Emergency Contraceptive Pills: An Important Option for Young Adults
6/13/12 9:33 AM
Emergency Contraceptive Pills:
An Important Option for Young Adults
July 1998
Young women under the age of 24 are more likely than older women to have an unplanned pregnancy, even where contraceptives are
readily available. Several factors account for this. Sex among young adults may be unplanned and sporadic.1 Youth, both married and
unmarried, are commonly ineffective users of contraceptives as they begin to establish their sexual and birth control practices.2 Often
they are poorly informed about sexuality and reproductive health. They may believe myths, for example, that a woman cannot get
pregnant the first time she has sex.
Emergency Contraceptive Pills (ECPs)—a contraceptive which can be used up to 72 hours after unprotected sex—are an important
option for young adults. Because ECPs prevent unintended pregnancy, they also help avert abortion and maternal morbidity and
mortality. ECPs may also help sexually active young people realize that they need to begin using regular contraception.3 It is important
that young men and women know about ECPs, so that if they have unprotected sex and find themselves facing the possibility of an
unplanned pregnancy and its health and social consequences, they know that they can still act to prevent this occurrence.
What are Emergency Contraceptive Pills and how do they work?
ECPs contain a special regimen of the same hormones as regular oral contraceptives (OCs). They are reserved for an emergency that
might produce a pregnancy—a broken condom or slipped diaphragm, non-use of contraception, or rape. A woman using ECPs takes
two doses, twelve hours apart, of particular formulations of regular OCs, normally containing estrogen and a progestin.4 An alternate
regimen of progestin-only pills—as effective as combined OCs but with a lower incidence of side effects—is also available in some
countries. With either regimen, the
first dose is taken as soon after unprotected sex as possible, but no later than 72 hours afterwards.
ECPs reduce the risk of pregnancy by about 75%. This rate is calculated using the following estimation: if 100 women have a single
act of unprotected intercourse in the second or third week of their menstrual cycle, only two would become pregnant if they used ECPs
as compared to the eight expected to become pregnant without use of the contraceptive.5
Informational materials, such as Pathfinder International’s training curriculum, provide detailed information on the formulation,
dosages, and clinical management of emergency contraceptive pills.6 Some women experience nausea and vomiting for a day or so
when using ECPs. Other possible side effects include spotting, temporary breast tenderness, headaches, dizziness and fatigue.
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Depending on when in her cycle a woman uses them, ECPs may work in several ways. Studies show that if a woman has not ovulated,
ECPs can stop or delay ovulation. Delaying ovulation may be the main or only mechanism of action. Although there is little evidence,
researchers hypothesize that ECPs may also work in other ways.7 If a woman has ovulated, ECPs may prevent fertilization; hinder the
transport of a fertilized egg down the fallopian tube, causing it to reach the uterus at the wrong time; or prevent implantation in the
uterus.8 More research is needed to determine if any of these mechanisms actually contribute to the effectiveness of ECPs.
ECPs cannot cause abortion. The medical community and regulatory agencies such as the U.S. Food and Drug Administration define
pregnancy as beginning after the implantation of a fertilized egg.9 ECPs cannot affect an implanted embryo. If used during an early
pregnancy, the best evidence suggests that there will be no harmful effects to the woman or fetus.10
What are the advantages of ECPs
for youth?
ECPs form an important safety net by providing a backup method in cases of unprotected sex.11 For young people who are not
prepared for a sexual experience or had involuntary sex, ECPs offer a second chance at contraception.
ECPs provide youth who have not previously sought services with an introduction to reproductive health care.12
Family planning programs can provide ECPs and counseling for sexually active young people either in advance of need, to be
kept on hand in case of an emergency, or for use within 72 hours of unprotected sex. Advance distribution with adequate
counseling and follow-up is most important for youth using barrier methods, which fail more often than hormonal
contraceptives do. Some young adult reproductive health experts advocate the provision of a package of ECPs with condoms,
and vice versa.13
ECPs aid sexually active young people as they move to sustained contraceptive use.14 ECPs should be viewed as a bridge to
regular contraception, because regular contraceptives have higher efficacy rates. For example, the unintended pregnancy rate
for condoms, as commonly used, is about 14% of women in the first year of use.15
What are the drawbacks of ECPs?
Like all hormonal contraceptives, ECPs do not protect against STDs, including HIV.
Because many young women do not act until they have missed a menstrual period, they may miss the opportunity to use ECPs
to prevent pregnancy.16
Because ECPs are only effective for 72 hours after unprotected sex, it should be made clear to youth that contraception is
needed for further acts of intercourse. ECPs do not provide protection for the rest of a woman’s monthly cycle.
