Emergency Contraception (EC) and the Prevention of Unintended Pregnancy Kenneth D. Rosenberg, MD, MPH Oregon Office of Family Health Portland, Oregon 8 th Annual MCH Epidemiology Conference December 12, 2002 Clearwater Beach, Florida 1

w About 10 million couples have sexual intercourse every night in America w Approximately 27,000 condoms break or slip w Even perfect contraceptors can and do experience contraceptive failure u Others may fail to use contraception at all 2 Why Is Emergency Contraception Needed? Source: Trussell & Kowal, 1998.

Unintended Pregnancy w Pregnancy that is unwanted or mistimed at conception w Approximately half of all unintended pregnancies end in abortion w Greater risks for mother u depression, physical abuse, risk of not achieving educational, financial, career goals, relationship challenges w Greater risks for child u low birthweight, infant mortality, abuse, neglect 3 Source: Institute of Medicine, 1995.

The Institute of Medicine Recommends That the Nation Adopt a New Social Norm All pregnancies should be intended – that is, they should be consciously and clearly desired at the time of conception. Source: Institute of Medicine,

Current Proportion of Unintended Pregnancy United States: 49% Oregon: 51% 43% of live births 95% of abortions Source: Henshaw, 1998, Oregon Health Division,

What Is Emergency Contraception? w Emergency Contraceptive Pills (ECPs) u Have been in use since the 1960s u Often referred to as “the morning-after pill” w IUD Insertion u Within 5 days (120 hours) of unprotected sex u Can also be a long-term contraceptive method 6

7 Emergency Contraceptive Pills w Consist of two doses of the same hormones found in birth control pills w Must be taken within three days (72 hours) of unprotected sex w Can be used to prevent pregnancy AFTER unprotected sex

ECPs Can Be Used Any Time Unprotected Intercourse Has Occurred w A woman was raped w No contraception used w Condom slipped, leaked, or broke w Diaphragm or cervical cap inserted incorrectly, removed too soon, or torn w Two consecutive birth control pills were missed w An IUD was partially or totally expelled w A three-month contraceptive injection was missed by more than two weeks w A one-month contraceptive injection was missed by more than three days 8

Limitations of ECPs w ECPs are not a good long-term method of contraception u Should be used as a bridge to a regular form of birth control w ECPs do not protect against STDs 9

Are ECPs Safe? w ECPs are safe and easy to use u The amount of active ingredient (hormone) is small u Short-term use w Repeated use is safe Source: WHO,

What if a Woman Is Already Pregnant? w ECPs cannot dislodge an established pregnancy u They do not cause abortion w ECPs do not affect fetal development Source: Lancet,

Two Types of ECPs Progestin-only w Reduces the risk of pregnancy by 89% w Side effects u Nausea (23%) u Vomiting (6%) Estrogen and Progestin w Reduces the risk of pregnancy by 75% w Side effects u Nausea (50%) u Vomiting (20%) Source: Lancet, Both Methods: First dose within 72 hours after intercourse First dose within 72 hours after intercourse Second dose 12 hours later Second dose 12 hours later 12

Effectiveness: Progestin Only 100 women have unprotected sex in the 2nd or 3rd week of their cycle 8 will become pregnant without emergency contraception 1 will become pregnant using progestin-only ECPs (89% reduction) (89% reduction) Source: FDA,

Effectiveness: Combination Pill (Estrogen + Progestin) 100 women have unprotected sex in the 2nd or 3rd week of their cycle 8 will become pregnant without emergency contraception 2 will become pregnant using combined ECPs (75% reduction) (75% reduction) Source: Trussell, Rodriguez, and Ellertson,

How Do ECPs Work? w The same way as ordinary birth control pills u They can prevent or delay the release of a woman’s egg (ovulation) w ECPs may affect the uterine lining so that a fertilized egg cannot implant w ECPs may prevent fertilization by affecting the movement of sperms and their ability to fertilize an egg 15 Source: Swahn et al., 1996; Ling et al., 1979; Rowlands et al., 1986; Ling et al., 1983; Kubba et al., 1986; Taskin et al., 1994; Von Hertzen & Van Look, 1996.

Pregnancy Prevention w NIH, FDA, and ACOG all define pregnancy as beginning with implantation w It takes about 6 days for a fertilized egg to begin to implant w Intervention within 72 hours cannot result in abortion w ECPs are not effective if a woman is already pregnant Source: Code of Federal Regulations, 1998; Hughes,

Key Points on Mechanism of Action w Will not interrupt or harm an established pregnancy w Will not affect future fertility w ECPs are not the same as the “abortion pill” (RU486), which is used after pregnancy is already established 17

Where Can Women Get ECPs? w Medical provider u Walk-in visit/appointment u Telephone screening w Call the Emergency Contraception Hotline for nearest location: NOT-2-LATE ( ) or visit the website at

Oregon PRAMS Survey w Annual survey of postpartum women w Since 1998 w Survey about 2000 women/year w Sample drawn from birth certificates 19

PRAMS Survey Results w : 70% of postpartum women had heard of “the morning-after pill” w Most likely to have not heard: u Less than 12 years education u Annual family income <$30,000 u Pregnancy unintended 20

Advance Prescription of ECPs w More effective when taken sooner w Reduces access barrier w Not more likely to use repeatedly w Filled or not filled 21

Expanded Access Through Pharmacies w Collaborative agreement between pharmacists and prescribers in Washington State u Pharmacists counsel and dispense without physician prescription u In first sixteen months of project almost 12,000 women received ECPs directly from a pharmacist w New laws in California and Alaska 22

Spread the Word: w Routinely discuss ECPs w Make ECP materials available in agency settings w Encouraging advance prescriptions w College providers w Emergency providers 23

Additional Resources w w American College of Obstetrics and Gynecology: w Program for Appropriate Technology in Health (PATH): w CD Summary article: w List of retail pharmacies that stock EC: