A review of global access to emergency contraception

Publication date: 2013

n Jen trac 0 y t se rs wa in r ed i ide of women in low-income countries have never heard of emergency contraception, International Journal of Gynecology and Obstetrics xxx (2013) xxx–xxx IJG-07671; No of Pages 3 Contents lists available at SciVerse ScienceDirect International Journal of Gy .e cy contraception offers women an important second chance to prevent pregnancy when a regular contraceptive method fails, was used incor- rectly, orwasnot used at all, orwhen sexwas forced. Emergency contra- ception is a unique addition to the range of contraceptive methods, as it is the only method that can be effective after sex has taken place. For this reason, it is especially important for women who have been raped or coerced into sex. Extensive research and monitoring efforts confirm that the main method of emergency contraceptive pills—containing LNG—is extreme- ly safe [1]. If a woman takes LNG-containing emergency contraception and it fails (or if a woman is already pregnantwhen she takes emergen- mately 80 [13,14]. When used for emergency contraception, the IUD is extremely effective. Dedicated emergency contraceptive pills have been on the market for over a decade, yet women’s access to them is still ex- tremely uneven. 2. Materials and methods To learnmore aboutwhetherwomen around theworld are able to ac- cess emergency contraception,we conducted amultifaceted scan of glob- al and country-level policies, availability of emergency contraception products within countries, donor support for emergency contraception, cy contraception), there are no adverse effect the ongoing pregnancy [2,3]. According to the ⁎ Corresponding author at: International Consortium Hosted by Family Care International, 588 Broadway, Suite Tel.: +1 917 650 6769; fax: +1 212 941 5563. E-mail address: ewestley@fcimail.org (E. Westley). 0020-7292/$ – see front matter © 2013 International Fed http://dx.doi.org/10.1016/j.ijgo.2013.04.019 Please cite this article as: Westley E, et al, A 10.1016/j.ijgo.2013.04.019 hormone levonorgestrel ulipristal acetate or mi- er of countries. Emergen- 1000 women who use emergency contraceptive pills after a contracep- tive emergency, approximately 20 will face an unintended pregnancy; without emergency contraceptive pills, this number would be approxi- (LNG); products containing the antiprogestins fepristone are on themarket in a limited numb of a copper-bearing intrauterine device uted emergency contraceptive pills con 1. Introduction The term “emergency contraception” refers to contraceptive meth- ods that can be used to prevent pregnancy after sex. These methods in- clude several kinds of emergency contraceptive pills, aswell as insertion (IUD). The most widely distrib- tain the Criteria [4], repeated use of emergency contraceptive pills is safe, so women can take them as often as needed. Like other hormonal contra- ceptive methods, emergency contraceptive pills offer no protection from sexually transmitted infections, including HIV. Studies of LNG- containing emergency contraceptive pills have shown that they reduce pregnancy by 52%–100% [5–12]. It has been estimated that, for every Conclusions: Despite more than a decade of concerted international and country-level efforts to ensure that women have access to emergency contraception, accessibility remains limited. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. a nd surveys find that many providers have negative attitudes toward providing emergency contraception. Low-income countries medicines lists, included in w data shows that the majority REVIEW ARTICLE A review of global access to emergency co Elizabeth Westley a,⁎, Nathalie Kapp b, Tia Palermo c, a Family Care International, NY, USA b World Health Organization, Geneva, Switzerland c Stony Brook University, NY, USA d University of South Florida, FL, USA a b s t r a c ta r t i c l e i n f o Article history: Received 11 March 2013 Accepted 24 June 2013 Keywords: Contraceptive access Contraceptive policies Emergency contraception Background: Emergency con on the market for close to 2 have access to this importan regulations, and other facto wide range of gray literature databases were searched.Ma ception products are register j ourna l homepage: www s to either the woman or WHO Medical Eligibility for Emergency Contraception, 503, New York, NY 10012, USA. eration of Gynecology and Obstetrics. review of global access to em traception nifer Bleck d eption has been known for several decades, and dedicated products have been ears. Yet it is unclear whether women, particularly in low-resource countries, cond-chance method of contraception. Objectives: To review relevant policies, related to access to emergency contraception worldwide. Search strategy: A s reviewed, several specific studies were commissioned, and a number of online esults: Several positive policies and regulations are in place: emergency contra- n themajority of countries around the world, listed inmany countries’ essential ly used guidance, and supported by most donors. Yet analysis of demographic necology and Obstetrics l sev ie r .com/ locate / i jgo and other aspects of emergency contraception access. Much of the data cited in the present article can be found in the International Consortium for EmergencyContraception (ICEC) online database of global emergency contraception product availability (www.emergencycontraception.org), maintained through periodic outreach to pharmaceutical companies and informal data collection via an international network. The database is coordinated and validated with partners at the Princeton Emergency Published by Elsevier Ireland Ltd. All rights reserved. ergency contraception, Int J Gynecol Obstet (2013), http://dx.doi.org/ 2 E. Westley et al. / International Journal of Gynecology and Obstetrics xxx (2013) xxx–xxx Contraceptionwebsite (www.not-2-late.com). Additionally, other data- bases such as RHInterchange, which is maintained by the Reproduc- tive Health Supply Coalition (http://www.myaccessrh.org/rhi-home), provide valuable information on supply of emergency contraception by governments and donors. ICEC also commissioned 2 studies: the first on donor policies regard- ing provision of emergency contraception, and the second on the social marketing sector. In addition, it commissioned the Population Council to review the peer-reviewed and gray literature on provider attitudes and practices regarding emergency contraception and analyzed, with a professor at the State University of New York Stony Brook, Demo- graphic and Health Survey data to inform on global awareness and use of emergency contraception. 