What have been the experiences of programs offering ECPs for youth?
The use of ECPs is limited in many countries, even though the effectiveness of the pills in an emergency has been known to the
medical community for three decades.17 Despite the limitations, more and more women have been hearing about ECPs and asking
their providers for them. In most countries, women can obtain ECPs only through service providers, although in some countries
contraceptive pill packages are available over the counter or through community outreach workers.
Some European countries—the United Kingdom, for example—have contraceptive pills packaged specifically for emergency use.18
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Women use ECPs widely in the United Kingdom and the Netherlands, where they form part of an integrated reproductive health
service and are covered in the national health insurance systems.19 The experience of the Netherlands demonstrates the acceptability of
ECPs among youth: in 1991, 70% of Dutch women receiving ECPs from general practitioners were less than 25 years old, and 34%
were younger than 20.20
Cost data from the United Kingdom indicate that providing ECPs and counseling ranges between $19 and $74, depending on the
provider.21 In developing countries, the understanding now is that the public sector purchase price will be about 25 cents to
governmental agencies, NGOs and social marketing organizations.22
What are the barriers to the use of ECPs by young adults?
Despite the importance and efficacy of ECPs, youth in need of emergency contraception face frustrating barriers. Many young people
are not aware of the existence of ECPs as a means to prevent unintended pregnancy. Health service providers are also often poorly
informed about emergency contraception and although there is no evidence to support the concern that ECPs encourage promiscuity,
providers frequently give this as a reason for not providing ECPs to youth.
Most providers in a Vietnamese study overestimated the incidence and severity of side effects and cited incorrect
contraindications. Some
providers stated that they did not promote ECPs because of the lack of publicized research findings, and the majority believed
that distribution should be strictly controlled.23
Confusion between ECPs and abortion still exists, and this confusion can block efforts to prevent unintended pregnancy, as has
been demonstrated in Malaysia.24
While there are some advocates for the provision of ECPs along with condoms, one study of university health centers in the
United States shows that some providers are concerned about this approach. These providers believe that telling students to use
condoms to prevent pregnancy and STDs—and then also offering ECPs because of the risk of condom breakage—sends a
mixed message about the effectiveness of condoms.25
Are there ECP programs underway in developing countries?
Despite such barriers, family planning programs are working globally to make ECPs known and available. For example, the
International Planned Parenthood Federation affiliate in Colombia, PROFAMILIA, holds daily educational activities for youth, their
parents and teachers. Educators include information on ECPs in their sessions on reproductive health. Young people want to know
what ECPs contain; how they work; if they cause abortion; and about their safety, legality and side effects. PROFAMILIA staff
instruct youth to use ECPs only for emergencies and encourage them to share information about ECPs with their peers.26
However, most of the programs making ECPs available to youth in developing countries remain in the pilot phase. They have not yet
yielded experiential information or data. Despite this, examples of these newer programs are still useful.
The Fertility Research Unit at the College of Medicine in Ibadan, Nigeria, has embarked on a three-year pilot project in six
reproductive health and family planning centers. The Youth Clinic of the Association for Reproductive and Family Health
(ARFH) is one of these sites. Grace Delano of ARFH calls ECPs "lifesaving,"27 in support of the project’s aim to increase
access to ECPs, especially among youth aged 15-24.28 Even young men visit ARFH clinics wanting ECPs for their partners.
ARFH counselors take
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this opportunity to tell youth not to rely on this emergency method, i.e., that to avoid anxiety about a possible unplanned
pregnancy, sexually active young people should adopt a regular contraceptive method.
The Kenya Medical Women’s Association and the Program for Appropriate Technology in Health (PATH) have put together a
short story, "What adolescents need to know about emergency contraception." The story opens with a young woman worried
about pregnancy after having unplanned sex for the first time. Fortunately, the girl’s mother discovers what has happened and
gives her daughter the facts about ovulation and fertilization. At her mother’s insistence, the girl visits a doctor to get ECPs and
avoids a possible pregnancy, and then vows not to have sex until marriage. The story ends by encouraging youth to spread the
news about emergency contraception to their friends who have had unprotected sex.29
The Mexico City-based Medical Center at the National University of Mexico has a pilot project with the Population Council
offering students ECP counseling and medical services.30 In addition, the Mexican Family Planning Foundation (MEXFAM)
and the Mexican Institute for Family and Population Research (IMIFAP) have put together educational materials in Spanish for
youth on ECPs and made them available via print and the Internet.31
What is the take-home message?
