What’s The Real Story On Emergency Contraception?

Amie Newman

A review of the use of emergency contraception implies that women with EC on hand are just as likely to become pregnant as those women who didn't have it at the ready. The lead author provides insights into the analysis.

This post has been updated: 3/26/10, 12:21pm EST

There’s been a resurgence of interest in emergency contraception this week with the release of a review entitled “Advance provision of emergency contraception,” that shows that women who keep emergency contraception on hand are just as likely to become pregnant as those women who did not receive the medication in advance. The review also concludes, however, that advanced provision of emergency contraception (EC) does not increase STI rates or negatively impact sexual or reproductive health behaviors (i.e., women are not having more unprotected sex or deciding not to use condoms simply because they have access to emergency contraception).

The review looked at 11 previously published studies on women from the U.S., China, Sweden and India to come to its conclusion that advanced provision does not appear to reduce pregnancy rates. The information comes at a particularly interesting time as the larger struggle for emergency contraception availability continues – especially in the U.S. where EC has been through a protracted battle, first under the Bush Administration when the FDA delayed on approving over-the-counter access to EC despite its own medical and scientific review panel’s stamp of approval.  Now, a full year after a federal court ruled that the FDA revisit its decision to restrict over-the-counter access to EC to those at least 17 years of age, telling the FDA it “acted in bad faith” and caved to political pressure, it has still done nothing to move closer to expanding access.

Advocates of expanded access to emergency contraception have long encouraged women to keep emergency contraception on hand, in a medicine cabinet, or somewhere at home to be used “just in case.” The reasoning has been that in cases of unintended, unprotected or unwanted sex, the more quickly a woman has access to EC, the more likely she is to be able to prevent pregnancy if that’s what she desires. And in many countries, emergency contraception is not available over-the-counter, requiring a doctor’s visit first. In the U.S., a woman over 17 years old can access EC from a pharmacy over-the-counter if the pharmacy in her area is open at the time she needs the medication, if the pharmacy in her area sells EC, and if the pharmacist does not decide to restrict access based on his or her personal beliefs. And, in fact, this review confirms that information about and timely access to emergency contraception is still an excellent way for women to safely and effectively prevent pregnancy.

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I went to the source and talked to the review’s lead researcher, Chelsea Polis of the Johns Hopkins Bloomberg School of Public Health, about the findings.

First of all, Chelsea quickly dispelled the idea that there is in fact anything “new” in this information.

“What came out,” she says, “was only an update to a review that was already published – in 2007. This information has been known for awhile. The update only added evidence from three new studies since the original review was published – and really didn’t change the conclusions much.”

To be clear, I asked her: Does your review mean that women should not have access to EC in advance if they want it? 

“Absolutely not! People seem to be confusing what we’ve done here – we looked at the effectiveness of a strategy not the efficacy of  the medication. The study is saying it’s probably not a good idea to hand out packets of EC to women in advance as a policy if you’re thinking that alone will increase the likelihood of preventing pregnancy. But it’s definitely not arguing against making access easier. In all the studies that have been done, when researchers handed a packet or two or three out to women in advance it had no effect on unintended pregnancy. At the same time, it’s also not making them increase risky behaviors like having more unprotected sex.”

“In short, there is no reason not to allow women to have access to emergency contraception as a safe and effective pregnancy prevention option.”

This, of course, led me to ask about the disconnect, potentially, between handing it out and having women actually take the medication.

“Well, sure. You can hand it out to women but you can’t stand there and make sure they are ingesting it when they need it. From looking at the actual studies, our best theory is that even for women who had EC in advance, not all of them used it when they had unprotected sex. Using data from one of the original studies, researchers went back and tried to determine which women were at low risk and which women were at higher risk of pregnancy based on a veriety of factors [including access to contraception in general, prior effective use of contraception, and an aversion to pregnancy among other factors]. When they went back and looked at the women who were provided EC in advance and compared those women who actually used it vs. those women who didn’t, the researchers found that women who were at lower risk of pregnancy already were the ones taking the EC – women who were ultra motivated to prevent pregnancy. But, in the end, it is true that in some of these studies we looked at not everyone who had it in advance actually used it.”

“The other possibility is that we don’t have a good estimate of how efficacious the medication EC actually is. We are now working with potentially overestimated efficacy estimates. We know EC is better than nothing. One piece of good news is that ella is coming out – a new form of emergency contraception that may be more effective at preventing pregnancy.”

In fact, according to a journal article in Contraception, republished on Rewire last year, reproductive health experts argue that while initial estimates of how dramatically EC might effect unintended pregnancy rates may have been “overly optimistic”, they say that it’s

“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.”

In other words, as Polis and the report acknowledge:

Emergency Contraception is still a “safe and effective way to prevent unintended pregnancies for individual women who will use it when needed.”

The review notes that women who were provided with EC in advance were more likely to report using it, and using it sooner after sex, than those women who were not provided the medication in advance.

So, is there a gap between what women are saying and what they are doing? While the majority of the studies used in the review did rely on self-reporting, Polis tells me:

Well, we are dealing with sensitive behaviors. It could be that women were saying they were using it more than they actually were. The methods of obtaining the data differed amongst the various studies we reviewed. And, it’s true that self reported information isn’t always reliable when it comes to contraceptive behavior…However, what’s striking is the consistency of the findings between all of the studies included in our review, regardless of how they obtained their information on pregnancy and STIs.

For the majority of women who are sexually active and able to conceive for upwards of  30 years or more over a lifetime, for the woman who is raped, for the woman who is told by her male partner that she is “not allowed” to use birth control  – emergency contraception can be a beacon. In other words, EC remains an important and useful birth control option. And while the review did report some findings that suggested an increase in unprotected or underprotected sex that may have been caused by the advance provision of EC, the report notes that, “these findings should be considered hypothesis-generating and do not influence our overall conclusions.” So, despite the anti-choice messages of old: that allowing women a chance to have sex and deal with the consequences afterwards is just dispensing a ‘girls-gone-wild’ license, the availability of EC (such as it is) does not appear to change women’s sexual behaviors and does not result in higher rates of STIs.

Says the Back Up Your Birth Control (BUYBC) campaign:

“We stand by our support of increased access to EC because, population studies aside, taking EC in a timely manner can make a world of difference to an individual woman who may otherwise face an unintended pregnancy.”

The review simply allows advocates and providers a deeper understanding of women’s actual behaviors in regards to contraceptive use – in this case EC. With any method of birth control we know how effective it can be if used and used correctly 100% of the time. But we also know that if it isn’t used, if it isn’t used correctly and it isn’t used (in EC’s case) within a particular time frame, its efficacy across a population is reduced to varying degrees.  This review should be a stepping stone to connect the ways in which we want women to use emergency contraception or the ways in which we think women should be using EC, and the ways in which women may actually be using emergency contraception in their lives.

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