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Emergency Contraception (EC)


Emergency Contraception (EC) in the United States

In the United States, half of all pregnancies are unintended: 3.1 million occurred in 2001 alone, the last year for which data are available (Trussell, 2008). According to a Kaiser Family Foundation study (2010), only 10% of women ages 15-44 (5.1 million) have ever used emergency contraception, even though 75% of post-partum women were aware that there was something they could do in the next few days after unprotected sex to prevent pregnancy. For more information, go to: www.kff.org/womenshealth/3344.cfm

An Article in Press (2011) titled "Use of Emergency Contraception by US Teens" from the Journal of Pediatric and Adolescent Gynecology reports on a study in which surveys were completed by 531 teens from 49 states. They state that of females ages 14 to 19 who had engaged in unprotected intercourse at a time when they were aware of EC, only 48% of participants reported ever using EC. This is a significantly higher percentage than that of the general female population.

In June 2010, the federal Emergency Contraception Education Act of 2010 (S. 3504/HR 5561) was introduced to fund national campaigns to educate women and health care providers about EC.

What is EC and what forms of EC are available in the US?

EC is a way to prevent pregnancy after unprotected sexual intercourse has occurred. Ecs available in the United States include: emergency contraceptive pills (ECP) as well as the Copper T intrauterine device (IUD).

Currently, there are four types of ECPs being sold in the United States: Plan B®, Plan B One Step®, and Next Choice® (generic brand). In August 2010, the FDA also approved ella®, a newer form of EC which is more effective and gives women a longer window of time (120 vs. 72 hours) to prevent unintended pregnancy than the other ECPs. Plan B®, Plan B One Step® and Next Choice® are progestin-based, while ella® is a single-dose ulipristal acetate pill. Study findings show that side effects for ella® are comparable to those for Plan B®, Plan B One Step® and Next Choice®.

Plan B®, Plan B One Step® and Next Choice® are the first progestin-only (no estrogen) emergency contraceptive products approved by the U.S. Food and Drug Administration (FDA). These approved and "dedicated" (meaning specifically for emergency use) contraceptive pills are more effective and causes fewer side effects than the oral contraceptives (which contain both the hormones estrogen and progestin) that have, up to now, been most commonly prescribed for EC at a higher dosage than what is used for regular birth control.

Plan B® - 2 pills (0.75 mg levonorgestrel/pill); take both pills at the same time as soon as possible, or one 12 hours after the first pill, (within 24 hours is most effective) after unprotected intercourse, or up to 72 hours for best results.

Next Choice™ [Plan B generic version] - 2 pills (0.75 mg levonorgestrel/pill); take both pills at the same time, or one 12 hours after the first pill, as soon as possible (within 24 hours is most effective) after unprotected intercourse, or up to 72 hours for best results.

Plan B® One-Step/i-Pill - 1 pill (1.5 mg levonorgestrel); take the pill as soon as possible (within 24 hours is most effective) after unprotected intercourse, or up to 72 hours for best results.

ella® - 1 pill (30 mg of ulipristal acetate, a progesterone receptor modulator). It is effective for up to 120 hours after unprotected intercourse.

All ECPs must be taken within 72 hours (Plan B®, Plan B One‑Step® and Next Choice®) and 120 hours (ella®) of unprotected sex. The sooner they are taken, the more effective they are at preventing pregnancy. They work in the same ways that regular birth control pills work to prevent pregnancy — by stopping the egg from being released or by changing the lining of the uterus so an egg can't attach and grow. If a woman is already pregnant (the egg already attached to the uterus lining) by the time she takes ECP, the pregnancy is not interrupted and the baby is not harmed.

Originally, the Plan B® regimen required two pills, taken 12 hours apart. More recently, Plan B One‑Step® became available and only requires one pill. Both types are still available, but the two-pill regimen is gradually being replaced by the more convenient Plan B One‑Step®.

Plan B®, Plan B One‑Step® and Next Choice® have been approved for over-the-counter (OTC) use by consumers 17 years and older. In most states women under 17 still require a prescription. However, pharmacists in Maine, New Hampshire and Vermont are allowed to dispense EC without prescription to women of all ages. For more information on Plan B® and Plan B One‑Step®, visit their website at www.planbonestep.

When designated EC pills are not available, certain birth control pills can be used in specified combinations as emergency contraception (see Trussell p. 23 for specific information.) In either case, the regimen is one dose followed by a second dose 12 hours later; each dose consists of 1, 2, 4, 5, or 6 pills, depending on the brand (Trussell, 2008).

