Global EC: The Path to Access

Elizabeth Westley

Emergency Contraception was conceptualized internationally, born abroad, piloted around the world and currently marketed through a combination of both international and domestic agencies. Elizabeth Westley takes us on a worldly journey through EC's beginnings, recent challenges and future.

Editor's Note: This post is the first in a series of "EC on the Global Scene" posts coming this fall on Rewire.

When I was in college in the 1980s, we heard about the "morning after pill" – but not from health providers. After I graduated and moved to New York, I asked my gynecologist (this was in the early 1990s) if she mentioned emergency contraception (EC) to her clients who were barrier method users. She looked uncomfortable. She never provided information about EC to her patients (and certainly had never given an advance supply or prescription). She did provide EC prescriptions if specifically asked, she said, and insisted that her patients were all "highly educated" and already knew about EC. Of course, despite her assertions, we know that EC was still a "best kept secret" at this time.

More than twenty years earlier, in 1967, International Planned Parenthood Federation (IPPF) documented the use of estrogens for post-coital use in their medical bulletin, and other evidence has accrued over the last four decades. But despite a substantial body of strong scientific evidence, EC's transition "from research to reality" has been slow.

The International Consortium for Emergency Contraception (ICEC) was established in 1996 to increase access to EC, with a focus on developing countries. Given the potential for EC to help women meet their own reproductive goals, it was important to determine why awareness was so low, and why health care providers didn't talk about EC.

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One key issue uncovered was that there was no "dedicated product" on the market – one labeled specifically for post-coital use. With many brands of birth control pills available, there was no standard EC regimen (online bulletin boards around the world sported lists such as: Alesse, five pink pills per dose, Ovral, two white pills, Triphasil, four yellow pills, etc). Apart from being confusing, this approach did not foster the view that EC was a legitimate family planning method. Using a prescription drug "off label" can provoke unease on the part of consumers as well as providers. A drug cannot be marketed for an off-label indication, so no pharmaceutical company was putting its advertising budget behind EC. And, an off-label product does not lend itself to social marketing – a highly successful way to distribute EC now being undertaken by DKT International, Population Services International, Prosalud Interamerica and others. (DKT recently reported that together, these three organizations and other social marketing programs sold almost 4 million doses of EC around the world in 2006, averting an estimated 440,000 unwanted pregnancies.)

To meet the clear need for a dedicated product, the Consortium and its partners approached a number of pharmaceutical companies in the birth control pill business. The majority were uninterested in producing a birth control pill labeled for emergency contraception. Eventually, the Consortium negotiated with a European pharmaceutical company, Gedeon Ricther, to adapt a contraceptive pill they would manufacture into a product labeled to be taken after sexual intercourse, on an occasional or emergency basis.

Once a dedicated product was ready to be shipped from the Gedeon Richter factory, ICEC piloted EC "introduction strategies" in four countries: Mexico, Sri Lanka, Kenya, and Indonesia. Many of the challenges encountered in these and other developing country settings foreshadowed issues that later arose in the United States: regulatory delays (and delays, and delays), gathering opposition forces, the conflation of EC with abortion, and extremely low levels of general awareness that prevented women from even knowing to ask for EC.

While these international efforts were getting underway, the needs of U.S. women (and their sometimes secretive health care providers) were not forgotten. Although the mission of ICEC was specifically focused on developing countries, the founding coordinator, Sharon Camp (now the President and CEO of the Guttmacher Institute) saw the clear need for a dedicated product in this country. She left the consortium to found a venture capital company to bring EC – which she named "Plan B" – into the U.S. market, since no industry partners were interested at the time. Plan B was later sold to Barr Labs. Last year, after a protracted struggle, Plan B was approved (more or less) for over-the- counter sale. Without Plan B on the market, it is unlikely that use of EC would have increased substantially in the United States.

Today, EC is available in over 140 countries, and is available without a prescription in over 30 of them. While we have, to a large degree, been able to ensure basic access to a dedicated EC product in the majority of countries, new challenges face us in the Consortium's second decade. In a special series of "EC on the Global Scene" posts on Rewire coming this fall, we will share some of the more recent advances as well as challenges that affect women's ability to access this critical "second chance" method of contraception.

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