception was not only useful but imperative. Thanks for calling my life immaterial. 

  • jayn

    Aside from the other flaws in your logic that have been pointed out, some women don’t want to (or can’t) use horomonal contraception.  Some of us don’t like messing with our bodies that way.  Other have bad side effects, making it not worth the trouble.  You’re plugging Implanon like it’s a cure-all.  It’s not–for some women it simply isn’t the best choice.

  • grayduck

    "While it’s true that long-acting contraceptives are more cost effective
    in the long run, they can still cost a patient up to $900 upfront.
    Which means that unless she has the funds at that time, she can’t get the device."

     

    Is the morning-after pill inexpensive? It may be that it is less expensive for one-time use. But if true, that fact would not falsify my point.

     

    Anyway, cost should only be an issue if the woman is raped. Otherwise, she should be able to expect the man who engaged in sexual intercourse with her to pay the cost of the contraception.

     

    "As for stopping rapes from occurring, I absolutely agree. However,
    that’a a monumental task that probably involves changing the way much
    of society approaches and processes the concept of consent. We should
    still be doing that, yes, but it’s going to take substantial time for
    society to get there."

     

    What have you done to stop rapes from occurring? 

     

    "EC is available now, so now is a good time to promote its use."

     

    I am not so much opposed to promoting the morning-after pill as I am puzzled as to why this site has devoted so much space to advocating the morning-after pill while Implanon goes virtually unmentioned. Implanon has science firmly behind it; the morning-after pill less so.

     

    http://www.abortiondiscussion.com

  • grayduck

    "Unless, you know, you’re one of the people for whom emergency contraception was not only useful but imperative. Thanks for calling my life immaterial."

     

    We are not talking about the past. Rather, we are talking about the future. It may very well be that more women would be impregnated by rape if precious resources were diverted from promoting a contraceptive method with empirical research supporting it to one that has little more than wishful thinking behind it. An increase in the use of Implanon versus other methods of pregnancy avoidance would almost certainly lead to fewer rape impregnations.

     

    http://www.abortiondiscussion.com

  • grayduck

    "…some women don’t want to (or can’t) use horomonal contraception.  Some
    of us don’t like messing with our bodies that way.  Other have bad side
    effects, making it not worth the trouble."

     

    The topic under discussion is the morning-after pill, which is also a form of hormonal contraception.

     

    "You’re plugging Implanon like it’s a cure-all."

     

    Nonsense.

     

    "…for some women it simply isn’t the best choice."

     

    That is not the issue under discussion. The issue under discussion is whether morning-after oral contraception should be promoted to the partial or complete exclusion of Implanon and other methods of contraception that have been demonstrated to reduce the number of unintended pregnancies.

     

    http://www.abortiondiscussion.com

  • frolicnaked

    Is the morning-after pill inexpensive? It may be that it is less
    expensive for one-time use. But if true, that fact would not falsify my
    point.

     

    Anyway, cost should only be an issue if the woman is raped.
    Otherwise, she should be able to expect the man who engaged in sexual
    intercourse with her to pay the cost of the contraception.

     Clearly,you and I operate in two different realities: I hope the weather is nice in yours. Good bye. 

     

  • jayn

    "The topic under discussion is the morning-after pill, which is also a form of hormonal contraception."

     

    EC is a one time dose.  Implanon is in your system constantly for up to three years.

     

    "That is not the issue under discussion. The issue under discussion is
    whether morning-after oral contraception should be promoted to the
    partial or complete exclusion of Implanon and other methods of
    contraception that have been demonstrated to reduce the number of
    unintended pregnancies"

     

    You’re the only one who has even implied such a think would (let alone should) happen.  You seem to forget that it’s called emergency contraception.  It’s there for when the unexpected happens–for example your condom breaks, or you’re raped.  No one is saying that women shouldn’t use other forms of contraception, just that EC should ALSO be available.

  • crowepps

    If I understand you correctly you are saying that all women should pay for and use Implanon, a hormonal birth control method, instead of the morning after pill, because the very high cost is actually less than using MAP dozens of times. Your assumption that those women would use MAP dozens of times doesn’t seem justified to me. Your assumption that all women are continuously sexually active isn’t borne out by the evidence. THe idea that women should use hormonal birth control just in case they are raped doesn’t seem very sensible either.

     

    Implanon DOES have side effects, you know:

    The use of IMPLANON® and other progestin-only hormonal contraceptives have been associated with ectopic pregnancy, bleeding irregularities, and ovarian cysts. The use of hormonal contraceptives is associated with increased risks of several serious side effects including blood clots which may lead to stroke or heart attack. Blood clots are a side effect of birth control pills and pregnancy. It is unknown if the risk of blood clots with IMPLANON® is different than with birth control pills. Some examples of blood clots are deep vein thrombosis (legs), pulmonary embolism (lungs), retinal thrombosis (eyes), stroke (head) and heart attack (heart). There have been reports of blood clots, including pulmonary emboli and strokes, in patients using IMPLANON®. Tell your doctor at least 4 weeks before if you are going to have surgery or will need to be on bed rest because you have an increased chance of experiencing blood clots during surgery or bed rest.

    Cigarette smoking increases the risk of serious cardiovascular side effects from the use of hormonal contraceptives. The risk increases with age (women >35), and with heavy smoking. Women who use hormonal contraceptives are strongly advised not to smoke.

    The most common side effect of IMPLANON® is a change in your menstrual periods. In studies, about 1 in 10 women stopped using IMPLANON® because of bleeding problems. Expect your menstrual periods to be irregular and unpredictable throughout the time you are using IMPLANON®. You may have more bleeding, less bleeding, or no bleeding. The time between periods may vary, and in between periods you may have spotting. Other common side effects reported in women using IMPLANON® during clinical trials include: headache; vaginitis; weight gain; acne; breast pain; viral infections such as colds, sore throats, sinus infections, or flu-like symptoms; stomach pain; painful periods; mood swings; nervousness or depression; back pain; nausea; dizziness; pain; and pain at the site of insertion.
    http://www.implanon-usa.com/Consumer/index.asp?C=83674400507869675926&source=google&HBX_PK=G%20Implanon%20Ad3&HBX_OU=50&gclid=CN7pwNyiv5wCFSUsawoddyZpNg

    While side effects are also known with MAP, using MAP one time in three years would expose the user to those side effects for approximately a week where exposure with Implanon would last three years. I’m beginning to think your posts are those of a shill for CuraScript or CVS Caremark.

  • hmprescott

    I’m a historian of medicine working on a book about the history of emergency contraception, so this story is fascinating to me. It would be very helpful to get more specifics about the individuals involved in the discussions you outline above.
    Since my study goes back to the 1960s, I have to say that these kinds of discussions are not new. Concerns about the failure of various contraceptive technologies to have the anticipated effect at a population level are a recurring theme in the history of family planning and population research.

     

    Heather Munro Prescott, Ph.D.
    Professor of History
    Central Connecticut State University
    1615 Stanley Street
    New Britain, CT 06050-4010
    http:/hmprescott.wordpress.com

  • crowepps

    Concerns about the failure of various contraceptive technologies to have the anticipated effect at a population level are a recurring theme in the history of family planning and population research.

    Unforunately when planning various contraceptive technologies those creating them always fail to account for the fact that they will be used by actual humans. Certainly they might learn from the failures to ‘wipe out disease’ through immunization and plans of mass testing and treatment. If humans individually or in groups actually used the logic and reason which planners tend to assume, there would be very few infectious diseases still active. Planners tend to plan for others like themselves without allowing for the fact that those who choose the field of planning are atypical.