1. Emergency Contraception and Emergency Contraceptive Pills (ECPs) Transparencies to accompany Emergency Contraceptive Pills: South East Asia Regional Training Manual Available at www.popcouncil.org/frontiers

2. Session 1 Emergency Contraception

3. 3 Session Objectives After the session the participants will have sufficient knowledge to be able to:  Understand need for Emergency Contraception (EC)  Define and describe EC  Describe situations when EC can be used  Describe methods of Emergency Contraception  Describe Emergency Contraceptive Pill (ECP), types, and mode of action  Describe dose, interval between doses, and time limit when ECP can be used  Describe effectiveness of ECPs  Describe indications and contraindications of ECP  Discuss side effects of ECPs

4. 4 Consequences of Unwanted Pregnancies It is estimated that worldwide each year: 20-22 million unsafe abortions are performed (WHO). 6.5 million in India. 67,000-204,000 maternal deaths occur each year. Almost all are in developing countries (IPPF). Innumerable women suffer long term morbidities including permanent infertility. 15 percent of maternal deaths in India are due to abortion complications (WHO 2004, BMMS 2003 and Singh et al. 1997).

5. 5 Modes of Prevention Many abortion-related deaths and morbidities can be averted by: Promoting family planning use to avoid unwanted pregnancy. Strengthening postabortion services in all clinics and making them widely and easily accessible. Educating women about the high risks or traditional methods of pregnancy termination. Introducing and educating women about ECP as a back-up support to avoid unwanted pregnancy from method failure or unprotected intercourse.

6. 6 Emergency Contraceptive Pills: Reproductive Health Intervention Offers back-up contraceptive support at a crucial time. ECP prevents possible unwanted pregnancy from unprotected intercourse. Reduces need for abortion and use of traditional methods for pregnancy termination. Decreases maternal morbidity and mortality.

7. 7 What is Emergency Contraception (EC)? Emergency contraception (EC) refers to contraceptive methods that can be used by women in the first few days following unprotected intercourse to prevent an unwanted pregnancy (WHO 1998).

8. 8 Situations When EC Should Be Used Voluntary sexual intercourse where no contraceptive is used. When there is a contraceptive method failure or a method is used incorrectly, such as:  Condom leakage  Failure to take OCP for 3 consecutive days  Delaying contraceptive injection more than 2 weeks  Miscalculation of the infertile (safe) period  Failed coitus interruptus Involuntary sex such as rape/sexual assault

9. 9 Methods of Emergency Contraception Emergency contraception can be provided using one of two methods: 1.Emergency contraceptive pills (ECPs)  Use within 72 hours 2. Intra-uterine devices (IUDs)  Insert within 5 days and continue use as long term method (CEC 2004; FHI 2002; WHO 1998) This presentation focuses on ECPs only.

10. 10 Types of ECP ECPs are hormonal methods that can be used to prevent pregnancy following unprotected intercourse. This includes: Increased doses of Combined Oral Contraceptive (COC) Pills: containing ethinyl estradiol and levonorgestrel High doses of Progestogen-only Oral Contraceptive (POC) Pills: containing levonorgestrel only

11. 11 Who Could Use ECP? All women can use ECPs, even those who are advised not to use OCP as a regular method. Breastfeeding mothers also can use ECP. One major contraindication for the use of ECP is pregnancy or suspected pregnancy. This is PRIMARILY because they will not be effective. (CEC 2004; FHI 2002; WHO 1998)

12. 12 ECPs: Possible Mechanism of Action Possibly inhibit or delay ovulation. May prevent fertilization or transport of sperm or ovum. Exact mechanism still not clear. Depending on when used during cycle: (WHO 1998)

13. 13 What is the Regimen? Combined OCPs (COC) (ethinyl estradiol + levonorgestrel) Low-dose or Standard-dose COC:  Each dose should contain at least 100 microgram (0.1mg) ethinyl estradiol and 500 microgram (0.5mg) levonorgestrel Progestogen-only pill (levonorgestrel)  Each dose should contain 750 microgram (0.75mg) levonorgestrel alone (CEC 2004; FHI 2002; WHO 1998)

14. 14 Emergency Contraceptive Pill: How It Should Be Taken When to take? Start as soon as possible. First dose must be started within 72 hours (3 days) of an unprotected intercourse How many doses? Hours between two doses? 2 doses 12 hours (CEC 2004; FHI 2002; WHO 1998) Each dose must contains at least 0.75 mg of levonorgestrel

15. 15 Effectiveness: Progestogen-only ECP If 100 women have a single act of unprotected intercourse during the 2 nd – 3 rd week of cycle: (CEC 2004; FHI 2002; WHO 1998) Eight women may become pregnant without ECPs. If all of them use ECPs within 72 hours of unprotected intercourse; only one woman may become pregnant. Thus, ECPs are 85% effective. It is more effective if used within 12-24 hours of unprotected intercourse.

