NEW FRONTIERS FOR EMERGENCY CONTRACEPTION IN AFRICA

SETTING THE STAGE  Describe what EC is  Review the current status of EC services in Africa  Introduce a new regional network on EC and describe its mission and activities  Highlight three issues of significance to the future of EC services in Africa and women’s access to them

WHAT IS EC?  Method of preventing pregnancy after unprotected sexual intercourse  Method that can not interrupt an established pregnancy  Not the “abortion pill”

TYPES OF EC  Combined OCs: 2 doses of pills containing ethinyl estradiol (100 mcg) & levonorgestrel (0.5 mg) taken 12 hrs apart → 75% reduction in risk (2/100 vs. 8/100 will get pregnant)  Progestin-only OC’s – in preferred regimen one dose of 1.5 mg levonorgestrel (or can be in 2 doses of 0.75mg, 12 hrs apart) → 88% reduction in risk (1/100 will get pregnant); less side effects (nausea and vomiting) than with COCs, 6% vs 23%

HOW DOES EC WORK? Possible means of action  Interferes with ovulation (only mechanism clearly supported by data)  alter endometrium, impairing implantation  alter cervical mucus, thus trapping sperm  change tubal transport of gametes or embryo EC does not affect an established pregnancy

EFFICACY OF EC Progestin-onlyCombined up to 24 hours25-48 hours49-72 hours Percentage of pregnancies prevented

FIRST APPEARANCES…  Twenty-six countries currently have a dedicated EC product registered with their national regulatory authorities Postinor 2 Norlevo/Vikela  Between 1995 and 2000, six African countries undertook pilot studies, designed to introduce EC into the public sector health care system  Across Africa, a plethora of initiatives are underway to expand access to EC

 Product registration does not mean availability  In not one of the six pilot countries has the delivery of EC services been maintained, let alone mainstreamed within in the public sector at a national level  Throughout Africa as a whole, only 13 countries include EC within their national national FP/RH guidelines and protocols – and only 9 of those are found in countries with a dedicated ECP …CAN BE DECEIVING

REMAINS LOW KNOWLEDGE AND USE OF EC REMAINS LOW KNOWLEDGE AND USE OF EC Knowledge of ECEver Use of EC Kenya (2003)23.7 [25.2] 0.9 [1.0] Eritrea (2002)10.4 [9.6] 0.4 [0.4] Benin (2001)15.2 [15.2] 1.5 [1.3] Mali (2001)6.4 [6.1] 0.2 [0.2] Nigeria (2003)15.7 [18.7] 2.8 [1.8] Ghana (2003)28.2 [28.8] 1.1 [1.1] Zambia (2001/02)9.4 [9.9] 0.3 [0.4]

 There are incentives that sustain the delivery of other contraceptives that do not exist for EC  Governments are unfamiliar with the status of post- introduction EC services  There are no natural constituencies in-country to shepherd EC through the system or to advocate for its mainstreaming  Africa remains marginalized from current international discourse over EC MAINSTREAM EC SERVICES? WHY THE FAILURE TO

THE SOLUTION?  A broad-based exchange of information, unencumbered by linguistic barriers, in support of efforts to introduce, deliver and mainstream quality emergency contraception services  A concerted, participatory effort at the national level to get EC “back on track” – especially in the countries where the method has already been introduced

GOALS OF EC AFRIQUE  To serve as a forum for exchanging of ideas among health care professionals engaged in efforts to expand EC services in Africa  To inspire interest and encourage new initiatives in the provision of EC services where there is an unmet need for them  To build collectively the knowledge and experience base needed to introduce, improve, and mainstream quality EC services, with a specific focus on the needs and challenges of Africa.

 Worldwide network of 20 founding members, and over 200 corresponding institutional and individual members  Active in over half of all countries in Africa EC AFRIQUE TODAY  Developed a comprehensive data- base of institutional and individual members

 Published and distributed five issues of EC AFRIQUE bulletin  Provided technical support to partner agencies, and other regional consortia under the auspices of EC AFRIQUE (proposal writing, translation, material development, information dissemination)  Attracted/leveraged new funding for EC-related research and service delivery in Africa  Disseminated information at international fora  Has already established itself as a respected, independent body for supporting EC initiatives across Africa EC AFRIQUE TODAY

 Commercial pricing can be a barrier to wider product access  Private sector distribution favors urban settings  Commercial distributors and/or licensees can restrict (or dictate) the terms of product availability  Private sector distribution can impede the provision of accurate information on EC coverage or utilization  Emphasis on dedicated ECP can undermine provision of Yuzpe formulation SOME LIMITATIONS PRIVATE SECTOR PROVISION:

 Private sector provision frees EC availability from dependence on private sector/donor procurement  Commercial interests have spawned a host of social marketing and private/public sector collaborations to increase product access  Increases product acceptability on the part of certain population segments  Market interests can further efforts to disseminate information on EC SOME ADVANTAGES PRIVATE SECTOR PROVISION:

 Traditional service delivery outlets are not necessarily (or even typically) the first points of contact for assault survivors  Existing policies and protocols are typically designed to satisfy the needs of the legal system – not the health needs of the victim  Despite the logical connection between the prevention of pregnancy and of HIV transmission, one must not become the “ball and chain” of the other VIOLENCE AND RAPE ADDRESSING SEXUAL

 Discourse on EC – both positive and negative - is dominated by concerns over HIV/AIDS  Young people are at especially high risk of unwanted pregnancy  Use of EC does not undermine continued use of regular contraception  We need better information on those who use EC and on the interplay between EC and condom use THE NEEDS OF YOUTH