Emergency Contraception: Have We Come Full Circle?

Elizabeth Westley Francine Coeytaux and Elisa Wells

Asserting that emergency contraception is "not effective enough" begs two questions: what level of effectiveness is enough and who decides this - women or providers?

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.

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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

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