3. Results Globally, policies support access to emergency contraception. Levonorgestrel-containing emergency contraception is included in the WHO Essential Medicines List [15] and in widely recognized norms and guidelines such as the Family Planning Handbook [16]. In addition, donor purchasing includes emergency contraceptive pills;more than20 million doses have been procured by donors and non-governmental or- ganizations since 2000; the USA began supporting emergency contra- ception purchasing through its bilateral aid programs in 2011 [17]. At the country level, policies in support of access are uneven. In 144 countries, an emergency contraceptive pill has been registered but 65 countries haveno registereddedicated emergency contraceptionproduct. Some of these countries do allow emergency contraception to be imported with a special license, indicating that emergency contraception may be available but possibly with an inconsistent supply. In some of the countrieswithnoproduct (e.g. Costa Rica,Honduras, and thePhilippines), emergency contraception is not on the market because of opposition to its availability. In other countries, the market may be too small or the political situation too chaotic to support product registrations. Globally, there are at least 40 manufacturers of emergency contra- ception products, many in the Southern Hemisphere. According to WHO national essential medicines lists, 59 countries include an emer- gency contraception product in their national policy document of es- sential medicines [18]. However, data collected by John Snow, Inc. (Boston, MA, USA) indi- cate that, in the public sector, where poorer women often seek services and where post-rape care is offered, just over half (23 out of 42) of the low-resource countries surveyed offered emergency contraception [19]. Social marketing programs are even less likely to offer emergency con- traception than the public sector; a survey in early 2012 found that only 33% of social marketing family-planning programs currently offered an emergency contraception product [20]. Providers also have a key role in ensuring access to emergency contraception. Surveys of key opinion leaders and providers in India, Senegal, and Nigeria indicate that significant gaps still exist in attitudes to and knowledge of emergency contraception [21]. For instance, a ma- jority of respondents were in favor of requiring a prescription to access emergency contraception and many opposed advance provision, by which emergency contraceptive pills are given to women in advance of need. These surveys also found significant variability in the providers’ access to information and training on emergency contraceptive pills. Moreover, the wide variety of attitudes, including particularly negative ones, found in these surveys is echoed by news reports on “provider re- fusals” in various settings, where pharmacists, doctors, or other health providers withhold information about emergency contraception or even refuse to provide it. Such refusals are a grave violation of women’s right to receive the full range of contraceptive information and methods, and indicate the need for additional training and sensitization for service providers. Important areas in which providers need to be better informed include knowledge of the mechanism of action of emergency contraceptive pills and their safety, including when used Please cite this article as: Westley E, et al, A review of global access to em 10.1016/j.ijgo.2013.04.019 more than once or multiple times within a single cycle and among spe- cial populations (e.g. adolescents). Evenwhere policies are favorable, emergency contraception is avail- able, and providers are supportive, women must be aware of emer- gency contraception as an option. Demographic and Health Surveys provide standardized, comparable data regarding women’s knowledge and use of emergency contraception in low-resource countries around the world. From these surveys, it is known that, despite more than 10 years of emergency contraception programming and marketing, women’s knowledge is still lacking in most low-income countries and use of emergency contraception in these settings is extremely low. Demographic and Health Surveys data from 45 countries in 4 re- gions were analyzed to learn more about the factors associated with women’s knowledge and use of emergency contraceptive pills. Knowl- edge of emergency contraception among all women was highest in Latin America (with a mean of 35%), followed by Europe and West Asia (24.43%), Africa (15.03%), then Asia (11%). A similar trendwas doc- umented for use of emergency contraception among the sample of women who had ever had sex, with the highest percentage found in Latin America (3.5%), followed by Europe and West Asia (2.3%), Africa (1.8%), then East Asia (0.33%). Percentages of women reporting knowl- edge and use of emergency contraception varied considerably within regions. Chad, Timor-Leste, Azerbaijan, and Haiti had the lowest rates of knowledge and use in their regions, while Kenya, Congo, Pakistan, Ukraine, and Colombia had the highest. In almost every country, the most highly educated and wealthiest women had the highest rates of knowledge and use. Furthermore, in all but 3 countries (Egypt, Sao Tome and Principe, and Philippines) women living in urban regions had higher rates of knowledge and use than rural women. Across regions, the highest rate of use and knowledge varied among the 20–24-year-old, 25–29-year-old, and 30–34-year-old age groups. In no country did women under 20 years of age have higher rates of knowl- edge or use than women who were 20 years or older (unpublished data). These data show that, even in the regions and countries with the best access, the majority of women (65% of women in Latin