Copper IUDs can be inserted up to the time of implantation (so as to not disrupt an already successful pregnancy) — five to seven days after ovulation— to prevent pregnancy. Thus, if a woman had unprotected intercourse three days before ovulation, the IUD could prevent pregnancy if inserted up to ten days after intercourse. Because of the difficulty in determining the day of ovulation, however, many protocols only allow insertion up to five days after unprotected intercourse. This is to ensure that a possible pregnancy will not be interrupted.

One drawback for using the IUD as a method of EC is that it requires an appointment with a medical practitioner to be inserted. This might be difficult to accomplish within the prescribed window of opportunity. One benefit of this method is that a copper IUD can be left in place to provide effective ongoing contraception for up to twelve years.

Experts agree that all Ecs including IUDs, Plan B®, Plan B One‑Step®, Next Choice®, ella® and other birth control pills are no substitute for correct use of regular contraception since they are less effective and do not protect against sexually transmitted infections (STIs), including HIV.

What kinds of EC methods are available over the counter?

The forms of EC that are available without having to see a doctor or go to a medical clinic are:

  • Plan B®, Plan B One-Step® and Next Choice® for consumers 17 years and older in most states.

  • Plan B® or Plan B One-Step® for consumers of all ages in Maine, New Hampshire and Vermont.

Why don't more women use EC?

Emergency contraception, sometimes known as the "morning after pill," is a method of birth control which has been used for decades to prevent unintended pregnancy. It is underutilized because:

  • EC is not generally taught by teachers or health educators.

  • While ECPs are considered safe and effective by the medical community, their history of off-label usage (i.e. the practice of prescribing drugs for a purpose outside the scope of the drug's approved use) has kept them in the shadows of general public acceptability.

  • The fact that EC is routinely discussed with patients by only 25% of OB/GYNs and 14% of Family Practice physicians means that it is understood and used by only a fraction of reproductive age women (Kaiser Family Foundation, 2003).

When should EC be used?

EC is designed to be used when emergencies happen, including the following situations:

  • a condom slips, leaks, or breaks
  • a diaphragm or cervical cap slips out of place
  • one or more daily contraceptive pills have been missed
  • no contraception was used at all, or
  • for cases of sexual assault

Health educators and medical care providers should routinely teach emergency contraception as a back-up method. It should be introduced along with other contraceptive methods that are used prior to sexual intercourse. Many educators and providers believe that emergency contraception should be prescribed "in advance" for women in the event of an emergency.

EC should be as well known as other methods and presented as an option for women to consider if they want to avoid becoming pregnant. While effective school health curricula play an important part in teen pregnancy prevention, the availability of safe and effective contraceptive methods is key to preventing pregnancy among sexually active young people.

Can EC be used as an ongoing method of contraception?

Regular use of EC as a contraceptive method is not recommended. First of all, a woman is more likely to skip a dose, which could result in an unintended pregnancy. Also, as reported in the Bixby Center Brief, Is Emergency Contraceptive Effective at Preventing Pregnancy?, increased side effects may occur with regular usage (Weiss et. Al., 2008.) These side effects include: menstrual problems (e.g., bleeding or spotting between periods), nausea, breast tenderness, headache, dizziness, or fatigue/weakness.

Why is EC so important?

If used effectively (effectiveness depends on both the product's properties and the user's behavior, such as frequency of unprotected sex), EC has the potential to have great medical, social, emotional and financial impacts. However, to increase its effectiveness, information about EC must become more widespread among the general public, and EC must be made widely available through medical settings. These potential impacts include:

  • Reducing the consequent need for abortion associated with unintended pregnancy. School health educators can impact the problem by becoming educated themselves, requesting information to help educate teens through resources listed further on in this article, or by phoning their local family planning clinics or health departments. Health educators may also choose to educate families, parents of teens and other adults who are equally interested in reducing the risk of pregnancy and the need for abortion.

  • Reducing the emotional costs paid by women who fear an unwanted pregnancy. While millions of women each year experience gut-wrenching fear and anxiety over a broken condom, missed birth control pills, or unprotected sex, only a small percentage know about EC, the contraceptive method which could give them a second chance to prevent an unintended pregnancy.

  • Reducing medical care costs associated with pregnancy, birth, and spontaneous or induced abortion. Emergency contraception is nearly always cost-effective (Trussell, 2008). According to a Bixby Center article on cost-effectiveness, "Even if EC is purchased at two or three times above the current public sector price, it would remain cost-effective given the high pregnancy- and childbirth-related costs it averts." (Weiss et. Al., 2008).