ECPs are an important emergency contraceptive option for sexually active young people. Because of barriers surrounding the issue of
youth sexuality and the confusion between ECPs and abortion, ECPs are underutilized. When ECPs are made available and accessible
to youth, they are well accepted. They help reduce the incidence of unplanned pregnancies and abortions, especially with proper
counseling. They can also help youth realize the significance of contraception and lead them to use a more reliable method on an
ongoing basis.
REFERENCES
1 Family Health International. Spring 1997. "Contraceptive Methods for Young Adults: Emergency Contraception." Network 17 (3): 16-17.
2 Glasier A. et al. June 1996. "Case Studies in Emergency Contraception from Six Countries." International Family Planning Perspectives 22 (2): 57-61.
3 Ibid.
4 USAID Fact Sheet on Emergency Contraception. October 1997. (Unpublished document provided by J. Spieler, Chief, Research Division, Office of Population, United States
Agency for International Development.)
5 Ibid.
6 Farrell B., C. Solter, and D. Huber. 1997. Module 5: Emergency Contraceptive Pills, Comprehensive Reproductive Health and Family Planning Training Curriculum. Watertown,
MA: Pathfinder International. (To request this document, contact Ms. Carol Wall at 617-924-7200, fax - 617-924-3833, or email <cwall%6381752@mcimail.com>.)
7 USAID Fact Sheet on Emergency Contraception, op. cit.
8 American Medical Association. October 2, 1996. Birth Control Enters the 21st Century with More Alternatives. In Science News Update [Online, cited September 10, 1997].
Available online: <http://www.ama-assn.org/sci-pubs/scinews/1996/
snr1002.htm
>.
9 USAID Fact Sheet on Emergency Contraception, op. cit.
10 Technical Guidance/Competence Working Group. September 1997. In Recommendations for Updating Selected Practices in Contraceptive Use, edited by Monica Gaines: Vol. 2,
134.
11 Glasier et al., op. cit.
12 Farrell et al., op. cit.
13 Robinson E.T., M. Metcalf-Whittaker, R. Rivera. June 1996. "Introducing Emergency Contraceptive Services: Communications Strategies and the Role of Women's Health
Advocates." International Family Planning Perspectives 22 (2): 71-75.
14 Glasier et al., op. cit.
15 Huber D. 1998. Personal communication, May.
16 Stewart L. 1998. Personal communication, January.
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17 USAID Fact Sheet on Emergency Contraception, op. Cit.
18 Consortium for Emergency Contraception. Questions and Answers for Decision Makers,
[Online, cited August 5, 1997] Available online: <http://www.path.org/ecconsor/qna.html>.
19 Glasier, A. et al. March/April 1996. "Emergency Contraception in the UK and the Netherlands." Family Planning Perspectives 28 (2): 49-51.
20 Glasier et al., "Case Studies in Emergency Contraception," op. cit.
21 Ibid.
22 Huber, D. 1998. Personal communication, May.
23 Nguyen T.N.N., et al. June 1997. "Knowledge and Attitudes About Emergency Contraception Among Health Workers in Ho Chi Minh City, Vietnam." International Family
Planning Perspectives 23(2): 68-72.
24 Glasier et al., "Case Studies in Emergency Contraception," op. cit.
25 Harper C., and C. Ellertson. July/August 1995. "Knowledge and Perceptions of Emergency Contraceptive Pills Among a College-Age Population: A Qualitative Approach." Family
Planning Perspectives 27 (4): 149-154.
26 Vargas C. 1997. Personal communication, August.
27 Delano, G. 1997. Personal communication, September.
28 Association for Reproductive and Family Health. March 1997. Emergency Contraceptive Pills: Proceedings of Two-day Orientation Seminar. Ibadan, Nigeria.
29 Program for Appropriate Technology in Health (PATH) for The Kenya Medical Women’s Association. 1996. What Adolescents Need to Know about Emergency Contraception.
Nairobi, Kenya
30 Solórzano Harris, E.M. 1998. Personal communication, February.
31 Pick, S. 1998. Personal communication, April.
u The In Focus series summarizes for professionals working in developing countries some of the program experience and limited
research available on young adult reproductive health concerns. This issue was prepared by Ann Klofkorn and was reviewed by the
FOCUS Editorial Board, some outside experts and the staff of the FOCUS program.
The In Focus publication series is available on the
FOCUS web site: http://www.pathfind.org/focus.htm
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