America and 85% of women in Africa) have no knowledge of emergency contra- ception, profoundly hindering their ability to access this important con- traceptive option. There are some settings inwhich access to emergency contraceptive pills is of special importance. Post-rape care is one such setting. Despite the fact that emergency contraceptive pills are included in the norms and guidelines for post-rape care in many countries, their provision to womenwho have been raped is uneven at best [22]. Themisapplication of conscientious objection, unsure supply chains, and uninformed or bi- ased providers all contribute to this situation. Similarly, in crisis settings such as during and after conflicts and natural disasters, women are in particular need of emergency contra- ceptive pills. In these settings, contraceptive supplies may be disrupted and women are often forced to move from their homes. Sexual assault and transactional sex may increase significantly as communities are displaced and destabilized. For these reasons, emergency contracep- tive pills have long been integrated into the Minimum Initial Service Package offered in crisis settings, and emergency contraception supplies are included in emergency medical kits [23]. Despite these efforts, as- sessments report that women have little access to emergency contra- ception in these situations; low initial knowledge is compounded by disrupted services and lives (unpublished data). The risks of unintended pregnancies and unsafe abortion are especially high in these settings. Finally, young women as a group have a special need for emergen- cy contraceptive pills because they are especially vulnerable to sexual coercion and forced sex, are less likely to be using an ongoing method, are likely to have less knowledge about contraception and reproduc- tive health, and in some settings face increased discrimination from pharmacists and healthcare providers [24]. They may also face addi- tional regulatory hurdles such as prescription requirements that are not mandated for older women. Adolescents and young women need ergency contraception, Int J Gynecol Obstet (2013), http://dx.doi.org/ both access and education to be able to use emergency contraceptive References 3E. Westley et al. / International Journal of Gynecology and Obstetrics xxx (2013) xxx–xxx shows that they are able to use emergency contraceptive pills as safely and effectively as older women and can understand the instructions necessary to access this method over the counter [25,26]. 4. Discussion Despite more than a decade of concerted international and country- level efforts to ensure thatwomenhave access to emergency contracep- tion, accessibility remains limited. Data indicate that the large majority ofwomen in low-income countries are unaware that emergency contra- ception exists as an option. The majority of social marketing family- planning programs do not include an emergency contraception product, and approximately half of low-resource countries surveyed do not offer emergency contraception through national healthcare systems. Governments in both high- and low-income countries should com- mit to ensuring full access to emergency contraception among their population, including through the public sector, where services are the most affordable. In particular, emergency contraception should be fully integrated into post-rape care, and counseling and provision of emergency contraception should be provided by all first responders. The data also highlight the need for better training for providers about emergency contraception. Pharmacists and other frontline health workers, in particular, are underrepresented in collected data, yet pro- vide the large majority of emergency contraceptive pills to women and theymayhave a particular need for training and support in order to pro- vide emergency contraceptionwith confidence. Special efforts should be made to update pharmacists andotherswhoprovide emergency contra- ception on the safety, time limits, and other issues related to themethod. Because pharmacy sales staff often have high turnover rates, strategies to sustain such information need to be developed; written materials for women and counter workers might be one such strategy. Women themselves can be the best advocates for correct and prompt use of emergency contraception. Raising the correct knowledge of emergency contraception among the general public is critical andwill leadwomen to seek it out for themselves. Today, innovative approaches such as mHealth, social networking, mass media, and peer education can all be applied and researched in an effort to improve knowledge of emergency contraception. Opposition,where it arises, is bestmetwith evidence-based advoca- cy that underlines emergency contraception’s unique place in the con- traceptive method mix, its safety, and where necessary its mechanism of action as a contraceptive rather than abortifacient medication. The marketing of emergency contraception offers valuable lessons for emerging reproductive health technologies that may best be provided through the commercial sector; subcutaneous depot medroxyprogesterone acetate, topical microbicides, and misoprostol for prevention of hemorrhage at the community level are examples of products that may face similar challenges. Pharmacy and commercial-sector access to emergency contraception may help demedicalize access to other contraceptive methods and reproductive health products, if access to a high-quality product with adequate in- formation provision can be assured. Yet the promise of emergency contraception has not yet been met; most women in low-income countries still lack access to this crucial contraceptive option, even as access for women in high-resource countries is increasingly as- sured. This inequity may still be righted. Conflict of interest The authors have no conflicts of interest. Please cite this article as: Westley E, et al, A review of global access to em 10.1016/j.ijgo.2013.04.019 [1] World Health Organization, International Consortium for Emergency Contraception, International Federation of Gynecologists and Obstetricians, International Planned Parenthood Federation. 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