  • Providing women with a last chance to prevent pregnancy after unprotected sex. Women deserve that last chance, and barriers to availability should be eliminated.

Effectiveness

  • EC pills (regular birth control pills) containing estrogen and progestin reduce the risk of pregnancy by 75%. Progestin-only EC pills (Plan B®, Plan B One Step® and Next Choice®) reduce the risk of pregnancy by 89% if taken within 72 hours. If taken between 72 and 120 hours after sexual intercourse, the effectiveness drops to 60%-64% (Weiss et. Al., 2008).

  • While Plan B®, Plan B One Step® and Next Choice® reduce chances of pregnancy with unprotected intercourse to 1 in 40, with ella® the risks are even better with the chance of pregnancy at 1 in 50.

  • Emergency IUD insertion within five days of unprotected intercourse reduces the risk of pregnancy by 99.9%.

  • EC does not provide protection against STIs. A condom should be used with EC to reduce the risk of STIs.

Resources for Further Information

  • Building Emergency Contraception Awareness Among Adolescents: A Tool Kit (2003) is a free tool kit from the Academy for Educational Development (AED) for people who work with teens on pregnancy prevention. A pdf version of this tool kit (143 pages) is available at scs.aed.org/publications/ECtoolkit3283.pdf


  • Controversies about Emergency Contraception: The Scientific Evidence (2008) from Weiss et. Al. at the Bixby Center for Global Reproductive Health (UCSF). This series of seven briefs on emergency contraception can be downloaded at bixbycenter.ucsf.edu/publications/internal.html#briefs


  • Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy (2008). This 26-page report by James Trussell, PhD and Elizabeth G. Raymond, MD, MPH is available online at ec.princeton.edu/questions/ec-review.pdf


  • Emergency Contraception website www.not-2-late.com. This website contains up-to-date and comprehensive information, including a zip code searchable database of emergency contraception providers.


  • Emergency Contraception: It's Not Too Late to Prevent Pregnancy (1998). From Program for Appropriate Technology in Health (PATH) is a brochure available online in 14 languages including Amharic, Arabic, Cambodian, Chinese, English, Haitian-Creole, Korean, Laotian, Portuguese, Russian, Somali, Spanish, or Vietnamese. Download at www.path.org/publications/details.php?i=1246.


  • Emergency Contraception: State Policies in Brief (2008): Access this 3-page Guttmacher Institute report at: www.guttmacher.org/statecenter/spibs/spib_EC.pdf


  • Emergency Contraception pamphlets (in English and Spanish), ETR Associates, 4 Carbonero Way, Scotts Valley, CA, 95066. Call 831-438-4060 and ask for Customer Service or order online at pub.etr.org/. Order pamphlets #R019 (Eng) and #R827 (Sp).


  • Emergency Contraception Information on the Association of Reproductive Health Professionals (ARHP) website at www.arhp.org/topics/emergency-contraception.


  • Emergency Contraception Tools Notebook: Reaching Diverse Audiences (1998) from Program for Appropriate Technology in Health (PATH). This can be downloaded at www.path.org/publications/details.php?i=667. It includes training and informational materials for health and social service providers, particularly those who work with low-income and diverse ethnic and language groups. The toolkit contains training curricula and other provider tools.

  • Emergency Contraception website (ec.princeton.edu/) provides current information on all aspects of emergency contraception and how to find a provider in your area. This website, established in 1994 at Princeton University, has information in English, Spanish, French and Arabic.


  • Just Had Sex? Afraid of Pregnancy? (2004) from Program for Appropriate Technology in Health (PATH). Part of the "diverse audiences" series, these wallet-sized trifold client brochures can be downloaded in English, Spanish, and Russian at www.path.org/publications/details.php?i=1061.


  • Key Facts About Emergency Contraception (2004). From Program for Appropriate Technology in Health (PATH). Part of the "diverse audiences" series, these fact sheets are available online only in English, Russian, and Spanish. http://www.path.org/publications/details.php?i=937.


  • Plan B® information can be found at www.go2planB.com.


  • Teenwire.com of Planned Parenthood Federation of America is a website for teens about sexuality with the goal for teens to reduce their risk of unintended pregnancy and sexually transmitted infections. Go to www.teenwire.com.

  • Women's Health Care Providers' Experiences with Emergency Contraception (2003). This survey snapshot (Report #3343 of the Henry J. Kaiser Family Foundation) is an update on women's health care providers' experiences with emergency contraception (EC). It provides information on prescribing practices and counseling for EC and views on increasing access to EC. It can be downloaded at www.kff.org/womenshealth/3343-index.cfm.

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