16. 16 Possible Side Effects Common side effects: Nausea Vomiting Generally, less than 20% women suffer from any side effects, and none last more than 24 hours (CEC 2004; FHI 2002; WHO 1998) Menstrual disturbance Fatigue Dizziness Headache Breast tenderness

17. Session 2 ECP Service Delivery Guidelines

18. 18 Session Objectives After the session the participants will have the knowledge and be able to understand:  Who should be provided with ECP services  How the clients are informed and provided with ECP services  Counsel clients what, when, and how to come back to regular FP methods  Guidelines in providing ECP, particularly in cases of method failure  Guidelines in managing side effects  What could be done in case of ECP failure

19. 19 Who Should be Provided ECP Service? ALL potential contraceptive users Regular FP clients using temporary methods

20. 20 How Will Clients Be Informed and Provided with ECP Service? Routinely inform all clients about ECP Distribute BCC materials Inform and address any misconceptions about ECP

21. 21 How Will Clients Be Informed and Provided with ECP Services?  Ask and assess  Date of last menstrual period  Length of woman’s normal menstrual cycle  Number of hours since the first unprotected intercourse  Inform client about ECP use  Remind client about salient points on ECP  Utilize opportunity for counseling on other FP methods  Counsel clients on how to resume regular contraception after use of ECP (cont.)

22. 22 What FP Methods Could Be Started After the Use of ECP? Condom OCPs Injection IUD Norplant Permanent Method MethodsWhen could be started Immediately after ECP use Next day after the 2nd dose of ECP or 1-7 days of next menses 1-7 days of starting of next period (CEC 2004; FHI 2002; WHO 1998) Natural Method 1-7 days of starting of next period

23. 23 Missed OCP for 3 Consecutive Days: What Should Be Done? Those who have started menstrual bleeding should be advised to continue the national guidelines as follows:  Stop taking OCP and discard rest of the pills and  Start a new packet of OCP on the 1 st day of the next menses Those who have not started menses and had intercourse should be advised to:  Take two doses of ECP 12 hours apart and  Continue to take rest of the OCPs-one tablets daily or  Use condom for any further intercourse and  Start a new packet of OCP on the first day of the next menstrual cycle

24. 24 Missed Injection Due Date: What Should Be Done?  Take two doses of ECP 12 hours apart and  Use condom until start of the next menstrual bleeding and  Receive an injection at the first day of the next menstrual bleeding Missed injection due date Can take injection up to 14 days late. Give her new injection. Have passed 14 days and come after unprotected intercourse.

25. 25 Condom Bursts or Leaks: What Should Be Done? The client should be advised to: Take two doses of ECP 12 hours apart and Use condom again until beginning of the next menstrual bleeding and Start using a condom again from the beginning of the next menstruation or If the client wants to change the method: Start a new packet of OCP after the second dose of ECP if want to change or Start any other method, such as injection, on the 1st day of the next menstruation

26. 26 Management of Side Effects Nausea may be reduced for some users if ECP is taken with food. Paracetamol and aspirin is effective against headache and breast tenderness. Can even use ibuprofen. No treatment is necessary for menstrual problems. Most side effects disappear within 24 hours.

27. 27 What Could be Done in Case of ECP Failure? Client became pregnant Used ECP Assure her there will be no harm to the fetus

28. Session 3 Counseling on ECP

29. 29 Session Objectives After the session the participants will have the knowledge and be able to:  Describe whom and what to be counseled about ECP.  Understand what, when, and how to start regular contraception after the use of ECP (contraception options).  Answer common questions related to ECP.

30. 30 Whom and What to Be Counseled About ECP? Potential Contraception Users:  Methods available for contraception  Details about FP methods  Scope of ECP as a back-up method Regular Temporary Family Planning Clients:  When and how to use ECP  Side effects of ECP and their management  Methods of contraception after the use of ECP  What to do when they miss cycle for more than 7 days

31. 31 Whom and What to Be Counseled About ECP? Special attention must be given to OCP users:  Properly explain what to do if they miss three pills  When and how to use ECP  What to do with the rest of the pills in the packet  Why they need to use a condom for any future intercourse  What to do when miss cycle for more than 7 days  How to come back to regular use of OCP in the next menstrual cycle  Why ECP can not be used as a regular method (cont.)

32. 32 Whom and What to be Counseled about ECP? For a client who has requested ECP, the following four steps could be followed. Before providing ECP, assess whether ECP is appropriate for the client then:  Inform about correct use of ECP, how it works, cannot use it regularly, its efficacy and failure rates  Explain when it is more effective  Remind of side effects and their management and when she should come back for follow-up  Return consult when and how to return to the regular FP methods (cont.)

33. 33 When Should Client Come Back for Follow-up? There is no need for follow-up in case of ECP use. However, clients should come back to the service provider if:  Her period is more than 7 days late  Menstrual bleeding is too light in terms of color  She wants to use regular FP method  She needs some clarification about ECP use (CEC 2004; FHI 2002; WHO 1998)

34. 34 Frequently Asked Questions about ECP What will be the impact of ECP on menses? Would it be effective for the next days of the cycle? How many times can one take ECP in a month? Will ECP cause abortion? Can a breastfeeding mother take ECP? Do women need to use ECP during the safe period?

35. 35 Frequently Asked Questions about ECP Can women use ECP before intercourse? Does ECP work if multiple intercourse occurs? If ECP fails to protect against pregnancy, will it cause harm to the fetus? Can ECP be used after 72 hours of unprotected intercourse? What should women do if they vomit within 1 hour of ECP use? (cont.)

36. 36 Please refer to the accompanying publication: Emergency Contraceptive Pills: South East Asia Regional Training Manual by Sharif Mohammed Ismail Hossain, M.E. Khan, Moshiur Rahman, and Mary Philip Sebastian. New Delhi: Population Council. 2005. Available at www.popcouncil.org/frontiers